Perioperative Risk of Noncardiac Surgery in Patients With Asymptomatic Significant Aortic Stenosis: A 10-Year Retrospective Study.

BACKGROUND: Aortic stenosis (AS) is a representative geriatric disease, and there is an anticipated rise in the number of patients requiring noncardiac surgeries in patients with AS. However, there is still a lack of research on the primary predictors of noncardiac perioperative complications in patients with asymptomatic significant AS. METHODS AND RESULTS: Among the cohort of noncardiac surgeries under general anesthesia, with an intermediate to high risk of surgery from 2011 to 2019, at Samsung Medical Center, 221 patients were identified to have asymptomatic significant AS. First, to examine the impact of significant AS on perioperative adverse events, the occurrences of major adverse cardiovascular events and perioperative adverse cardiovascular events were compared between patients with asymptomatic significant AS and the control group. Second, to identify the factors influencing the perioperative adverse events in patients with asymptomatic significant AS, a least absolute shrinkage and selection operator regression model was used. There was no significant difference between the control group and the asymptomatic significant AS group in the event rate of major adverse cardiovascular events (4.6% at control group versus 5.5% at asymptomatic significant AS group; P=0.608) and perioperative adverse cardiovascular events (13.8% at control group versus 18.3% at asymptomatic significant AS group; P=0.130). Cardiac damage stage was a significant risk factor of major adverse cardiovascular events and perioperative adverse cardiovascular events. CONCLUSIONS: There was no significant difference in major postoperative cardiovascular events between patients with asymptomatic significant AS and the control group. Advanced cardiac damage stage in significant AS is an important factor in perioperative risk of noncardiac surgery.

Identification of hub genes in calcific aortic valve disease.

Calcific aortic valve disease (CAVD) is a heart valve disorder characterized primarily by calcification of the aortic valve, resulting in stiffness and dysfunction of the valve. CAVD is prevalent among aging populations and is linked to factors such as hypertension, dyslipidemia, tobacco use, and genetic predisposition, and can result in becoming a growing economic and health burden. Once aortic valve calcification occurs, it will inevitably progress to aortic stenosis. At present, there are no medications available that have demonstrated effectiveness in managing or delaying the progression of the disease. In this study, we mined four publicly available microarray datasets (GSE12644 GSE51472, GSE77287, GSE233819) associated with CAVD from the GEO database with the aim of identifying hub genes associated with the occurrence of CAVD and searching for possible biological targets for the early prevention and diagnosis of CAVD. This study provides preliminary evidence for therapeutic and preventive targets for CAVD and may provide a solid foundation for subsequent biological studies.

Prevalence of moderate-severe aortic stenosis in patients with cardiac amyloidosis in a referral center.

BACKGROUND: Aortic stenosis (AS) is currently the most common valvular disease, with an estimated prevalence of over 4% in octogenarians. OBJECTIVE: To describe the prevalence of moderate-severe aortic stenosis (AS) in patients with wild type transthyretin amyloidosis (ATTRwt). Also, describe the clinical features, echocardiographic characteristics and clinical evolution. METHOD: Retrospective cohort of patients with diagnosis of ATTRwt, belonging to Hospital Italiano de Buenos Aires Institutional Amyloidosis Registry, from 30/11/2007 to 31/05/2021. Patients follow up was carried out through the institution clinical history. The prevalence of moderate-severe AE was estimated and presented as a percentage with its 95% confidence interval (95% CI). The characteristics were compared by groups according to whether or not they had moderate-severe AS. RESULTS: 104 patients with ATTRwt were included. Median follow up was 476 days [interquartile range: 192-749]. Moderate-severe AS prevalence at the ATTRwt time of diagnosis was 10.5% (n = 11; 95% CI: 5-18%). The median age of patients with AS moderate-severe at the time of diagnosis of ATTRwt was 86 years [78-91] and the male sex predominated (82%). Most of the patients had a history of heart failure (n = 8) and atrial fibrillation (n = 8) prior to the diagnosis of ATTRwt. Most of the patients were subclassified as low flow low gradient severe AS group (n = 7). Four patients underwent some intervention on the aortic valve. During follow-up, 5 patients (46%) were hospitalized for decompensated heart failure and 4 (36%) died. CONCLUSIONS: In our cohort, the coexistence of both pathologies had a similar prevalence as reported in the international literature. It was an elderly population with a high percentage of atrial fibrillation and history of heart failure. Most of the patients presented with severe AS with low flow low gradient.

ANTECEDENTES: La estenosis aórtica (EA) es actualmente la enfermedad valvular más frecuente, con una prevalencia estimada de más del 4 % en octogenarios. OBJETIVO: Describir la prevalencia de estenosis aórtica (EA) moderada-grave en pacientes con amiloidosis por transtiretina wild type (ATTRwt). Además, describir las características clínicas, ecocardiográficas y la evolución en este grupo de pacientes. MÉTODO: Estudio de cohorte retrospectiva de pacientes con diagnóstico de ATTRwt, pertenecientes al Registro Institucional de Amiloidosis del Hospital Italiano de Buenos Aires, en el periodo del 30/11/2007 al 31/05/2021. El seguimiento de los pacientes se realizó a través de la historia clínica electrónica de la institución. Se estimó la prevalencia de EA moderada-grave, que se presenta como porcentaje con su intervalo de confianza del 95% (IC 95%). Se compararon las características por grupos según tuvieran o no EA moderada-grave. RESULTADOS: Se incluyeron 104 pacientes con diagnóstico de ATTRwt. La mediana de seguimiento fue de 476 días [rango intercuartílico: 192-749]. La prevalencia de EA moderada-grave al momento del diagnóstico de ATTRwt fue del 10.5% (n = 11; IC95%: 5-18%). La mediana de edad de los pacientes con EA fue de 86 años [78-91] y predominó el sexo masculino (81.8%). La mayoría de los pacientes tenían el antecedente de insuficiencia cardiaca (n = 8) y fibrilación auricular (n = 8). Predominaron los pacientes con EA grave de bajo flujo y bajo gradiente (n = 7). Cuatro pacientes fueron sometidos a alguna intervención en la válvula aórtica. Durante el seguimiento, 5 pacientes (46%) tuvieron internaciones por insuficiencia cardiaca descompensada y 4 (36%) fallecieron. CONCLUSIONES: En nuestra cohorte, la coexistencia de ambas patologías tuvo una prevalencia similar a la reportada en la literatura internacional. Se trató de una población añosa con alto porcentaje de fibrilación auricular y antecedente de insuficiencia cardiaca. La mayoría presentaron EA grave de bajo flujo y bajo gradiente.

Comparative analysis of early postoperative results of transcatheter aortic valve implantation and surgical aortic valve replacement with a biological prosthesis.

OBJECTIVE: . Aim: The choice of aortic valve stenosis correction method is determined by a number of clinical and technical parameters. The task was to compare early postoperative outcomes in patients after correction of aortic valve stenosis using TAVI and surgical aortic valve replacement with a biological prosthesis. PATIENTS AND METHODS: Materials and Methods: This retrospective study analyzed the medical records of adult patients (18 years of age and older) who had transcatheter aortic valve implantation or surgical aortic valve replacement with a biological prosthesis at the State Institution "Heart Institute of the Ministry of Health" in the period from 2018 to 2022. RESULTS: Results: In 47 (47.5%) cases, TAVI was performed and in 52 (52.5%) cases, SAVR with a biological prosthesis was performed. Patients who underwent TAVI were significantly older (p=0.002) and had a higher EuroSCORE II operative risk score (p<0.001). In patients with TAVI, larger diameter aortic valve prostheses were significantly more often used compared with the SAVR group with biological prosthesis (27.5±2.74 vs. 22.5±1.84, p<0.001). The early postoperative period in patients with TAVI was characterized by an 11.4% (p=0.046) and 15.4% (p=0.006). The length of stay in the ICU (p=0.024), as well as the duration of hospitalization in general (p=0.005), was also significantly lower in patients with TAVI compared with patients with biological prosthesis SAVR. CONCLUSION: Conclusions: Despite the higher surgical risk of surgery according to EuroSCORE II, TAVI was characterized by a lower incidence of postoperative complications, with shorter duration of stay in ICU and hospitalization in general in comparison with patients undergoing SAVR with a biological prosthesis.

Poor Oral Health Is Associated With Inflammation, Aortic Valve Calcification, and Brain Volume Among Forager-Farmers.

Poor oral health is associated with cardiovascular disease and dementia. Potential pathways include sepsis from oral bacteria, systemic inflammation, and nutritional deficiencies. However, in post-industrialized populations, links between oral health and chronic disease may be confounded because the lower socioeconomic exposome (poor diet, pollution, and low physical activity) often entails insufficient dental care. We assessed tooth loss, caries, and damaged teeth, in relation to cardiovascular and brain aging among the Tsimane, a subsistence population living a relatively traditional forager-horticulturalist lifestyle with poor dental health, but minimal cardiovascular disease and dementia. Dental health was assessed by a physician in 739 participants aged 40-92 years with cardiac and brain health measured by chest computed tomography (CT; n = 728) and brain CT (n = 605). A subset of 356 individuals aged 60+ were also assessed for dementia and mild cognitive impairment (n = 33 impaired). Tooth loss was highly prevalent, with 2.2 teeth lost per decade and a 2-fold greater loss in women. The number of teeth with exposed pulp was associated with higher inflammation, as measured by cytokine levels and white blood cell counts, and lower body mass index. Coronary artery calcium and thoracic aortic calcium were not associated with tooth loss or damaged teeth. However, aortic valve calcification and brain tissue loss were higher in those who had more teeth with exposed pulp. Overall, these results suggest that dental health is associated with indicators of chronic diseases in the absence of typical confounds, even in a population with low cardiovascular and dementia risk factors.

Limited Access to Aortic Valve Procedures in Socioeconomically Disadvantaged Areas.

BACKGROUND: To explore how differences in local socioeconomic deprivation impact access to aortic valve procedures and the treatment of aortic valve disease, in comparison to other open and minimally invasive surgical procedures. METHODS AND RESULTS: Procedure volume data were obtained from the Healthcare Cost and Utilization Project from 18 states from 2016 to 2019 and merged with area deprivation index data, an index of zip code-level socioeconomic distress. We estimate the relationship between local deprivation ranking and differences in volumes of aortic valve replacement, which include transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR), versus coronary artery bypass graft surgery and laparoscopic colectomy (LC). All regressions control for state and year fixed effects and an array of zip code-level characteristics. TAVR procedures have increased over time across all zip codes. The rate of increase is negatively correlated with deprivation ranking, regardless of the higher share of hospitalizations per population in high deprivation areas. Distributional analysis further supports these findings, showing that lower area deprivation index areas account for a disproportionately large share of SAVR, TAVR, and LC procedures in our sample relative to their share of all hospitalizations in our sample. By comparison, the cumulative distribution of coronary artery bypass graft procedures was nearly identical to that of total hospitalizations, suggesting that this procedure is equitably distributed. Regressions show high area deprivation index areas have lower prevalence of SAVR (ß=-15.1%, [95% CI, -26.8 to -3.5]), TAVR (ß=-9.1%, [95% CI, -18.0 to -0.2]), and LC (ß=-19.9%, [95% CI, -35.4 to -4.4]), with no statistical difference in the prevalence of coronary artery bypass graft (ß=-2.5%, [95% CI, -12.7 to 7.6]), a widespread and commonly performed procedure. In the population aged ≥80 years, results show high area deprivation index areas have a lower prevalence of TAVR (ß=-11.9%, [95% CI, -18.7 to -5.2]) but not SAVR (ß=-0.8%, [95% CI, 8.1 to 6.3]), LC (ß=-3.5%, [95% CI, -13.4 to -6.4]), or coronary artery bypass graft (ß=5.2%, [95% CI, -1.1 to 1.1]). CONCLUSIONS: People living in high deprivation areas have less access to life-saving technologies, such as SAVR, and even moreso to device-intensive minimally invasive procedures such as TAVR and LC.

Transthyretin cardiac amyloidosis in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement: experience of a single center.

BACKGROUND: Even if prevalent among patients with severe aortic stenosis (AS), the clinical suspicion for transthyretin cardiac amyloidosis (ATTR-CA) remains difficult in this subset. We report our single center experience on ATTR-CA detection among TAVR candidates to provide insights on the prevalence and clinical features of dual pathology as compared to lone AS. METHODS: Consecutive severe AS patients undergoing transcatheter aortic valve replacement (TAVR) evaluation at a single center were prospectively included. Those with suspected ATTR-CA based on clinical assessment underwent 99m Tc-3,3-diphosphono-1,2-propanodicarboxylic acid (DPD) bone scintigraphy. The RAISE score, a novel screening tool with high sensitivity for ATTR-CA in AS, was retrospectively calculated to rule-out ATTR-CA in the remaining patients. Patients were categorized as follow: "ATTR-CA+": patients with confirmed ATTR-CA at DPD bone scintigraphy; "ATTR-CA-": patients with negative DPD bone scintigraphy or a negative RAISE score; "ATTR-CA indeterminate": patients not undergoing ATTR-CA assessment with a positive RAISE score. The characteristics of ATTR-CA+ and ATTR-CA- patients were compared. RESULTS: Of 107 included patients, ATTR-CA suspicion was posed in 13 patients and confirmed in six. Patients were categorized as follow: 6 (5.6%) ATTR-CA+, 79 (73.8%) ATTR-CA-, 22 (20.6%) ATTR-CA indeterminate. Excluding ATTR-CA indeterminate patients, the prevalence of ATTR-CA was 7.1% (95% CI 2.6-14.7%). As compared to ATTR-CA - patients, ATTR-CA + patients were older, had higher procedural risk and more extensive myocardial and renal damage. They had higher left ventricle mass index and lower ECG voltages, translating into a lower voltage to mass ratio. Moreover, we describe for the first time bifascicular block as an ECG feature highly specific of patients with dual pathology (50.0% vs. 2.7%, P<0.001). Of note, pericardial effusion was rarely found in patients with lone AS (16.7% vs. 1.2%, P=0.027). No difference in procedural outcomes was observed between groups. CONCLUSIONS: Among severe AS patients, ATTR-CA is prevalent and presents with phenotypic features that may aid to differentiate it from lone AS. A clinical approach based on routine search of amyloidosis features might lead to selective DPD bone scintigraphy with a satisfactory positive predictive value.

Prevalence and Clinical Outcomes of Noncardiac Surgery After Transcatheter Aortic Valve Replacement.

Aortic stenosis is a prevalent valvular heart disease, especially in the older people. They often coexist with other co-morbidities, and noncardiac surgery carries a higher risk because of the underlying valve condition. Despite the growing concern about the safety and optimal management of noncardiac surgery post-transcatheter aortic valve replacement (TAVR), there is limited evidence on this matter. This study aims to assess the clinical outcomes of noncardiac surgeries after TAVR. This retrospective study included 718 patients who underwent TAVR. Of these, 36 patients underwent noncardiac surgery after TAVR. The primary end point was the incidence of cardiovascular adverse events post-TAVR and the secondary end point was the incidence of structural valve deterioration. Composite end points included disabling stroke, heart failure requiring hospitalization, and cardiac death as defined by Valve Academic Research Consortium 3. Most of these surgeries were orthopedic and classified as intermediate risk. All noncardiac surgeries were performed without perioperative adverse events. There was no observed structural valve deterioration, and the incidence of composite end points did not significantly differ between the surgical and nonsurgical groups during the follow-up period. Noncardiac surgery after TAVR can be performed safely and does not have a negative impact on prognosis. Further studies are warranted to determine the optimal strategy for noncardiac surgery after TAVR.

Dietary Vitamin K1 Intake and Incident Aortic Valve Stenosis.

BACKGROUND: Leaflet calcification contributes to the development and progression of aortic valve stenosis. Vitamin K activates inhibitors of vascular calcification and may modulate inflammation and skeletal bone loss. Therefore, we aimed to determine whether higher dietary intakes of vitamin K1 are associated with a lower incidence of aortic stenosis. METHODS: In the Danish Diet, Cancer and Health study, participants aged 50 to 64 years completed a 192-item food frequency questionnaire at baseline, from which habitual intakes of vitamin K1 were estimated. Participants were prospectively followed using linkage to nationwide registers to determine incident aortic valve stenosis (primary outcome) and aortic stenosis with subsequent complications (aortic valve replacement, heart failure, or cardiovascular disease-related mortality; secondary outcome). RESULTS: In 55 545 participants who were followed for a maximum of 21.5 years, 1085 were diagnosed with aortic stenosis and 615 were identified as having subsequent complications. Participants in the highest quintile of vitamin K1 intake had a 23% lower risk of aortic stenosis (hazard ratio, 0.77 [95% CI, 0.63-0.94]) and a 27% lower risk of aortic stenosis with subsequent complications (hazard ratio, 0.73 [95% CI, 0.56-0.95]), compared with participants in the lowest quintile after adjusting for demographics and cardiovascular risk factors. CONCLUSIONS: In this study, a high intake of vitamin K1-rich foods was associated with a lower incidence of aortic stenosis and a lower risk of aortic stenosis with subsequent complications.

Lipoprotein(a) and calcific aortic valve disease: current evidence and future directions.

PURPOSE OF REVIEW: Calcific aortic valve disease (CAVD), the most common cause of aortic stenosis (AS), is characterized by slowly progressive fibrocalcific remodelling of the valve cusps. Once symptomatic, severe AS is associated with poor survival unless surgical or transcatheter valve replacement is performed. Unfortunately, no pharmacological interventions have been demonstrated to alter the natural history of CAVD. Lipoprotein(a) [Lp(a)], a low-density lipoprotein-like particle, has been implicated in the pathophysiology of CAVD. RECENT FINDINGS: The mechanisms by which Lp(a) results in CAVD are not well understood. However, the oxidized phospholipids carried by Lp(a) are considered a crucial mediator of the disease process. An increasing number of studies demonstrate a causal association between plasma Lp(a) levels and frequency of AS and need for aortic valve replacement, which is independent of inflammation, as measured by plasma C-reactive protein levels. However, not all studies show an association between Lp(a) and increased progression of calcification in individuals with established CAVD. SUMMARY: Epidemiologic, genetic, and Mendelian randomization studies have collectively suggested that Lp(a) is a causal risk factor for CAVD. Whether Lp(a)-lowering can prevent initiation or slow progression of CAVD remains to be demonstrated.

Ethnicity Is Associated With Differing Presentation and Outcomes of Patients Undergoing Aortic Valve Replacement for Calcific Aortic Stenosis in Aotearoa New Zealand.

AIM: Surgical aortic valve replacement (SAVR) has been the gold standard for treatment of severe symptomatic aortic stenosis (AS) for decades. We examined whether ethnic differences exist in the presentation and outcomes of patients undergoing aortic valve replacement (AVR) for AS in New Zealand. METHODS: Patients of New Zealand European, Maori, and Pacific Island ethnicities undergoing SAVR with or without other procedures in New Zealand public hospitals from 2017 to 2019 were included. Major postoperative outcomes were compared between ethnic groups, with 30-day mortality being the primary outcome. RESULTS: A total of 1,175 patients were included: 1,085 European, 50 Maori, and 40 Pacific. The mean age was 71.1±9.4 years, and men accounted for more than half of all patients (69.9%). Maori (64.7±9.4 years) and Pacific (65.4±10.1 years) patients were younger when undergoing SAVR compared with European patients (71.7±9.2; analysis of variance p<0.001). Maori and Pacific patients had a higher prevalence of diabetes, poorer renal function, and worse left ventricular function; 30-day mortality was higher in Maori and Pacific compared with European patients (6% and 10% vs 2.4%, respectively; Fisher's exact test p=0.011), with odds ratio of 3.06 (95% confidence interval [CI] 0.88-10.66) for Maori patients after adjustment for EuroSCORE II and odds ratio of 5.23 (95% CI 1.79-16.07) for Pacific patients. CONCLUSIONS: There are significant differences in presentation and outcomes of patients undergoing AVR in New Zealand. Maori and Pacific patients undergo SAVR at a younger age, have more preoperative comorbidities, and have higher rates of 30-day mortality than European patients.

Volume-outcome relationship in balloon aortic valvuloplasty: results of a consecutive, patient-level data analysis from a Japanese nationwide multicentre registry (J-SHD).

OBJECTIVE: Transcatheter balloon aortic valvuloplasty (BAV) remains an important alternative treatment for severe, symptomatic aortic stenosis. With increasing numbers of BAVs being performed, the need for large-scale volume-outcome relationship assessments has become evident. Here, we aimed to explain such relationships by analysing consecutive, patient-level BAV data recorded in a prospective Japanese nationwide multicentre registry. DESIGN: Prospective study. SETTING: Data of 1920 BAVs performed in 200 Japanese hospitals from January 2015 to December 2019. PARTICIPANTS: The mean patient age was 85 years, and 36.9% of procedures involved male patients. METHODS: The efficacy of BAV was assessed by reducing the mean transaortic valve gradient after the procedure. We also assessed in-hospital complication rates, including in-hospital death, bleeding, urgent surgery, distal embolism, vessel rupture and contrast-induced nephropathy. Based on the distribution of case volume (median 20, IQR 10-46), we divided the patients into high-volume (≥20) and low-volume (<20) groups. In-hospital complication risk was assessed with adjustment by logistic regression modelling. RESULTS: Indications for BAV included palliative/destination (44.2%), bridge to transcatheter aortic valve replacement (34.5%), bridge to surgical aortic valve replacement (7.4%) and salvage (9.7%). Reduction of the mean transaortic valve gradient was similar between the high-volume and low-volume groups (20 mm Hg vs 20 mm Hg, p=0.12). The proportion of in-hospital complications during BAV was 4.2%, and the incidence of complications showed no difference between the high-volume and low-volume groups (4.2% vs 4.1%, p=1.00). Rather than hospital volume, salvage procedure was an independent predictor of in-hospital complications (OR, 4.04; 95% CI, 2.03 to 8.06; p<0.001). CONCLUSION: The current study demonstrated that procedural outcomes of BAV were largely independent of its institutional volume.

Surgical vs. transcatheter aortic valve replacement in patients over 75 years with aortic stenosis: sociodemographic profile, clinical characteristics, quality of life and functionality.

Background: Aortic valve stenosis (AVS) affects 25% of the population over 65 years. At present, there is no curative medical treatment for AVS and therefore the surgical approach, consisting of transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR), is the treatment of choice. Methodology: The aim of this study was to analyze the sociodemographic and clinical characteristics, quality of life and functionality of a sample of patients with AVS over 75 years of age, who underwent TAVR or SAVR, applying standard clinical practice. A prospective multicenter observational study was conducted in two hospitals of the Spanish National Health System. Data were collected at baseline, 1, 6 months and 1 year. Results: In total, 227 participants were included, with a mean age of 80.6 [SD 4.1]. Statistically significant differences were found in terms of quality of life, which was higher at 1 year in patients who underwent SAVR. In terms of functionality, SAVR patients obtained a better score (p < 0.01). However, patients who underwent TAVR began with a worse baseline situation and managed to increase their quality of life and functionality after 1 year of follow-up. Conclusion: The individualized choice of TAVR or SAVR in patients with AVS improves patients' quality of life and function. Moreover, the TAVR procedure in patients with a worse baseline situation and a high surgical risk achieved a similar increase in quality of life and functionality compared to patients undergoing SAVR with a better baseline situation.

A Systematic Review and Meta-Analysis of Prevalence, Characteristics, and Impact of Mitral Annular Calcification on Outcomes After Transcatheter Aortic Valve Implantation.

There is a paucity of data on the prognostic impact of mitral annular calcification (MAC) in patients who underwent transcatheter aortic valve implantation (TAVI) with conflicting results being reported by the studies that are published. Therefore, we performed a meta-analysis to assess the short-term and long-term outcomes of MAC in patients after TAVI. Of 25,407 studies identified after the initial database search, 4 observational studies comprising 2,620 patients (2,030 patients in the nonsevere MAC arm and 590 patients in the severe MAC arm) were included in the final analysis. Compared with patients with nonsevere MAC, the severe MAC group was associated with significantly higher incidences of overall bleeding (0.75 [0.57 to 0.98], p = 0.03, I2 = 0%) at 30 days. However, no significant difference was observed between the 2 groups for the rest of the 30-day outcomes: all-cause mortality (0.79 [0.42 to 1.48], p = 0.46, I2 = 9%), myocardial infarction (1.62 [0.37 to 7.04], p = 0.52, I2 = 0%), cerebrovascular accident or stroke (1.22 [0.53 to 2.83], p = 0.64, I2 = 0%), acute kidney injury (1.48 [0.64 to 3.42], p = 0.35, I2 = 0%), and pacemaker implantation (0.70 [0.39 to 1.25], p = 0.23, I2 = 68%). Similarly, follow-up outcomes also showed no significant difference between the 2 groups: all-cause mortality (0.69 [0.46 to 1.03], p = 0.07, I2 = 44%), cardiovascular mortality (0.52 [0.24 to 1.13], p = 0.10, I2 = 70%) and stroke (0.83 [0.41 to 1.69], p = 0.61, I2 = 22%). The sensitivity analysis, however, demonstrated significant results for all-cause mortality (0.57 [0.39 to 0.84], p = 0.005, I2 = 7%) by removing the study by Okuno et al5 and cardiovascular mortality (0.41 [0.21 to 0.82], p = 0.01, I2 = 66%) by removing the study by Lak et al.7 In conclusion, our meta-analysis corroborates the notion that isolated MAC is not an independent predictor of long-term mortality after TAVI and determines severe MAC to be a predictor of mortality at follow-up because of the higher incidence of mitral valve dysfunction associated with it.

Cardiorespiratory Fitness and Risk of Aortic Stenosis (from a Prospective Cohort Analysis).

Cardiorespiratory fitness (CRF) is a major risk factor and predictor of atherosclerotic cardiovascular disease. However, the relationship between CRF and risk of aortic stenosis (AS) has not been previously investigated. Thus, we aimed to assess the prospective association between CRF and risk of AS. CRF, as measured by maximal oxygen uptake, was assessed using a respiratory gas exchange analyzer during cardiopulmonary exercise testing in 2,308 men aged 42 to 61 years recruited into the Kuopio Ischemic Heart Disease prospective cohort study. Hazard ratios (HRs) with 95% confidence intervals (CIs) were estimated for AS. During a median follow-up of 27 years, 101 cases of AS occurred. Dose-response analysis suggested there might be a nonlinear relation between CRF levels and AS risk. In an analysis adjusted for age, body mass index, systolic blood pressure, total cholesterol, high-density lipoprotein cholesterol, smoking, history of type 2 diabetes mellitus, and coronary heart disease, the HRs 95% (CIs) of AS were 0.57 (0.34 to 0.96) and 0.91 (0.53 to 1.57) for participants in the middle and upper third of CRF levels, respectively, compared with participants in the bottom third. After further adjustment for alcohol consumption, the corresponding HRs (95% CIs) were 0.58 (0.34 to 0.97) and 0.91 (0.53 to 1.56), respectively. In conclusion, higher CRF levels may be associated with a lower incidence of AS in middle-aged and older Finnish men. Given the likely limitations of low statistical power, further research is needed to provide insights into the dose-response nature of any relationship between CRF and AS.

Racial and ethnic disparities in diagnosis, management and outcomes of aortic stenosis in the Medicare population.

IMPORTANCE: Aortic stenosis (AS) is one of the most common heart valve conditions and its incidence and prevalence increases with age. With the introduction of transcatheter aortic valve replacement (TAVR), racial and ethnic disparities in AS diagnosis, treatment and outcomes is poorly understood. OBJECTIVE: In this study we assessed racial and ethnic disparities in AS diagnosis, treatment, and outcomes among Medicare beneficiaries. DESIGN: We conducted a population-based cohort study of inpatient, outpatient, and professional claims from a 20% sample of Medicare beneficiaries. MAIN OUTCOMES AND MEASURES: Incidence and Prevalence was determined among Medicare Beneficiaries. Outcomes in this study included management; the number of (non)-interventional cardiology and cardiothoracic surgery evaluation and management (E&M) visits, and number of transthoracic echocardiograms (TTE) performed. Treatment, which was defined as Surgical Aortic Valve Replacement and Transthoracic Aortic Valve Replacement. And outcomes described as All-cause Hospitalizations, Heart Failure Hospitalization and 1-year mortality. RESULTS: A total of 1,513,455 Medicare beneficiaries were diagnosed with AS (91.3% White, 4.5% Black, 1.1% Hispanic, 3.1% Asian and North American Native) between 2010 and 2018. Annual prevalence of AS diagnosis was lower for racial and ethnic minorities compared with White patients, with adjusted rate ratios of 0.66 (95% CI 0.65 to 0.68) for Black patients, 0.67 (95% CI 0.64 to 0.70) for Hispanic patients and 0.75 (95% CI 0.73 to 0.77) for Asian and North American Native patients as recent as 2018. After adjusting for age, sex and comorbidities, cardiothoracic surgery E&M visits and treatment rates were significantly lower for Black, Hispanic and Asian and North American Native patients compared with White patients. All-cause hospitalization rate was higher for Black and Hispanic patients compared with White patient. 1-year mortality was higher for Black patients, while Hispanic and Asian and North American Native patients had lower 1-year mortality compared with White patients. CONCLUSIONS AND RELEVANCE: We demonstrated significant racial and ethnic disparities in the diagnosis, management and outcomes of AS. The factors driving the persistence of these disparities in AS care need to be elucidated to develop an equitable health care system.

Aortic Valve Calcium in Relation to Subclinical Cardiac Dysfunction and Risk of Heart Failure.

BACKGROUND: The link between (mild) aortic valve calcium (AVC) with subclinical cardiac dysfunction and with risk of heart failure (HF) remains unclear. This research aims to determine the association of computed tomography-assessed AVC with echocardiographic measurements of cardiac dysfunction, and with HF in the general population. METHODS: We included 2348 participants of the Rotterdam Study cohort (mean age 68.5 years, 52% women), who had AVC measurement between 2003 and 2006, and without history of HF at baseline. Linear regression models were used to explore relationship between AVC and echocardiographic measures at baseline. Participants were followed until December 2016. Fine and Gray subdistribution hazard models were used to assess the association of AVC with incident HF, accounting for death as a competing risk. RESULTS: The presence of AVC or greater AVC were associated with larger mean left ventricular mass and larger mean left atrial size. In particular, AVC ≥800 showed a strong association (body surface area indexed left ventricular mass, ß coefficient: 22.01; left atrium diameter, ß coefficient: 0.17). During a median of 9.8 years follow-up, 182 incident HF cases were identified. After accounting for death events and adjusting for cardiovascular risk factors, one-unit larger log (AVC+1) was associated with a 10% increase in the subdistribution hazard of HF (subdistribution hazard ratio, 1.10 [95% CI, 1.03-1.18]), but the presence of AVC was not significantly associated with HF risk in fully adjusted models. Compared with the AVC=0, AVC between 300 and 799 (subdistribution hazard ratio, 2.36 [95% CI, 1.32-4.19]) and AVC ≥800 (subdistribution hazard ratio, 2.54 [95% CI, 1.31-4.90]) were associated with a high risk of HF. CONCLUSIONS: Presence and high levels of AVC were associated with markers of left ventricular structure, independent of traditional cardiovascular risk factors. Larger computed tomography-assessed AVC is an indicative of increased risk for the development of HF.

LGE prevalence and patterns in severe aortic stenosis: When "junctional" means the same.

BACKGROUND: Left ventricular (LV) remodeling in severe aortic valve stenosis (AS) is a complex process that goes beyond hypertrophic response. Reparative/replacement fibrosis is considered irreversible and has recognized value in both risk stratification and prognosis. Currently, cardiac magnetic resonance (CMR) is the gold-standard imaging technique for fibrosis identification through late gadolinium enhancement (LGE) assessment. However, its prevalence and distribution are quite variable among series. Our goal was to assess LGE prevalence and patterns in severe AS. METHODOLOGY: Single-center prospective cohort of 140 patients with severe symptomatic high-gradient AS (mean age 72 ± 8 years; mean valvular transaortic gradient 61 ± 18 mmHg; mean LV ejection fraction by echocardiogram 58 ± 9%) undergoing surgical aortic valve replacement. Those with previous myocardial infarction and/or non-ischemic cardiomyopathy were excluded. All patients performed 1.5 T LGE-CMR prior to surgery. RESULTS: Overall, 103 patients (74%) had non-ischemic LGE (median LGE mass 2.8 g [IQR 0.0-7.8] g), many of them with combined mid-wall and junctional enhancement pattern (36%). LGE was most frequently observed in the mid-basal segments of the interventricular septum. Seventy-four patients (53%) had non-exclusively junctional LGE. Contrary to those with junctional enhancement, patients with non-exclusively junctional LGE had higher LV volumes/mass, worse LV ejection fraction and worse global longitudinal strain. CONCLUSION: Among patients with severe, symptomatic, high-gradient AS, LGE is frequent, primarily affecting the mid-basal interventricular septum. Contrary to junctional LGE, the presence of non-junctional LGE seems to correlate with adverse markers of LV remodeling.

The Associations of Aortic Valve Sclerosis, Aortic Annular Increased Reflectivity, and Mitral Annular Calcification with Subsequent Aortic Stenosis in Older Individuals: Findings from the Cardiovascular Health Study.

BACKGROUND: Although aortic valve sclerosis (AVS) is well described as preceding aortic stenosis (AS), the associations of AS with antecedent mitral annular calcification (MAC) and aortic annular increased reflectivity (AAIR) have not been characterized. In a population-based prospective study, the authors evaluated whether MAC, AAIR, and AVS are associated with the risk for incident AS. METHODS: Among participants of the Cardiovascular Health Study free of AS at the 1994-1995 visit, the presence of MAC, AAIR, AVS, and the combination of all three was evaluated in 3,041 participants. Cox proportional-hazards regression was used to assess the association between the presence of calcification and the incidence of moderate or severe AS in three nested models adjusting for factors associated with atherosclerosis and inflammation both relevant to the pathogenesis of AS. RESULTS: Over a median follow-up period of 11.5 years (interquartile range, 6.7-17.0 years), 110 cases of incident moderate or severe AS were ascertained. Strong positive associations with incident moderate or severe AS were found for all calcification sites after adjustment for the main model covariates: AAIR (hazard ratio [HR], 2.90; 95% CI, 1.95-4.32; P < .0005), AVS (HR, 2.20; 95% CI, 1.44-3.37; P < .0005), MAC (HR, 1.67; 95% CI, 1.14-2.45; P = .008), and the combination of all three (HR, 2.50; 95% CI, 1.65-3.78; P < .0005). In a secondary analysis, the risk for AS increased with the number of sites at which calcification was present. CONCLUSIONS: In a large cohort of community-dwelling elderly individuals, there were strong associations between each of AAIR, AVS, MAC, and the combination of the three and incident moderate or severe AS. The novel finding that AAIR had a particularly strong association with incident AS, even after adjusting for other calcification sites, suggests its value in identifying individuals at risk for AS and potential inclusion in routine assessment by transthoracic echocardiography.