Aortic Stenosis: Risk Stratification and Timing of Surgery.

PURPOSE OF REVIEW: This review summarizes the current management of patients with newly diagnosed aortic stenosis. RECENT FINDINGS: Recent developments include detection of early myocardial dysfunction using serum B-type natriuretic peptide levels and global longitudinal strain, as well as ongoing trials of transcatheter aortic valve replacement in asymptomatic patients and patients with moderate aortic stenosis complicated by symptoms or left ventricular systolic dysfunction. Given the high mortality associated with severe symptomatic aortic stenosis, all symptomatic patients should be referred for aortic valve replacement. Asymptomatic patients with left ventricular systolic dysfunction, abnormal exercise stress test, high degree of stenosis, rapid disease progression, or elevated serum B-type natriuretic peptide level may also have an indication for valve replacement, based on established criteria. The progress in management of severe aortic stenosis has been in the direction of earlier detection and earlier valve replacement.

American Society of Echocardiography Algorithm for Degenerative Mitral Regurgitation: Comparison With CMR.

OBJECTIVES: The purpose of this study was to compare the American Society of Echocardiography (ASE) algorithm for assessing mitral regurgitation (MR) to cardiac magnetic resonance (CMR) and left ventricular (LV) remodeling following mitral intervention. BACKGROUND: The ASE recommends integrating multiple echocardiographic parameters for assessing MR. The ASE guidelines include an algorithm that weighs the parameters and highlights those considered indicative of definitely mild or definitely severe MR. METHODS: We prospectively enrolled 152 (age 62 ± 13 years; 59% male) patients with degenerative MR who underwent ASE algorithm-guided echocardiographic and CMR grading of MR severity. Using the ASE algorithm, patients were graded as definitely mild, grade I, grade II, grade III, grade IV, or definitely severe MR. CMR MR volume was graded as mild (<30 mL), grade II moderate (30-44 mL), grade III moderate (45-59 mL), or severe (≥60 mL). A subgroup of 63 patients underwent successful mitral intervention, of whom 48 had postintervention CMR. RESULTS: Only 52% of patients with definitely severe MR by the ASE algorithm had severe MR by CMR, and 10% had mild MR by CMR. There was an increase in post mitral intervention LV reverse remodeling with worsening MR severity using CMR (P < 0.0001) but not the ASE algorithm (P = 0.07). Severe MR by CMR was an independent predictor of post mitral intervention LV reverse remodeling and definitely severe MR by the ASE algorithm was not. CONCLUSIONS: In patients with degenerative MR, agreement between CMR and the ASE algorithm was suboptimal. Severe MR by CMR was an independent predictor of post mitral intervention LV reverse remodeling, whereas definitely severe MR by the ASE algorithm was not. These findings suggest an important role for CMR in surgical decision making in degenerative MR. (Comparison Study of Echocardiography and Cardiovascular Magnetic Resonance Imaging in the Assessment of Mitral and Aortic Regurgitation; NCT04038879).

Characterization of Primary Mitral Regurgitation With Flail Leaflet and/or Wall-Impinging Flow.

BACKGROUND: Echocardiography guidelines note that a flail leaflet is a specific criterion for severe mitral regurgitation (MR) and that regurgitant severity is underestimated in wall-impinging jets (Coanda effect). Both findings are often considered to be pathognomonic of severe MR. OBJECTIVES: In this study, the authors sought to determine the association of flail leaflet and Coanda effect with MR severity quantified by means of cardiac magnetic resonance (CMR). METHODS: The authors enrolled 158 consecutive patients with primary MR according to echocardiography and CMR. The presence of a flail leaflet or Coanda was determined for each patient. CMR regurgitant volume (RV) and regurgitant fraction (RF) were quantified for all patients. RESULTS: There were 55 patients (35%) with a flail leaflet, 52 (33%) with Coanda, and 22 (14%) with a flail leaflet and Coanda. The mean CMR mitral RV and RF progressively increased in patients without a Coanda or flail, a Coanda, a flail, or a Coanda and a flail (RV: 28 ± 21 mL vs 43 ± 23 mL vs 58 ± 29 mL vs 64 ± 25 mL [P < 0.001]; RF: 25% ± 16% vs 34% ± 14% vs 41% ± 12% vs 45% ± 12% [P < 0.001]). With the use of CMR RV, 35%, 46%, and 59% of patients had severe MR with the presence of a Coanda, flail leaflet, or both, respectively. With the use of CMR RF, 25%, 31%, and 40% of patients had severe MR with the presence of a Coanda, flail leaflet, or both, respectively. CONCLUSIONS: While the presence of a flail leaflet and Coanda effect on echocardiography are associated with higher regurgitant volumes and fractions, they are frequently not associated with severe MR as assessed by means of CMR. (Comparison Study of Echocardiography and Cardiovascular Magnetic Resonance Imaging in the Assessment of Mitral and Aortic Regurgitation; NCT04038879).

2-Year Outcomes for Transcatheter Repair in Patients With Mitral Regurgitation From the CLASP Study.

OBJECTIVES: This study reports 2-year outcomes from the multicenter, prospective, single-arm CLASP study with functional mitral regurgitation (FMR) and degenerative MR (DMR) analysis. BACKGROUND: Transcatheter repair is a favorable option to treat MR. Long-term prognostic impact of the PASCAL transcatheter valve repair system in patients with clinically significant MR remains to be established. METHODS: Patients had clinically significant MR ≥3+ as evaluated by the echocardiographic core laboratory and were deemed candidates for transcatheter repair by the heart team. Assessments were performed by clinical events committee to 1 year (site-reported thereafter) and core laboratory to 2 years. RESULTS: A total of 124 patients (69% FMR, 31% DMR) were enrolled with a mean age of 75 years, 56% were male, 60% were New York Heart Association functional class III to IVa, and 100% had MR ≥3+. At 2 years, Kaplan-Meier estimates showed 80% survival (72% FMR, 94% DMR) and 84% freedom from heart failure (HF) hospitalization (78% FMR, 97% DMR), with 85% reduction in annualized HF hospitalization rate (81% FMR, 98% DMR). MR ≤1+ was achieved in 78% of patients (84% FMR, 71% DMR) and MR ≤2+ was achieved in 97% (95% FMR, 100% DMR) (all p < 0.001). Left ventricular end-diastolic volume decreased by 33 ml (p < 0.001); 93% of patients were in New York Heart Association functional class I to II (p < 0.001). CONCLUSIONS: The PASCAL repair system demonstrated sustained favorable outcomes at 2 years in FMR and DMR patients. Results showed high survival and freedom from HF rehospitalization rates with a significantly reduced annualized HF hospitalization rate. Durable MR reduction was achieved with evidence of left ventricular reverse remodeling and significant improvement in functional status. The CLASP IID/IIF randomized pivotal trial is ongoing.

Accuracy of the Single Cycle Length Method for Calculation of Aortic Effective Orifice Area in Irregular Heart Rhythms.

INTRODUCTION: In irregular heart rhythms, echocardiographic calculation of aortic effective orifice area (EOA) requires averaging measurements from multiple cardiac cycles. Whether a single cycle length method can be used to calculate aortic EOA in aortic stenosis with nonsinus rhythms is not known. METHODS: Transthoracic echocardiograms of 100 patients with aortic stenosis and either atrial fibrillation (AF) or frequent ectopy (FE) were retrospectively reviewed. The aortic valve velocity time integral (VTIAV) and the left ventricular outflow tract VTI (VTILVOT) were measured by two methods: the standard method (averaging multiple beats) and the single cycle length method. The latter matches the R-R intervals for VTIAV and VTILVOT. Stroke volume, EOA, and Doppler velocity index were calculated by both methods in all patients. The single cycle length method was used for short and long R-R cycles in AF and for postectopic beats (long R-R cycles) in FE. RESULTS: In AF, long R-R cycles resulted in larger stroke volumes (73 ± 21 vs 63 ± 18 mL; P ≤ .0001) but no difference in EOA (0.84 ± 0.27 vs 0.82 ± 0.27 cm2; P = .11), whereas short R-R cycles resulted in smaller stroke volumes (55 ± 18 vs 63 ± 18 mL, P ≤ .0001) but a larger EOA (0.86 ± 0.28 vs 0.82 ± 0.27 cm2; P = .01). In FE, the postectopic beat led to larger stroke volumes (96.1 ± 28 vs 78 ± 23 mL; P < .0001) and a larger EOA (0.99 ± 0.32 vs 0.94 ± 0.32 cm2; P = .0006) and Doppler velocity index (0.24 ± 0.07 vs 0.23 ± 0.07; P < .001). CONCLUSIONS: In AF patients, the single, long cycle length method of calculating EOA can be used instead of averaging multiple cardiac cycles. The single cycle length method used on a postextrasystolic beat results in a larger EOA than a normal sinus beat and may have utility in clinical decision-making.

Mitral Valve Replacement With Sapien 3 Transcatheter Valve in Severe Mitral Annular Calcification.

Transcatheter valve implantation in the mitral position with severe calcific mitral stenosis has been described in patients who are at an increased risk for conventional mitral valve surgical procedures. We report the direct deployment of the Sapien 3 valve in the mitral position with severe mitral annular calcification through a sternotomy in an arrested heart in two cases.

Timing of surgery in valvular heart disease: prophylactic surgery vs watchful waiting in the asymptomatic patient.

In the absence of randomized controlled trial data, the management of patients with severe valvular heart disease without symptoms, ventricular dysfunction, or other identified triggers for surgery is controversial. In this review, we frame the debate between prophylactic surgery vs close follow-up until triggers occur (watchful waiting) for severe aortic stenosis and degenerative mitral regurgitation (MR), the 2 conditions for which the pros and cons of these approaches are best articulated. Classic high-gradient severe aortic stenosis is generally accurately diagnosed. In asymptomatic patients, stress testing can be used to confirm asymptomatic status and identify high-risk features including reduced exercise tolerance, exercise-induced symptoms, and absolute or relative hypotension. Resting echocardiographic predictors of disease progression and/or adverse events include very high gradients, rapid progression, and extensive calcification. Surgical risk calculators can help estimate perioperative morbidity/mortality with the ultimate choice of a medical vs a prophylactic surgical approach to be made after discussion with the patient. With degenerative MR, severity can be inaccurately estimated. Stress testing might clarify whether the patient is truly asymptomatic and identify features associated with worse prognosis and symptom onset. Selecting patients with high probability of repair can be challenging. Perioperative risk and postoperative risks including those of unanticipated valve replacement and recurrent MR after repair are also considerations. In aggregate, management of patients with valvular disease who are asymptomatic and who have no clear trigger for surgery is complex, requires individualization, and should be carried out by or in collaboration with a heart valve centre of excellence.