Increased left ventricular remodelling index in paradoxical low-flow severe aortic stenosis with preserved left ventricular ejection fraction compared to normal-flow severe aortic stenosis.

INTRODUCTION: Patients with paradoxical low-flow (LF) severe aortic stenosis (AS) despite preserved left ventricular ejection fraction (LVEF) appear distinct from normal-flow (NF) patients, showing worse prognosis, more concentric hypertrophy and smaller left ventricular (LV) cavities. The left ventricular remodelling index (LVRI) has been demonstrated to reliably discriminate between physiologically adapted athlete's heart and pathological LV remodelling. METHODS: We studied patients with index echocardiographic diagnosis of severe AS (aortic valve area <1 cm2) with preserved LVEF (>50%). The LVRI was determined by the ratio of the LV mass to the end-diastolic volume, as previously reported, and was compared between patients with LF and NF AS. Patients were prospectively followed up for at least 3 years, and clinical outcomes were examined in association with LVRI. RESULTS: Of the 450 patients studied, 112 (24.9%) had LF AS. While there were no significant differences in baseline clinical profile between LF and NF patients, LVRI was significantly higher in the LF group. Patients with high LVRI (>1.56 g/mL) had increased all-cause mortality (log-rank 9.18, P = 0.002) and were more likely to be admitted for cardiac failure (log-rank 7.61, P = 0.006) or undergo aortic valve replacement (log-rank 18.4, P < 0.001). After adjusting for the effect of age, hypertension, aortic valve area and mean pressure gradient on multivariate Cox regression, high LVRI remained independently associated with poor clinical outcomes (hazard ratio 1.64, 95% confidence interval 1.19-2.25, P = 0.002). CONCLUSION: Pathological LV remodelling (increased LVRI) was more common in patients with LF AS, and increased LVRI independently predicts worse clinical outcomes.

Propensity-score matched analysis of patent foramen ovale closure in real-world study cohort with cryptogenic ischemic stroke.

INTRODUCTION: Patent foramen ovale (PFO) occurs in 25% of the general population and in 40% of cryptogenic ischemic stroke patients. Recent trials support PFO closure in selected patients with cryptogenic stroke. We examined the outcomes of transcatheter PFO closure in a real-world study cohort with cryptogenic stroke. METHODS: Consecutive ischemic stroke patients who were classified as cryptogenic on the TOAST aetiology and diagnosed with a PFO were included. All patients underwent either transcatheter PFO closure or medical therapy. A 2:1 propensity score matching by sex and Risk-of-Paradoxical-Embolism (RoPE) score was performed. Multivariable regression models adjusted for sex and RoPE score. RESULTS: Our cohort comprised 232 patients with mean age 44.3 years (SD 10.8) and median follow-up 1486.5 days. 33.2% were female. PFO closure (n=84) and medical therapy (n=148) groups were well-matched with <10% mean-difference in sex and RoPE score. Two patients in the treated group (2.4%) and seven in the control group (4.7%) had a recurrent ischemic stroke event. Multivariable Cox regression demonstrated a hazard-ratio of 0.26 (95%CI 0.03-2.13, P=0.21) for PFO closure compared to control. The incidence of atrial fibrillation (AF) detected post-PFO closure was similar between the treated and control (1.19% vs 1.35%, multivariable logistic regression odds-ratio 0.90, 95%CI 0.04-9.81, P=0.94). There were no major periprocedural complications documented. The difference in restricted mean survival-time free from stroke at two years between treated and control was 26.2 days (95%CI 5.52-46.85, P=0.013). CONCLUSIONS: In this Asian cohort, we report a low incidence of ischemic stroke recurrence and new-onset AF in patients who underwent PFO closure. When compared to the medical therapy group, there was no significant difference in the incidence of stroke recurrence and new-onset AF. Further studies involving larger real-world cohorts are warranted to identify patients who are more likely to benefit from PFO closure.

First use of large-bore suction thrombectomy for acute pulmonary embolism in Asia-Pacific: feasibility and short-term clinical outcomes.

Clinical outcomes for intermediate or high-risk pulmonary emboli (PE) remain sub-optimal, with limited improvements in survival for the past 15 years. Anticoagulation alone results in slow thrombus resolution, persistent right ventricular (RV) dysfunction, patients remaining at risk of haemodynamic decompensation and increased likelihood of incomplete recovery. Thrombolysis elevates risk of major bleeding and is thus reserved for high-risk PE. Thus, a huge clinical need exists for an effective technique to restore pulmonary perfusion with minimal risk and avoidance of lytic therapy. In 2021, large bore suction thrombectomy (ST) was introduced in Asia for the first time and this study assessed the feasibility and short-term outcomes of Asian patients undergoing ST for acute PE. 40 consecutive patients (58% male, mean age of 58.3 ± 16.6 years) with intermediate (87.5%) or high-risk PE (12.5%) were enrolled in this prospective registry. 20% had prior VTE, 42.5% had contraindications to thrombolysis, and 10% failed to respond to thrombolysis. PE was idiopathic in 40%, associated with active cancer in 15% and post-operative status in 12.5%. Procedural time was 124 ± 30 min. Emboli were aspirated in all patients without the need for thrombolytics, resulting in a 21.4% reduction in mean pulmonary arterial pressures and 123% increase TASPE-PASP ratio, a prognostic measure of RV-arterial coupling. (both p < 0.001) Procedural complications were 5% and 87.5% patients survived to discharge without symptomatic VTE recurrence during 184 days of mean follow-up. ST affords an effective reperfusion option for PE without thrombolytics, normalises RV overload and provides excellent short-term clinical outcomes.

Association of Shunt Size and Long-Term Clinical Outcomes in Patients with Cryptogenic Ischemic Stroke and Patent Foramen Ovale on Medical Management.

INTRODUCTION: Patent foramen ovale (PFO) is a potential source of cardiac embolism in cryptogenic ischemic stroke, but it may also be incidental. Right-to-left shunt (RLS) size may predict PFO-related stroke, but results have been controversial. In this cohort study of medically-managed PFO patients with cryptogenic stroke, we aimed to investigate the association of shunt size with recurrent stroke, mortality, newly detected atrial fibrillation (AF), and to identify predictors of recurrent stroke. METHODS: Patients with cryptogenic stroke who screened positive for a RLS using a transcranial Doppler bubble study were included. Patients who underwent PFO closure were excluded. Subjects were divided into two groups: small (Spencer Grade 1, 2, or 3; n = 135) and large (Spencer Grade 4 or 5; n = 99) shunts. The primary outcome was risk of recurrent stroke, and the secondary outcomes were all-cause mortality and newly detected AF. RESULTS: The study cohort included 234 cryptogenic stroke patients with medically-managed PFO. The mean age was 50.5 years, and 31.2% were female. The median period of follow-up was 348 (IQR 147-1096) days. The rate of recurrent ischemic stroke was higher in patients with large shunts than in those with small shunts (8.1% vs. 2.2%, p = 0.036). Multivariate analyses revealed that a large shunt was significantly associated with an increased risk of recurrent ischemic stroke [aOR 4.09 (95% CI 1.04-16.0), p = 0.043]. CONCLUSIONS: In our cohort of cryptogenic stroke patients with medically managed PFOs, those with large shunts were at a higher risk of recurrent stroke events, independently of RoPE score and left atrium diameter.

Bayesian Meta-analysis of Direct Oral Anticoagulation Versus Vitamin K Antagonists With or Without Concomitant Antiplatelet After Transcatheter Aortic Valve Implantation in Patients With Anticoagulation Indication.

Patients undergoing transcatheter aortic valve implantation (TAVI) commonly have co-morbidities requiring anticoagulation. However, the optimal post-procedural anticoagulation regimen is not well-established. This meta-analysis investigates safety and efficacy outcomes of direct oral anticoagulants (DOACs) and Vitamin K Antagonist (VKA), with or without concomitant antiplatelet therapy. We searched EMBASE and MEDLINE for appropriate studies. Subgroup analyses were performed for anticoagulant monotherapy and combined therapy with antiplatelet agents. Eleven studies (6359 patients) were included. Overall, there were no differences between DOACs and VKA for all-cause mortality (Odds Ratio [OR]: .69; Credible Interval [CrI]: .40-1.06), cardiovascular-related mortality (OR: .76; Crl: .13-3.47), bleeding (OR: .95; CrI: .75-1.17), stroke (OR: 1.04; CrI: .65-1.63), myocardial infarction (OR: 1.51; CrI: .55-3.84), and valve thrombosis (OR: .29; CrI: .01-3.54). For DOACs vs VKA monotherapy subgroup, there were no differences in outcomes. For the combined therapy subgroup, there was decreased odds of all-cause mortality in the DOACs group compared with the VKA group (OR: .13; CrI: .02-.65), but no differences for bleeding and stroke. DOACs and VKA have similar safety and efficacy profiles for post-TAVI patients with anticoagulation indication. However, if concomitant antiplatelet therapy is required, DOACs were more favorable than VKA for all-cause mortality.

The Impact of Cognitive Impairment on Clinical Outcomes After Transcatheter Aortic Valve Implantation (from a Systematic Review and Meta-Analysis).

This study sought to investigate the impact of pre-existing cognitive impairment on outcomes after transcatheter aortic valve implantation (TAVI). TAVI has been increasingly used in seniors, and evidence suggests better outcomes than surgical aortic valve replacement. Although frailty has been shown to be associated with poorer outcomes after TAVI, the effect of pre-existing cognitive impairment on patient outcomes after TAVI remains unclear. We searched the Medline, Embase, Scopus and Cochrane databases until May 14, 2022. The risk of bias was assessed using the Newcastle-Ottawa scale. The primary outcome was short-term (6 months to 1 year) mortality, and secondary outcomes included long-term (1 year to 3 years) mortality, in-hospital mortality, and postoperative delirium. A total of 14 studies with 32,746 patients (5,098 patients with cognitive impairment at baseline, 27,648 without) were included in our meta-analysis. Among studies that reported the raw proportion of patients with mortality of postoperative delirium, cognitive impairment significantly increased mortality (risk ratio 2.10, 95% confidence intervals [CIs] 1.43 to 3.08, p = 0.0002) and postoperative delirium (risk ratio 2.27, 95% CI 1.76 to 2.93, p <0.0001). Studies which reported the hazards for mortality (pooled hazards ratio 1.97, 95% CI 1.50 to 2.60, p <0.0001) and odds of postoperative delirium (pooled odds ratio 2.40, 95% CI: 1.51 to 3.80, p = 0.0002) yielded results consistent with the primary meta-analysis. In conclusion, pre-existing cognitive impairment is a significant risk factor for poorer outcomes after TAVI and should be carefully considered in this group of patients. Guidelines and future studies should take cognitive impairment into consideration for preoperative risk stratification.

Coronary Artery Disease in Patients Undergoing Transvalvular Aortic Valve Implantation.

Coronary artery disease (CAD) is common in patients with severe aortic stenosis. With the advent of transcatheter aortic valve implantation (TAVI) as a therapeutic option, management of CAD in such patients has undergone a revolution. Younger patients are now candidates for treatment, and have a greater life-time probability of requiring post-TAVI coronary access. Considerations include pre-procedural assessment and revascularisation, procedural planning to avoid coronary obstruction as well as optimisation of post-procedural coronary access. The authors review the challenges of managing CAD in TAVI patients, shed light on the evidence base, and provide guidance on how to optimise management.

A systematic review and meta-analysis of non-vitamin K antagonist oral anticoagulants vs vitamin K antagonists after transcatheter aortic valve replacement in patients with atrial fibrillation.

PURPOSE: Transcatheter aortic valve replacement (TAVR) is increasingly carried out in patients with aortic valvular conditions. Atrial fibrillation (AF) is a common comorbidity among patients undergoing TAVR. Despite this, there remains a paucity of data and established guidelines regarding anticoagulation use post-TAVR in patients with AF. METHODS: Four databases were searched from inception until 12 October 2021. A title and abstract sieve, full-text review and data extraction were conducted by independent authors, and articles including patients without AF were excluded. The Review Manager (Version 5.4) was utilised in data analysis. RESULTS: A total of 25,199 post-TAVR patients with AF were included from seven articles, with 9764 patients on non-vitamin K antagonist oral anticoagulants (NOAC) and 15,435 patients on vitamin K antagonists (VKA). In this analysis, there was a significantly lower risk of all-cause mortality at 1 year (RR: 0.75, CI: 0.58-0.97, p = 0.04, I2 = 56%), and bleeding at 1 year (RR: 0.73, CI: 0.68-0.79, p = < 0.00001, I2 = 0%), between patients on NOAC and VKA. There were no detectable differences between patients on NOAC and VKA for all-cause mortality at 2 years, stroke within 30 days, stroke within 1 year, ischaemic stroke at 1 year and life-threatening bleeding at 30 days. CONCLUSION: While the results of this analysis reveal NOAC as a potential alternate treatment modality to VKA in post-TAVR patients with AF, further research is needed to determine the full safety and efficacy profile of NOAC (PROSPERO: CRD42021283548).

Cost-effectiveness of transcatheter aortic valve implantation in patients with severe symptomatic aortic stenosis of intermediate surgical risk in Singapore.

OBJECTIVE: The objective was to assess the cost-effectiveness of transcatheter aortic valve implantation (TAVI) in patients with severe aortic stenosis with intermediate surgical risk in Singapore. METHODS: A de novo Markov model with three health states - stroke with long-term sequelae, no stroke, and death - was developed and simulated using Monte Carlo simulations with 10,000 iterations over a five-year time horizon from the Singapore healthcare system perspective. A 3% annual discount rate for costs and outcomes and monthly cycle lengths were used. By applying the longest available published clinical evidence, simulated patients received either TAVI or surgical aortic valve replacement (SAVR) and were at risk of adverse events (AEs) such as moderate-to-severe paravalvular aortic regurgitation (PAR). RESULTS: When five-year PARTNER 2A data was applied, base-case analyses showed that the incremental cost-effectiveness ratio (ICER) for TAVI compared to SAVR was US$315,760 per quality-adjusted life year (QALY) gained. The high ICER was due to high incremental implantation and procedure costs of TAVI compared to SAVR, and marginal improvement of 0.10 QALYs as simulated mortality of TAVI exceeded SAVR at 3.75 years post-implantation. One-way sensitivity analysis showed that the ICERs were most sensitive to cost of PAR, utility values of SAVR patients, and cost of TAVI and SAVR implants and procedures. When disutilities for AEs were additionally applied, the ICER decreased to US$300,070 per QALY gained. TAVI was dominated by SAVR when the time horizon increased to 20 years. Clinical outcomes projected from one-year PARTNER S3i data further reduced the ICER to US$86,337 per QALY gained for TAVI, assuming early all-cause mortality benefits from TAVI continued to persist. This assumption was undermined when longer term data showed that TAVI's early mortality benefits diminished at five years. LIMITATIONS AND CONCLUSION: TAVI is unlikely to be cost-effective in intermediate surgical-risk patients compared to SAVR in Singapore.

Prognostically Distinct Phenotypes of Metabolic Health Beyond Obesity in Aortic Stenosis.

Although current evidence is in favor of metabolic health and nonobesity in the reduction of incident cardiovascular disease, little is known regarding the prognosis across the metabolic phenotypes once cardiovascular disease occurs. This study examined the prognosis of patients with significant aortic stenosis (AS) on the basis of the presence of metabolic health and obesity. This a retrospective cohort study on consecutive patients who presented with moderate-to-severe AS to a tertiary hospital between 2010 and 2015. Patients were allocated into 4 groups on the basis of obesity and metabolic health: metabolically healthy obese (MHO), metabolically healthy nonobese (MHNO), metabolically unhealthy obese (MUO), and metabolically unhealthy nonobese (MUNO). Metabolic health was defined in accordance to the Adult Treatment Panel III criteria. The primary outcome was all-cause mortality. Cox regression examined independent associations between mortality and metabolic phenotypes, adjusting for aortic valve area, ejection fraction, age, gender, chronic kidney disease, and aortic valve replacement as a time-dependent covariate. Of 727 patients, the majority (51.6%) were MUNO, followed by MUO (32.7%), MHNO (11.4%), and MHO (4.3%). MHNO had the highest mortality (43.0%), followed by the MUNO (37.5%), MUO (30.0%), and MHO (6.9%) groups (p = 0.001). Compared with MHNO, MHO (hazard ratio 0.159, 95% confidence interval 0.038 to 0.668, p = 0.012) and MUO (hazard ratio 0.614, 95% confidence interval 0.403 to 0.937, p = 0.024) were independently associated with lower all-cause mortality rates after adjusting for confounders. In patients who are obese, metabolic health had favorable survival compared with metabolically unhealthy (p = 0.015), but this protective impact of metabolic health was not observed in patients with overweight or normal weight. Obesity had favorable survival compared with overweight and normal weight in both patients who are metabolically healthy (p = 0.002) and unhealthy (p = 0.007). In conclusion, patients who are MHO with AS have the most favorable prognosis, whereas the seemingly healthy MHNO group had the worst survival. There should be a paradigm shift toward prioritizing metabolic health rather than weight reduction in patients with significant AS.

Prevalence, Risk Factors and Intervention for Depression and Anxiety in Pulmonary Hypertension: A Systematic Review and Meta-analysis.

BACKGROUND: Current guidelines recommend psychological support for patients with pulmonary hypertension suffering from psychological adversity. However, little is known about the prevalence and risk factors of depression and anxiety in patients with pulmonary hypertension (PH). METHODS: Medline and Embase were searched from inception to 6 May 2021. Meta-analysis of proportions using the generalized linear mixed model was conducted to analyze the pooled prevalence rates of depression and anxiety in PH patients. Risk factors for depression and anxiety in PH patients were evaluated using meta regression. RESULTS: A total of 24 studies involving 2,161 PH patients were included. The pooled prevalence of depression in PH was 28.0% (95% CI: 20.5-36.8) and pooled prevalence of anxiety was 37.1% (95% CI: 28.7-46.4). There was a significantly higher prevalence of anxiety (p = 0.0013) amongst PH patients in Asia (61.1%) compared to Europe (40.3%) and North America (22.9%). In terms of risk factors, congenital heart disease-related pulmonary arterial hypertension (PAH-CHD) were significantly associated with both depression (OR: 1.68, 95% CI: 1.27-2.23, p = 0.024) and anxiety (OR: 1.63, 95% CI: 1.45-1.83, p = 0.002). On the other hand, chronic thromboembolic pulmonary hypertension (CTEPH, OR: 1.18, 95% CI: 1.10-1.26, p = 0.004) was significantly associated with depression, whereas worse pulmonary vascular resistance (ß: 0.30, 95% CI: 0.09-0.52, p = 0.005) and cardiac index (ß: -0.96, 95% CI: -1.58 to -0.35, p = 0.002) were significantly correlated with anxiety. CONCLUSION: The prevalence of anxiety and depression in PH patients is alarmingly high, with an increased prevalence of anxiety in Asia compared to Europe or North America. Psychological support is warranted for patients with PH, particularly those with underlying congenital heart disease, CTEPH, and severe disease. SYSTEMATIC REVIEW REGISTRATION: CRD42021251733.

Long-term Prognosis in Patients With Concomitant Acute Coronary Syndrome and Aortic Stenosis.

BACKGROUND: Aortic stenosis (AS) and acute coronary syndrome (ACS) share similar cardiovascular risk factors. The incidence of concomitant AS and ACS is increasing with aging population, yet studies investigating the prognosis of these patients remain scarce. METHODS: This retrospective single-centre cohort study examined consecutive patients who presented with ACS and AS from January 1, 2011, to March 31, 2021. The cohort was divided into mild, moderate, and severe AS based on the index echocardiogram. The primary outcome was all-cause mortality. RESULTS: Of 563 patients, 264 (46.9%) had mild, 193 (34.3%) moderate, and 106 (18.8%) severe AS. The mean follow-up duration was 2.5 years. All-cause mortality was higher among patients with moderate and severe AS compared with mild AS within 30 days (17.0% vs 13.0% vs 6.4%, respectively; P = 0.005) and in the long term (49.7% vs 51.4% vs 35.6%; P = 0.002). Concomitant moderate (hazard ratio [HR] 1.453, 95% confidence interval [CI] 1.020-2.068; P = 0.038) or severe AS (HR 1.873, 95% CI 1.176-2.982; P = 0.008) was an independent predictor of all-cause mortality. Kaplan-Meier curves demonstrated higher mortality in patients with moderate and severe AS compared with mild AS (P < 0.001). Similar survival trends were observed regardless of ACS type and in those with preserved left ventricular ejection fraction. Patients with reduced left ventricular ejection fraction had poor prognosis regardless of AS severity. CONCLUSIONS: ACS patients with concomitant moderate or severe AS have similar high long-term mortality, regardless of ACS type. The high early mortality in moderate and severe AS emphasises the imperative to attempt to mitigate this risk urgently.

Meta-Analysis Comparing Risk Factors, Incidence, and Outcomes of Patients With Versus Without Prosthesis-Patient Mismatch Following Transcatheter Aortic Valve Implantation.

Current guidelines on the management of patients with aortic valvular disease have widened the use of transcatheter aortic valve implantation (TAVI) with an emphasis on avoidance of prosthesis-patient mismatch (PPM). This study sought to examine the incidence, risk factors, and all-cause mortality of PPM after TAVI. Medline and Embase databases were searched from inception to August 10, 2021. Patients were compared along 2 arms: (1) any degree of PPM and those without PPM, (2) severe PPM, and nonsevere PPM. A total of 22 articles involving 115,442 patients after TAVI were included. Pooled incidence for any degree of PPM was 30.1% and 10.7% in severe PPM. Incidence was significantly higher (p <0.001) for any degree of PPM in Europe (33.1%) and North America (34.4%) compared with Asia (10.4%). Incidence of severe PPM was higher (p = 0.015) in older generation (13.6%) compared with current-generation valves (6.3%). Severe PPM increased the risk of all-cause mortality relative to nonsevere PPM (hazard ratio: 1.86, 95% confidence interval: 1.05 to 3.29, p = 0.034). Patients of younger age, increased body surface area, lower left ventricular ejection fraction, and classified New York Heart Association Class III/IV were at greater risk of both any degree and severe PPM. Smaller prosthesis size increased the risk of any degree of PPM, whereas postdilation and larger prostheses were protective factors. In conclusion, all-cause mortality was significantly affected in severe PPM compared with nonsevere cases, whereas this excess mortality was not observed between those with any degree of PPM and those without. Closer attention to patient and bioprosthetic valve factors is required to minimize the occurrence of severe PPM.

Clinical, echocardiographic and prognostic outcomes of patients with concordant and discordant high-gradient aortic stenosis in an Asian cohort.

Literature of patients with severe high-gradient aortic stenosis (HG AS) (mean pressure gradient [MPG] ≥ 40 mmHg and aortic valve area [AVA] ≥ 1.0 cm2) remains limited. This study seeks to compare the prognostic outcomes of patients with high-gradient concordant (HGCON-AS) and discordant AS (HGDIS-AS) in an Asian cohort. From 2010 to 2015, patients with moderate-to-severe AS with preserved left ventricular ejection fraction (LVEF ≥ 50%) were recruited and stratified into 3 groups based on index echocardiogram-(1) HGDIS-AS, (2) HGCON-AS and (3) moderate AS (MOD-AS). The primary study endpoints was all-cause mortality, with secondary endpoints of congestive heart failure (CHF) admissions and aortic valve replacement (AVR). Multivariable Cox regression was used and Kaplan-Meier curves were constructed to evaluate associations between HGDIS-AS, HGCON-AS and MOD-AS, and the study outcomes. A total of 467 patients were studied, comprising of 6.2% HGDIS-AS, 13.9% HGCON-AS and 79.9% MOD-AS patients. There was significantly higher AVR rates in the HGCON-AS group (58.5%), followed by HGDIS-AS (31.0%) and MOD-AS (4.6%), p < 0.001) groups. After adjusting for confounders, HGCON-AS was significantly associated with all-cause mortality (HR 3.082, 95% CI 1.479-6.420, p = 0.003) and CHF admissions (HR 12.728, 95% CI 2.922-55.440 p = 0.001) but not HGDIS-AS, with MOD-AS as the reference group. Both HGDIS-AS (HR 7.715, 95% CI 2.927-20.338; p < 0.001) and HGCON-AS (HR 21.960, 95% CI 10.833-44.515, p < 0.001) were independent predictors of AVR. After exclusion of reversible high-flow states, HGDIS-AS patients appear to have a more favourable prognostic profile compared to HGCON-AS patients. Large prospective interventional studies examining the prognostic differences between the two groups will be the next important step.

Transcatheter aortic valve replacement for aortic regurgitation in Asians: TAVR for aortic regurgitation in Asians.

AIMS: Although surgical aortic valve replacement (SAVR) is currently the recommended intervention for patients with native AR without aortic stenosis, a significant proportion of Asian patients undergo transcatheter aortic valve replacement (TAVR), which has not been studied fully for safety and outcomes. This systematic review aims to examine the characteristics and outcomes of Asian patients with pure native aortic regurgitation (AR) undergoing TAVR. METHODS AND RESULTS: PubMed, Embase, Scopus, Web of Science and Cochrane CENTRAL were systematically searched for randomised controlled trials, observational studies and case reports published  from inception to 2 April 2020, involving patients of Asian ethnicity with pure native aortic regurgitation who had undergone TAVR. Our primary outcome was all-cause mortality, with secondary outcomes including all major complications. Five studies (n=274 patients) and eight case reports were included. Device success was reported in 94.9% of the patients, the all-cause mortality rate was 4.4%, 2.5% were converted to SAVR, 1.7% had post-operative paravalvular leak and 6.7% required permanent pacemaker implantation. CONCLUSIONS: TAVR has demonstrated acceptable safety and efficacy in Asian patients with pure AR displaying low mortality rates and few adverse outcomes.

Prognostic Implications of Bicuspid and Tricuspid Aortic Valve Phenotype on Progression of Moderate Aortic Stenosis and Ascending Aorta Dilatation.

Studies on the impact of aortic valve anatomy (bicuspid aortic valve [BAV] or tricuspid aortic valve [TAV]) on the progression of moderate aortic stenosis (AS) and ascending aorta (AA) dilatation and its prognostic implications are limited. From 1991 to 2016, 288 asymptomatic patients with moderate AS detected during index echocardiography with at least 1 year of echocardiographic follow-up were retrospectively studied. Baseline clinical and echocardiographic characteristics were compared between patients with BAV (n = 80) and patients with TAV (n = 208). Co-primary outcomes were 1-year hemodynamic and anatomic progression of AS and AA dilatation. Secondary end points were the incidence of AA rapid progressors, all-cause mortality, aortic valve replacement, and congestive heart failure. Determinants of AS progression, AA diameters, AA dilatation, and prognostic outcomes were evaluated. Similar 1-year progression of the aortic valve peak velocity, Vmax (9 ± 18 vs 9 ± 23 cm/s), mean gradient (1.5 ± 2.3 vs 1.3 ± 3.2 mm Hg), and aortic valve area (AVA) (-0.04 ± 0.09 vs -0.05 ± 0.10 cm2) were noted for BAV and TAV groups, respectively. One-year progressions of AA were similar at Valsalva (0.11 ± 0.88 vs 0.14 ± 1.10 mm) and tubular levels (0.12 ± 0.68 vs 0.30 ± 1.51 mm) in BAV and TAV groups, respectively. A trend toward increased rapid AA progression in patients with BAV (31.3%) was observed compared with patients with TAV (14.8%, p = 0.099). BAV was associated with progression of Vmax (ß = 0.17, p = 0.036), the dimensionless index (ß = -0.17, p = 0.008), and AVA (ß = -0.14, p = 0.048), but not mean gradient after adjusting for age, baseline severity indexes, gender, hypertension, diabetes, and body surface area. Although BAV was a determinant of larger baseline AA diameter, there was no significant association between BAV and AA rapid progressors. Adjusted Kaplan-Meier curves demonstrated no differences in congestive heart failure, aortic valve replacement, or mortality between valve morphology. In conclusion, there was a similar 1-year disease progression in terms of AVA, Vmax, mean gradient, and AA diameters between patients with BAV and patients with TAV. BAV was associated with a significant increase in Vmax, dimensionless index, and AVA after adjusting for important confounders. Close and prolonged follow-up is warranted in both groups of patients.

Comparison of Outcomes of Asymptomatic Moderate Aortic Stenosis With Preserved Left Ventricular Ejection Fraction in Patients ≥80 Years Versus 70-79 Years Versus <70 Years.

Aortic stenosis (AS) is increasingly diagnosed in the aging population with more studies focused on the prognostic outcomes of severe asymptomatic AS. However, little is known about the outcomes of moderate asymptomatic AS in the elderly population. From 2001 to 2020, 738 consecutive patients with asymptomatic moderate AS with preserved left ventricular ejection fraction were studied. They were allocated according to the age group at the index echocardiography: very elderly (≥80 years), elderly (70 to 79 years) and control group (<70 years). The primary study outcomes were aortic valve replacement (AVR), congestive cardiac failure (CCF) and all-cause mortality. Overall, about one-third of the subjects were in the very elderly, elderly and control groups each. The median follow-up duration was 114.2 (interquartile range, 27.0 to 183.7) months. There was significantly higher all-cause mortality in the very elderly group (47.9%) followed by elderly (34.8%) and control group (21.9%). Similarly, there was significantly higher CCF rates in the very elderly group (5.8%) compared to elderly (5.1%) and control group (2.8%). There were significantly lower rates of AVR offered and completed in the very elderly group compared to control group. Multivariable logistic regression demonstrated that age ≥80 years remained an independent predictor of mortality after adjusting for important prognostic cofounders (Adjusted HR 2.424, 95% CI 1.728 to 3.400, p < 0.001). Cox regression showed no significant difference in mortality between patients ≥80 years with moderate AS compared to a younger age-group ≥70 years with severe AS. In conclusion, very elderly patients of ≥80 years of age with moderate AS have worse prognostic outcomes than their younger counterparts. They share similar unfavorable prognostic outcomes as those of a younger age-group ≥70 years with severe AS. Closer surveillance are warranted in this group of at-risk elderly patients.

Does pulmonary artery pulsatility index predict mortality in pulmonary arterial hypertension?

AIMS: Pulmonary artery pulsatility index (PAPi), defined as [(pulmonary artery systolic pressure - diastolic pulmonary artery pressure)/mean right atrial pressure], is a novel haemodynamic index that predicts right ventricular failure after myocardial infarction and left ventricular assist device implantation. We analysed if a low PAPi is associated with death in our 14 - â€‹year pulmonary arterial hypertension (PAH) registry. METHODS: Consecutive patients with newly diagnosed PAH and complete haemodynamic data were prospectively enrolled into our standing registry between January 2003 and December 2016. PAPi was calculated from baseline invasive right heart catheterization data. A prognostic cut-off value was determined with a decision tree. Baseline characteristics of 'high' and 'low' PAPi groups based on this cut-off were compared, as well as odds of death and time-to-death. RESULTS: One hundred and two patients were included. Mean age was 53 years, and 77% were women. Our multi-ethnic cohort was 64% Chinese, 23% Malay, and 10% Indian. The aetiologies were idiopathic (33%), connective tissue disease (31%), congenital heart disease (24%), and others (12%). The low PAPi group (<5.3) had a greater age (56 years vs. 49 years), lower pulmonary artery systolic pressure (71 mmHg vs. 85 mmHg), and higher mean right atrial pressure (14 mmHg vs. 6 mmHg). Mortality risk was higher in the low PAPi group (adjusted odds ratio: 2.98 and adjusted hazard ratio: 2.23). Mean right atrial pressure was the strongest predictor (hazard ratio 1.114, P = 0.009) when components of PAPi were analysed. CONCLUSIONS: Pulmonary artery pulsatility index was found to be predictive of mortality in PAH and may be a valuable marker for risk stratification. Its prognostic strength may be driven by mean right atrial pressure.