Immediate Outcomes of Aortic Valve Neocuspidization with Glutaraldehyde-treated Autologous Pericardium: a Multicenter Study.

OBJECTIVE: To determine the feasibility of aortic valve neocuspidization (AVNeo) with glutaraldehyde-treated autologous pericardium. METHODS: One hundred and seventy (170) AVNeo (84 males/86 females) were performed from January 2017 through March 2019 in three centers. All the records were prospectively collected and retrospectively reviewed. RESULTS: Most of the patients were older than 60 years and over 95% were operated for aortic stenosis. Preoperatively, pressure gradients were 69.9±21.3 mmHg for patients with aortic stenosis, and the surgical annular diameter was 21.0±2.0 mm for all patients. Effective orifice area (EOA) and indexed EOA (iEOA) averaged 0.7±0.3 cm2 and 0.4±0.2 cm2/m2 for patients with aortic stenosis before surgery, respectively. There was no conversion to prosthetic aortic valve replacement. Eight patients needed reoperation for bleeding, but no patient needed reoperation due to early infective endocarditis. There were five in-hospital deaths due to noncardiac cause. Compared to preoperative echocardiographic measurements, postoperative peak pressure gradient decreased significantly (-58.7±1.7 mmHg; P<0.001) and reached 11.2±5.6 mmHg, and mean pressure gradient also decreased significantly (-36.8±1.1 mmHg; P<0.001) and reached 6.0±3.5 mmHg. Accordingly, EOA and iEOA increased significantly 2.0 cm2 and 1.0 cm2/m2 (both P<0.001) to reach 2.7±0.6 cm2 and 1.4±0.3 cm2/m2 after surgery, respectively, with minimal significant aortic regurgitation (0.6% > mild). CONCLUSION: AVNeo is feasible and reproducible with good clinical results. Hemodynamically, AVNeo produces immediate postoperative low-pressure gradients, large EOA, and minimal regurgitation of the aortic valve. Further studies are necessary to evaluate mid- and long-term evolution.

Immediate outcomes of aortic valve neocuspidization with glutaraldehyde-treated autologous pericardium: a multicenter study

Abstract Objective: To determine the feasibility of aortic valve neocuspidization (AVNeo) with glutaraldehyde-treated autologous pericardium. Methods: One hundred and seventy (170) AVNeo (84 males/86 females) were performed from January 2017 through March 2019 in three centers. All the records were prospectively collected and retrospectively reviewed. Results: Most of the patients were older than 60 years and over 95% were operated for aortic stenosis. Preoperatively, pressure gradients were 69.9±21.3 mmHg for patients with aortic stenosis, and the surgical annular diameter was 21.0±2.0 mm for all patients. Effective orifice area (EOA) and indexed EOA (iEOA) averaged 0.7±0.3 cm2 and 0.4±0.2 cm2/m2 for patients with aortic stenosis before surgery, respectively. There was no conversion to prosthetic aortic valve replacement. Eight patients needed reoperation for bleeding, but no patient needed reoperation due to early infective endocarditis. There were five in-hospital deaths due to noncardiac cause. Compared to preoperative echocardiographic measurements, postoperative peak pressure gradient decreased significantly (-58.7±1.7 mmHg; P<0.001) and reached 11.2±5.6 mmHg, and mean pressure gradient also decreased significantly (-36.8±1.1 mmHg; P<0.001) and reached 6.0±3.5 mmHg. Accordingly, EOA and iEOA increased significantly 2.0 cm2 and 1.0 cm2/m2 (both P<0.001) to reach 2.7±0.6 cm2 and 1.4±0.3 cm2/m2 after surgery, respectively, with minimal significant aortic regurgitation (0.6% > mild). Conclusion: AVNeo is feasible and reproducible with good clinical results. Hemodynamically, AVNeo produces immediate postoperative low-pressure gradients, large EOA, and minimal regurgitation of the aortic valve. Further studies are necessary to evaluate mid- and long-term evolution.

Calcific Aortic Valve Stenosis and Atherosclerotic Calcification.

PURPOSE OF REVIEW: This review summarizes the pathophysiology of calcific aortic valve stenosis (CAVS) and surveys relevant clinical data and basic research that explain how CAVS arises. RECENT FINDINGS: Lipoprotein(a) [Lp(a)], lipoprotein-associated phospholipase A2 (Lp-PLA2), oxidized phospholipids (OxPL), autotaxin, and genetic driving forces such as mutations in LPA gene and NOTCH gene seem to play a major role in the development of CAVS. These factors might well become targets of medical therapy in the coming years. CVAS seems to be a multifactorial disease that has much in common with coronary artery disease, mainly regarding lipidic accumulation and calcium deposition. No clinical trials conducted to date have managed to answer the key question of whether Lp(a) lowering and anti-calcific therapies confer a benefit in terms of reducing incidence or progression of CAVS, although additional outcome trials are ongoing.

Determinants of Aortic Prosthesis Mismatch in a Brazilian Public Health System Hospital: Big Patients or Small Prosthesis? / Determinantes da Desproporção de Prótese Aórtica em Hospital de Atendimento de Saúde Pública Brasileiro: Pacientes Grandes ou Próteses Pequenas?

Abstract Background: Prosthesis-patient mismatch (PPM) is associated with worse outcomes. Objective: Determine the frequency and evaluate preoperatory variables independently associated with severe PPM in a tertiary hospital focused on Public Health Care. Methods: A total of 316 patients submitted to aortic valve replacement, who had echocardiography performed within the first 30 days after surgery, were retrospectively analyzed. The indexed effective orifice area (iEOA) of the prosthesis was used to classify the patients into three groups, according to PPM, considering body mass index (BMI): severe PPM (iEOA) < 0.65 cm2/m2), mild to moderate PPM (iEOA, 0.65 cm2/m2 - 0.85 cm2/m2) and without PPM (iEOA > 0.85 cm2/m2) for a BMI < 30 kg/m2 and severe PPM (iEOA) < 0.55 cm2/m2), mild to moderate (iEOA, 0.55 cm2/m2- 0.70 cm2/m2) and without PPM (iEOA > 0.7 cm2/m2) for a BMI > 30 kg/m2. Statistical significance was considered when p < 0.05. Results: iEOA was obtained in 176 patients. The frequency of severe and moderate PPM was 33.4% and 36.2%, respectively. Severe PPM patients were younger and had larger BMI, but smaller left ventricular outflow tract diameter (LVOTD). The independent variables used to predict severe PPM were male gender, BMI > 25 kg/m2, age < 60 years, LVOTD < 21 mm, and rheumatic etiology with an area under the ROC curve of 0.82. Conclusion: The frequency of severe PPM is high in a Brazilian population representative of the Public Health System, and it is possible to predict PPM from preoperative variables such as rheumatic valvular disease, gender, BMI, age and LVOTD.

Resumo Fundamento: A desproporção entre o tamanho da prótese aórtica-paciente (DPP) está associada a maior mortalidade. Objetivo: Determinar a frequência e avaliar variáveis ​​pré-operatórias associadas à DPP acentuada no cenário da saúde pública em hospital terciário. Métodos: 316 pacientes submetidos à troca valvar aórtica (TVA), com ecocardiograma realizado nos primeiros 30 dias após cirurgia, foram analisados retrospectivamente. A área de orifício efetivo indexado (AOEi) da prótese foi utilizada para classificar os pacientes em três grupos de acordo com a DPP, considerando o índice de massa corporal (IMC): DPP acentuada (AOEi) < 0,65 cm2/m2, DPP discreta a moderada (AOEi, 0,65 cm2/m2 - 0,85 cm2/m2) e sem DPP (iEOA > 0,85 cm2/m2) para IMC < 30 kg/m2 e DPP acentuada (AOEi) < 0,55 cm2/m2), discreta a moderada (AOEi, 0,55 cm2/m2 - 0,70 cm2/m2) e sem DPP (AOEi > 0,7 cm2/m2) para IMC > 30 kg/m2. Significância estatística foi considerada com p < 0,05. Resultados: A AOEi foi obtida em 176 pacientes. A frequência de DPP acentuada foi de 33,4% e moderada de 36,2%. Pacientes com DPP acentuada foram mais jovens e com maior IMC, mas menor diâmetro da via de saída do ventrículo esquerdo (DVSVE). As variáveis independentes que podem predizer DPP acentuada são: gênero masculino, IMC > 25 kg/m2, idade < 60 anos, DVSVE < 21 mm e etiologia reumática com área sob a curva ROC de 0,82. Conclusão: A frequência de DPP acentuada é alta em uma população brasileira submetida à TVA no Sistema Público de Saúde. Os principais determinantes de DPP acentuada são: valvopatia reumática, gênero masculino, IMC alto, idade < 60 anos e menor DVSVE.

Determinants of Aortic Prosthesis Mismatch in a Brazilian Public Health System Hospital: Big Patients or Small Prosthesis?

BACKGROUND: Prosthesis-patient mismatch (PPM) is associated with worse outcomes. OBJECTIVE: Determine the frequency and evaluate preoperatory variables independently associated with severe PPM in a tertiary hospital focused on Public Health Care. METHODS: A total of 316 patients submitted to aortic valve replacement, who had echocardiography performed within the first 30 days after surgery, were retrospectively analyzed. The indexed effective orifice area (iEOA) of the prosthesis was used to classify the patients into three groups, according to PPM, considering body mass index (BMI): severe PPM (iEOA) < 0.65 cm2/m2), mild to moderate PPM (iEOA, 0.65 cm2/m2 - 0.85 cm2/m2) and without PPM (iEOA > 0.85 cm2/m2) for a BMI < 30 kg/m2 and severe PPM (iEOA) < 0.55 cm2/m2), mild to moderate (iEOA, 0.55 cm2/m2- 0.70 cm2/m2) and without PPM (iEOA > 0.7 cm2/m2) for a BMI > 30 kg/m2. Statistical significance was considered when p < 0.05. RESULTS: iEOA was obtained in 176 patients. The frequency of severe and moderate PPM was 33.4% and 36.2%, respectively. Severe PPM patients were younger and had larger BMI, but smaller left ventricular outflow tract diameter (LVOTD). The independent variables used to predict severe PPM were male gender, BMI > 25 kg/m2, age < 60 years, LVOTD < 21 mm, and rheumatic etiology with an area under the ROC curve of 0.82. CONCLUSION: The frequency of severe PPM is high in a Brazilian population representative of the Public Health System, and it is possible to predict PPM from preoperative variables such as rheumatic valvular disease, gender, BMI, age and LVOTD.

Prosthesis-patient mismatch negatively affects outcomes after mitral valve replacement: meta-analysis of 10, 239 patients

Abstract Objective: This study sought to evaluate the impact of prosthesis-patient mismatch on the risk of perioperative and long-term mortality after mitral valve replacement. Methods: Databases were researched for studies published until December 2018. Main outcomes of interest were perioperative and 10-year mortality and echocardiographic parameters. Results: The research yielded 2,985 studies for inclusion. Of these, 16 articles were analyzed, and their data extracted. The total number of patients included was 10,239, who underwent mitral valve replacement. The incidence of prosthesis-patient mismatch after mitral valve replacement was 53.7% (5,499 with prosthesis-patient mismatch and 4,740 without prosthesis-patient mismatch). Perioperative (OR 1.519; 95%CI 1.194-1.931, P<0.001) and 10-year (OR 1.515; 95%CI 1.280-1.795, P<0.001) mortality was increased in patients with prosthesis-patient mismatch. Patients with prosthesis-patient mismatch after mitral valve replacement had higher systolic pulmonary artery pressure and transprosthethic gradient and lower indexed effective orifice area and left ventricle ejection fraction. Conclusion: Prosthesis-patient mismatch increases perioperative and long-term mortality. Prosthesis-patient mismatch is also associated with pulmonary hypertension and depressed left ventricle systolic function. The findings of this study support the implementation of surgical strategies to prevent prosthesis-patient mismatch in order to decrease mortality rates.

Prosthesis-Patient Mismatch Negatively Affects Outcomes after Mitral Valve Replacement: Meta-Analysis of 10,239 Patients.

OBJECTIVE: This study sought to evaluate the impact of prosthesis-patient mismatch on the risk of perioperative and long-term mortality after mitral valve replacement. METHODS: Databases were researched for studies published until December 2018. Main outcomes of interest were perioperative and 10-year mortality and echocardiographic parameters. RESULTS: The research yielded 2,985 studies for inclusion. Of these, 16 articles were analyzed, and their data extracted. The total number of patients included was 10,239, who underwent mitral valve replacement. The incidence of prosthesis-patient mismatch after mitral valve replacement was 53.7% (5,499 with prosthesis-patient mismatch and 4,740 without prosthesis-patient mismatch). Perioperative (OR 1.519; 95%CI 1.194-1.931, P<0.001) and 10-year (OR 1.515; 95%CI 1.280-1.795, P<0.001) mortality was increased in patients with prosthesis-patient mismatch. Patients with prosthesis-patient mismatch after mitral valve replacement had higher systolic pulmonary artery pressure and transprosthethic gradient and lower indexed effective orifice area and left ventricle ejection fraction. CONCLUSION: Prosthesis-patient mismatch increases perioperative and long-term mortality. Prosthesis-patient mismatch is also associated with pulmonary hypertension and depressed left ventricle systolic function. The findings of this study support the implementation of surgical strategies to prevent prosthesis-patient mismatch in order to decrease mortality rates.

Impact of surgical aortic root enlargement on the outcomes of aortic valve replacement: a meta-analysis of 13 174 patients.

OBJECTIVES: This study sought to evaluate the impact of surgical aortic root enlargement (ARE) on the perioperative outcomes of aortic valve replacement (AVR). METHODS: Databases were searched for studies published until April 2018 to carry out a systematic review followed by meta-analysis of results. RESULTS: The search yielded 1468 studies for inclusion. Of these, 10 articles were analysed and their data extracted. A total of 13 174 patients (AVR with ARE: 2819 patients; AVR without ARE: 10 355 patients) were included from studies published from 2002 to 2018. The total rate of ARE was 21.4%, varying in the studies from 5.7% to 26.3%. The overall odds ratio (OR) [95% confidence interval (CI)] for perioperative mortality showed a statistically significant difference between the groups (among 10 studies), with a higher risk in the 'AVR with ARE' group (OR 1.506, 95% CI 1.209-1.875; P < 0.001), but not when adjusted for isolated AVR + ARE without any concomitant procedures such as mitral valve surgery, coronary artery bypass surgery, etc. (OR 1.625, 95% CI 0.968-2.726; P = 0.066-among 6 studies). The 'AVR with ARE' group showed an overall lower risk of significant patient-prosthesis mismatch among 9 studies (OR 0.472, 95% CI 0.295-0.756; P = 0.002) and a higher overall difference in means of indexed effective orifice area among 10 studies (random-effect model: 0.06 cm2/m2, 95% CI 0.029-0.103; P < 0.001). CONCLUSIONS: Surgical ARE seems to be associated with increased perioperative mortality but with lower risk of patient-prosthesis mismatch.

Surgical aortic valve replacement and patient-prosthesis mismatch: a meta-analysis of 108 182 patients.

OBJECTIVES: This study sought to evaluate the impact of patient-prosthesis mismatch (PPM) on the risk of perioperative, early-, mid- and long-term mortality rates after surgical aortic valve replacement. METHODS: Databases were searched for studies published until March 2018. The main outcomes of interest were perioperative mortality, 1-year mortality, 5-year mortality and 10-year mortality. RESULTS: The search yielded 3761 studies for inclusion. Of these, 70 articles were analysed, and their data were extracted. The total number of patients included was 108 182 who underwent surgical aortic valve replacement. The incidence of PPM after surgical aortic valve replacement was 53.7% (58 116 with PPM and 50 066 without PPM). Perioperative mortality [odds ratio (OR) 1.491, 95% confidence interval (CI) 1.302-1.707; P < 0.001], 1-year mortality (OR 1.465, 95% CI 1.277-1.681; P < 0.001), 5-year mortality (OR 1.358, 95% CI 1.218-1.515; P < 0.001) and 10-year mortality (OR 1.534, 95% CI 1.290-1.825; P < 0.001) were increased in patients with PPM. Both severe PPM and moderate PPM were associated with increased risk of perioperative mortality, 1-year mortality, 5-year mortality and 10-year mortality when analysed together and separately, although we observed a higher risk in the group with severe PPM. CONCLUSIONS: Moderate/severe PPM increases perioperative, early-, mid- and long-term mortality rates proportionally to its severity. The findings of this study support the implementation of surgical strategies to prevent PPM in order to decrease mortality rates.

Recomendações para Avaliação por Imagens das Próteses Valvares Cardíacas / Recommendations for the Imaging Assessment of Prosthetic Heart Valves

Disfunção de prótese valvar cardíaca (PVC) é rara, porém é uma potencial ameaça à vida. Estabelecer o exato mecanismo da disfunção da PVC é desafiador, no entanto é essencial para determinar a estratégia terapêutica apropriada. Na prática clinica, uma abordagem abrangente que integra vários parâmetros de morfologia e função avaliados pelo eco transtorácico 2D/3D e transesofágico são fundamentais para detectar e quantificar a disfunção da PVC. A cinefluoroscopia, a tomografia computadorizada com multidectetores, a ressonância magnética cardíaca, e em menor escala, a imagem nuclear, são ferramentas complementares para o diagnóstico e abordagem das complicações das PVC. Este documento apresenta recomendações para o uso de imagem em multimodalidade para avaliação das PVCs

Standardized definition of structural valve degeneration for surgical and transcatheter bioprosthetic aortic valves

ABSTRACT: Bioprostheses are prone to structural valve degeneration, resulting in limited long-term durability. A significant challenge when comparing the durability of different types of bioprostheses is the lack of a standardized terminology for the definition of a degenerated valve. This issue becomes especially important when we try to compare the degeneration rate of surgically inserted and transcatheter bioprosthetic valves. This document, by the VIVID (Valve-in-Valve International Data), proposes practical and standardized definitions of valve degeneration and provides recommendations for the timing of clinical and imaging follow-up assessments accordingly. Its goal is to improve the quality of research and clinical care for patients with deteriorated bioprostheses by providing objective and strict criteria that can be utilized in future clinical trials. We hope that the adoption of these criteria by both the cardiological and surgical communities will lead to improved comparability and interpretation of durability analyses.

Recommendations for the imaging assessment of prosthetic heart valves: a report from the European Association of Cardiovascular Imaging endorsed by the Chinese Society of Echocardiography, the Inter-American Society of Echocardiography, and the Brazilian Department of Cardiovascular Imaging.

Prosthetic heart valve (PHV) dysfunction is rare but potentially life-threatening. Although often challenging, establishing the exact cause of PHV dysfunction is essential to determine the appropriate treatment strategy. In clinical practice, a comprehensive approach that integrates several parameters of valve morphology and function assessed with 2D/3D transthoracic and transoesophageal echocardiography is a key to appropriately detect and quantitate PHV dysfunction. Cinefluoroscopy, multidetector computed tomography, cardiac magnetic resonance imaging, and to a lesser extent, nuclear imaging are complementary tools for the diagnosis and management of PHV complications. The present document provides recommendations for the use of multimodality imaging in the assessment of PHVs.

Predictors and impact of myocardial injury after transcatheter aortic valve replacement: a multicenter registry.

BACKGROUND: Cardiac biomarker release signifying myocardial injury post-transcatheter aortic valve replacement (TAVR) is common, yet its clinical impact within a large TAVR cohort receiving differing types of valve and procedural approaches is unknown. OBJECTIVES: This study sought to determine the incidence, clinical impact, and factors associated with cardiac biomarker elevation post TAVR. METHODS: This multicenter study included 1,131 consecutive patients undergoing TAVR with balloon-expandable (58%) or self-expandable (42%) valves. Transfemoral and transapical (TA) approaches were selected in 73.1% and 20.3% of patients, respectively. Creatine kinase-myocardial band (CK-MB) measurements were obtained at baseline and at several time points within the initial 72 h post TAVR. Echocardiography was performed at baseline and at 6- to 12-month follow-up. RESULTS: Overall, 66% of the TAVR population demonstrated some degree of myocardial injury as determined by a rise in CK-MB levels (peak value: 1.6-fold [interquartile range (IQR): 0.9 to 2.8-fold]). A TA approach and major procedural complications were independently associated with higher peak of CK-MB levels (p < 0.01 for all), which translated into impaired systolic left ventricular function at 6 to 12 months post TAVR (p < 0.01). A greater rise in CK-MB levels independently associated with an increased 30-day, late (median of 21 [IQR: 8 to 36] months) overall and cardiovascular mortality (p < 0.001 for all). Any increase in CK-MB levels was associated with poorer clinical outcomes, and there was a stepwise rise in late mortality according to the various degrees of CK-MB increase after TAVR (p < 0.001). CONCLUSIONS: Some degree of myocardial injury was detected in two-thirds of patients post TAVR, especially in those undergoing TA-TAVR or presenting with major procedural complications. A greater rise in CK-MB levels associated with greater acute and late mortality, imparting a negative impact on left ventricular function.