Valvulitis: a new echocardiographic criterion for the diagnosis of bioprosthetic aortic valve infective endocarditis.

INTRODUCTION AND OBJECTIVES: Diffuse homogeneous hypoechoic leaflet thickening, with a wavy leaflet motion documented by transesophageal echocardiography (TEE), has been described in some cases of prosthetic valve endocarditis (PVE) involving aortic bioprosthesis (AoBio-PVE). This echocardiographic finding has been termed valvulitis. We aimed to estimate the prevalence of valvulitis, precisely describe its echocardiographic characteristics, and determine their clinical significance in patients with AoBio-PVE. METHODS: From 2011 to 2022, 388 consecutive patients with infective endocarditis (IE) admitted to a tertiary care hospital were prospectively included in a multipurpose database. For this study, all patients with AoBio-PVE (n=86) were selected, and their TEE images were thoroughly evaluated by 3 independent cardiologists to identify all cases of valvulitis. RESULTS: The prevalence of isolated valvulitis was 12.8%, and 20.9% of patients had valvulitis accompanied by other classic echocardiographic findings of IE. A total of 9 out of 11 patients with isolated valvulitis had significant valve stenosis, whereas significant aortic valve regurgitation was documented in only 1 patient. Compared with the other patients with AoBio-PVE, cardiac surgery was less frequently performed in patients with isolated valvulitis (27.3% vs 62.7%, P=.017). In 4 out of 5 patients with valve stenosis who did not undergo surgery but underwent follow-up TEE, valve gradients significantly improved with appropriate antibiotic therapy. CONCLUSIONS: Valvulitis can be the only echocardiographic finding in infected AoBio and needs to be identified by imaging specialists for early diagnosis. However, this entity is a diagnostic challenge and additional imaging techniques might be required to confirm the diagnosis. Larger series are needed.

Carbohydrate antigen 125-guided pre-TAVI medical optimization: impact on quality of life and clinical outcomes.

INTRODUCTION AND OBJECTIVES: Carbohydrate antigen 125 (CA125), a biomarker associated with fluid overload, has proven useful in managing diuretic therapy in heart failure. We aimed to evaluate the impact of diuretic optimization guided by CA125 before transcatheter aortic valve implantation (TAVI) on outcomes. METHODS: This prospective interventional study enrolled patients scheduled for TAVI, in whom baseline CA125 was measured 2 weeks before TAVI. Patients with CA125 ≥ 20 U/mL underwent diuretic up-titration before TAVI. Three groups were included: group I) baseline CA125 <20 U/mL; IIa) CA125 ≥ 20 U/mL that decreased after treatment, and IIb) CA125 ≥ 20 U/mL that did not decrease. The primary outcome was changes in the Kansas City Cardiomyopathy Questionnaire at 3 and 12 months. The secondary endpoint was clinical events. RESULTS: The study included 184 patients (115 group I, 46 IIa, and 23 IIb). Groups I and IIa exhibited early and sustained improvements in the Kansas City Cardiomyopathy Questionnaire (group I: 18.9 points [95%CI, 15.7-22.1; P <.001] at 90 days, and 18.1 [95%CI, 14.9-21.4, P <.001] at 1 year; group IIa: 21.1 points [95%CI, 15.4-26.7; P <.001] and 19.5 [95%CI, 13.9-25.1; P <.001] respectively). In contrast, in group IIb there was no significant improvement at 90 days (P=.12), with improvement being significant only at 1 year (17.8 points, 95%CI, 5.9-29.6; P=.003). Over a median follow-up of 20.7 months, there were 63 (27.83%) deaths or heart failure admissions. Multivariate analysis showed a lower risk of events in group I vs IIb (HR, 0.28; 95%CI, 0.14-0.58; P <.001), and IIa vs IIb (HR, 0.24; 95%CI, 0.11-0.55; P <.001). CONCLUSIONS: Patients with persistently high CA125 despite diuretic therapy pre-TAVI showed slower functional recovery and poorer clinical outcomes after TAVI.

Surgical aortic valve replacement in octogenarians: Single-center perioperative outcomes and five-year survival.

INTRODUCTION AND OBJECTIVES: Aortic stenosis is the most common valvular heart disease. The number of octogenarians proposed for intervention is growing due to increased lifespan. In this manuscript we aim to evaluate perioperative outcome and long-term survival after surgical aortic valve replacement (SAVR) in octogenarians, comparing patients with low surgical risk (EuroscoreII <4%) with intermediate-high risk (EuroscoreII ≥4%). METHODS: A retrospective observational single-center cohort study with 195 patients aged ≥80 years old, who underwent SAVR between 2017 and 2021, was conducted. Patients were divided into two groups according to EuroscoreII: (1) Low risk (EuroscoreII <4%) with intermediate-high risk (EuroscoreII ≥4%). Continuous variables are presented in median (IQR), analyzed using Wilcoxon rank sum test; categorical variables in percentages, analyzed using chi-squared test; and survival was analyzed by Kaplan-Meier, open cohort, and the log-rank test was performed. RESULTS: The overall median age was 82 (IQR 81-83), with 4.6% of the patients ≥85 years old. 23.6% of the patients presented EuroscoreII ≥4%. No complications were observed in 26.2%, with a significantly higher rate in intermediate-high risk patients. Postoperative need for hemodynamic support was the most frequent complication, followed by postoperative acute kidney injury and the use of blood products. Overall median ICU stay was three days (2-4) and hospital length of stay (LOS) six days (5-8). Patients with intermediate-high risk and those with complications had longer ICU LOS. At 12 months, overall survival was 96.4%, at three years 94.1% and 5 years 75.4%. Patients with low surgical risk had higher survival proportions up to 5 years. CONCLUSION: SAVR in patients ≥80 years is associated with low in-hospital mortality, although a significant proportion of patients develop complications. Long-term follow-up up to five years after surgery is acceptable in octogenarians with low surgical risk.

Self-expanding TAVI using the cusp overlap technique versus the traditional technique: electrocardiogram changes and 1-year cardiovascular outcomes.

INTRODUCTION AND OBJECTIVES: Transcatheter aortic valve implantation (TAVI) using the cusp overlap technique (COT) has shown a lower pacemaker implantation rate at 30 days. The objective of this study was to compare electrocardiogram changes and clinical outcomes between COT and the traditional technique (TT) at 1 year of follow-up. METHODS: Observational, retrospective, nonrandomized study of consecutive patients undergoing TAVI between January 2015 and January 2021. Patients were matched using a propensity score and the TT was compared with COT. The primary endpoints were electrocardiogram changes and a combined endpoint including pacemaker implantation, hospitalization, or cardiovascular death at 1 year. RESULTS: We included 254 patients. After propensity score matching, 184 patients (92 per group) remained. There were no statistically significant differences in baseline characteristics. At 1 year, COT patients showed a significant reduction in new onset left bundle branch block (49% vs 27%, P=.002) and less P wave (13.1±21.0 msec vs 5.47±12.5 msec; P=.003) and QRS prolongation (29.77±27.0 msec vs 16.38±25.4 msec, P <.001). COT was associated with a significant reduction in the occurrence of the primary endpoint (SHR, 0.39 [IC95%, 0.21-0.76]; P=.005). CONCLUSIONS: At 1 year of follow-up, COT reduced the incidence of new onset left bundle branch block and diminished QRS and P wave widening compared with the TT. COT was also associated with a statistically significant reduction in the occurrence of the combined primary cardiovascular endpoint.

Interventional cardiology in cancer patients: A position paper from the Portuguese Cardiovascular Intervention Association and the Portuguese Cardio-Oncology Study Group of the Portuguese Society of Cardiology.

The field of Cardio-Oncology has grown significantly, especially during the last decade. While awareness of cardiotoxicity due to cancer disease and/or therapies has greatly increased, much of the attention has focused on myocardial systolic disfunction and heart failure. However, coronary and structural heart disease are also a common issue in cancer patients and encompass the full spectrum of cardiotoxicity. While invasive percutaneous or surgical intervention, either is often needed or considered in cancer patients, limited evidence or guidelines are available for dealing with coronary or structural heart disease. The Society for Cardiovascular Angiography and Interventions consensus document published in 2016 is the most comprehensive document regarding this particular issue, but relevant evidence has emerged since, which render some of its considerations outdated. In addition to that, the recent 2022 ESC Guidelines on Cardio-Oncology only briefly discuss this topic. As a result, the Portuguese Association of Cardiovascular Intervention and the Cardio-Oncology Study Group of the Portuguese Society of Cardiology have partnered to produce a position paper to address the issue of cardiac intervention in cancer patients, focusing on percutaneous techniques. A brief review of available evidence is provided, followed by practical considerations. These are based both on the literature as well as accumulated experience with these types of patients, as the authors are either interventional cardiologists, cardiologists with experience in the field of Cardio-Oncology, or both.

Características y resultados del Registro español de válvula aórtica bicúspide en pediatría (REVAB) / Characteristics and outcomes of the Spanish registry for pediatric patients with bicuspid aortic valve (REVAB)

Introducción y objetivos: La válvula aórtica bicúspide (VAB) es la cardiopatía congénita más frecuente. El objetivo de este estudio es describir las características de los pacientes en edad pediátrica con VAB en un registro poblacional. Métodos: Los datos de los pacientes se obtuvieron del Registro español de válvula aórtica bicúspide (REVAB) en pediatría (menores de 18 años). Para el análisis de datos, se dividió a los pacientes en 2 grupos según sus características: pacientes con VAB solo y pacientes con VAB y cardiopatía congénita concomitantes. Resultados: Se analizó a un total de 1.681 pacientes de 33 hospitales. La mayoría (1.158, 69,6%) eran varones. La morfología de la válvula fue horizontal en el 63,4% (1.012), y puras (tipo 0 Sievers), el 28,4% (469). El 63,7% (1.060) tenían solo VAB y en el 23,4% (390) concurrían lesiones obstructivas del lado izquierdo. Del total, el 8,6% (145) precisó alguna intervención en la válvula aórtica. Conclusiones: Estos datos representan la primera descripción de base poblacional de la presentación clínica y los resultados en los pacientes del REVAB Pediátrico.(AU)

Introduction and objectives: Bicuspid aortic valve (BAV) disorder is the most common congenital heart disease. The aim of this study was to describe the characteristics of 0- to 18-year olds with BAV in a population-based registry. Methods: Data from all pediatric patients were obtained from the Spanish registry for pediatric patients with bicuspid aortic valve (REVAB) (< 18 years). For data analysis, patients with BAV were divided into 2 groups by their features: isolated BAV and BAV with associated congenital heart disease. Results: We included 1681 patients from 33 hospitals. Males accounted for 69.6% (n = 1158). Valve morphology was horizontal in 63.4% (n = 1012) and pure (Sievers type 0) in 28.4% (n=469). Isolated BAV was present in 63.7% (n=1060), and concomitant left-sided obstructive lesions in 23.4% (n=390). Interventions were required in 8.6% (n=145). Conclusion: These data represent the first large, population-based description of the clinical presentations and outcomes of patients enrolled in the Spanish registry for pediatric patients with bicuspid aortic valve.(AU)

Angina en pacientes con estenosis aórtica grave sometidos a implante percutáneo de la válvula aórtica / Angina in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement

Introducción y objetivos: Evaluar la prevalencia, las características clínicas y el impacto de la angina en pacientes con estenosis aórtica sometidos a implante percutáneo de válvula aórtica (TAVI). Métodos: Se analizó a 1.687 pacientes consecutivos con estenosis aórtica sometidos a TAVI, clasificados en función de la presencia o ausencia basal de angina. Los datos basales, del procedimiento y del seguimiento se recogieron en una base de datos local. Resultados: Un total de 497 pacientes (29%) presentaban angina antes del TAVI. Los pacientes con angina basal presentaban peor clase funcional (NYHA> II, el 69% frente al 63%; p=0,017) y una mayor prevalencia de enfermedad coronaria (el 74% frente al 56%; p <0,001). La angina basal no mostró impacto pronóstico a 1 año en mortalidad por cualquier causa (HR=1,02; IC95%, 0,71-1,48; p=0,898) ni en mortalidad cardiovascular (HR=1,2; IC95%, 0,69-2,11; p=0,517). Sin embargo, la persistencia de angina 30 días después del procedimiento se asoció con un incremento en la mortalidad a 1 año, tanto total (HR=4,86; IC95%, 1,71-13,8; p=0,003) como de causa cardiovascular (HR=20,7; IC95%, 3,50-122,6; p=0,001). Conclusiones: Más de un cuarto de los pacientes con estenosis aórtica sometidos a TAVI tenían angina antes del procedimiento. La angina basal no mostró impacto pronóstico alguno. Sin embargo, la persistencia de angina 30 días después del procedimiento se asoció con una mayor mortalidad al año.(AU)

Introduction and objectives: To evaluate the prevalence, clinical characteristics, and outcomes of patients with angina undergoing transcatheter aortic valve replacement (TAVR) for severe aortic stenosis. Methods: A total of 1687 consecutive patients with severe aortic stenosis undergoing TAVR at our center were included and classified according to patient-reported angina symptoms prior to the TAVR procedure. Baseline, procedural and follow-up data were collected in a dedicated database. Results: A total of 497 patients (29%) had angina prior to the TAVR procedure. Patients with angina at baseline showed a worse New York Heart Association (NYHA) functional class (NYHA class> II: 69% vs 63%; P=.017), a higher rate of coronary artery disease (74% vs 56%; P <.001), and a lower rate of complete revascularization (70% vs 79%; P <.001). Angina at baseline had no impact on all-cause mortality (HR, 1.02; 95%CI, 0.71-1.48; P=.898) and cardiovascular mortality (HR, 1.2; 95%CI, 0.69-2.11; P=.517) at 1 year. However, persistent angina at 30 days post-TAVR was associated with increased all-cause mortality (HR, 4.86; 95%CI, 1.71-13.8; P=.003) and cardiovascular mortality (HR, 20.7; 95%CI, 3.50-122.6; P=.001) at 1-year follow-up. Conclusions: More than one-fourth of patients with severe aortic stenosis undergoing TAVR had angina prior to the procedure. Angina at baseline did not appear to be a sign of a more advanced valvular disease and had no prognostic impact; however, persistent angina at 30 days post-TAVR was associated with worse clinical outcomes.(AU)

Incidence, predictors, and prognostic significance of impaired functional status early after transcatheter aortic valve replacement.

INTRODUCTION AND OBJECTIVES: There are scarce data on the factors associated with impaired functional status after transcatheter aortic valve replacement (TAVR) and its clinical impact. This study aimed to determine the incidence, predictors, and prognostic implications of impaired functional class (NYHA class III-IV) following TAVR. METHODS: This multicenter study included 3462 transarterial TAVR patients receiving newer generation devices. The patients were compared according to their NYHA class at 1 month of follow-up (NYHA I-II vs NYHA III-IV). A multivariate logistic regression was performed to identify the predictors of 30-day NYHA class III-IV. Patient survival was compared with the Kaplan-Meier method and factors associated with decreased survival were identified with Cox regression analysis. RESULTS: The mean age of the study population was 80.3±7.3 years, with 47% of women, and a median Society of Thoracic Surgeons score of 3.8% [IQR, 2.5-5.8]. A total of 208 patients (6%) were in NYHA class III-IV 1 month after TAVR. Predictors of 30-day NYHA class III-IV were baseline NYHA class III-IV (OR, 1.76; 95%CI, 1.08-2.89; P=.02), chronic pulmonary obstructive disease (OR, 1.80; 95%CI, 1.13-2.83; P=.01), and post-TAVR severe mitral regurgitation (OR, 2.00; 95%CI, 1.21-3.31; P<.01). Patients in NYHA class III-IV 1 month after TAVR were at higher risk of death (HR, 3.68; 95%CI, 2.39-5.70; P<.01) and heart failure-related hospitalization (HR, 6.00; 95%CI, 3.76-9.60; P<.01) at 1-year follow-up. CONCLUSIONS: Up to 6% of contemporary TAVR patients exhibited an impaired functional status following TAVR. Worse baseline NYHA class, chronic pulmonary obstructive disease, and severe mitral regurgitation predicted 30-day NYHA class III/IV, and this determined a higher risk of mortality and heart failure hospitalization at 1-year follow-up. Further studies on the prevention and treatment optimization of patients with impaired functional status after TAVR are needed.

Última generación de prótesis percutáneas expandibles con balón y autoexpandibles en la estenosis aórtica bicúspide: estudio TRITON / Latest-iteration balloon- and self-expandable transcatheter valves for severe bicuspid aortic stenosis: the TRITON study

Introducción y objetivos: La última generación de válvulas cardiacas expandibles con balón y autoexpandibles para implante percutáneo no se han comparado en valvulopatía aórtica bicúspide (VAB).Métodos: Registro multicéntrico de pacientes consecutivos con VAB y estenosis grave tratados con las válvulas cardiacas expandibles con balón (Myval y SAPIEN 3 Ultra [S3U]) o autoexpandible Evolut PRO+(EP+). Se realizó un análisis de tripletes mediante el software TriMatch para minimizar el impacto de las diferencias basales. El objetivo primario del estudio fue evaluar la tasa de éxito del dispositivo a 30 días y los objetivos secundarios, el objetivo combinado de seguridad y sus componentes individuales a 30 días.Resultados: Se incluyó a 360 pacientes (media de edad, 76,6±7,6 años; el 71,9% varones); 122 con Myval (33,9%), 129 con S3U (35,8%) y 109 con EP+(30,3%). La media de puntuación STS fue de 3,6±1,9%. No hubo ningún caso de oclusión coronaria, rotura de anillo, disección aórtica o mortalidad periprocedimiento. El evento primario de éxito del dispositivo a 30-días fue significativamente superior en el grupo que recibió Myval (Myval, 100%; S3U, 87,5%, y EP+, 81,3%), fundamentalmente a expensas de mayor gradiente residual con S3U y mayor tasa de insuficiencia aórtica al menos moderada con EP+. La tasa no ajustada de implante de marcapasos no presentó diferencias significativas.Conclusiones: En la VAB con estenosis grave y cirugía contraindicada, Myval, S3U y EP+tuvieron una seguridad comparable, aunque Myval presentó mejor gradiente residual que S3U y ambos dispositivos expandibles con balón resultaron en menos fuga perivalvular residual que EP+. Por lo tanto, ajustándose a los riesgos específicos de cada paciente, se puede seleccionar cualquiera de los 3 dispositivos con resultados óptimos.(AU)

Introduction and objectives: No comparisons have been published yet regarding the newest iteration of balloon- and self-expandable transcatheter heart valves for the treatment of bicuspid aortic valve (BAV) stenosis.Methods: Multicenter registry of consecutive patients with severe BAV stenosis treated with balloon-expandable transcatheter heart valves (Myval and SAPIEN 3 Ultra, S3U) or self-expanding Evolut PRO+(EP+). TriMatch analysis was carried out to minimize the impact of baseline differences. The primary endpoint of the study was 30-day device success, and the secondary endpoints were the composite and individual components of early safety at 30 days.Results: A total of 360 patients (age 76.6±7.6 years, 71.9% males) were included: 122 Myval (33.9%), 129 S3U (35.8%), and 109 EP+(30.3%). The mean STS score was 3.6±1.9%. There were no cases of coronary artery occlusion, annulus rupture, aortic dissection, or procedural death. The primary endpoint of device success at 30 days was significantly higher in the Myval group (Myval: 100%; S3U: 87.5%; and EP+: 81.3%), mainly due to higher residual aortic gradients with S3U and greater≥moderate aortic regurgitation (AR) with EP+. No significant differences were found in the unadjusted rate of pacemaker implantation.Conclusions: In patients with BAV stenosis deemed unsuitable for surgery, Myval, S3U and EP+showed similar safety but balloon-expandable Myval had better gradients than S3U, and both balloon-expandable devices had lower residual AR than EP+, suggesting that, taking into consideration the patient-specific risks, any of these devices can be selected with optimal outcomes.(AU)

Impacto de un Heart Team en pacientes con estenosis aórtica candidatos a reemplazo percutáneo / Impact of a Heart Team in patients with aortic stenosis who are candidates for transcatheter aortic valve replacement

RESUMEN La difusión del reemplazo valvular aórtico percutáneo (TAVI) en la estenosis aórtica (EAo) generó la creación de un Heart Team (HT), para elegir el mejor tratamiento. Existen pocos reportes sobre su utilidad. Objetivos: analizar los resultados del tratamiento de los pacientes con EAo evaluados por un HT durante 10 años Material y métodos: Inclusión consecutiva de todos los pacientes con EAo candidatos a TAVI entre enero del 2012 y julio del 2021 para seleccionar el mejor tratamiento, incluyendo además Cirugía de reemplazo valvular aórtico (CRVA) y Tratamiento médico conservador (TMC). Resultados: De 841 pacientes, se asignaron a TAVI 455 (53%), CRVA 213 (24%) y TMC 183 (23%). El porcentaje asignado a TAVI aumentó con el tiempo de 48 a 62% (p < 0,05). Los pacientes que fueron a TAVI, con respecto a los enviados a CRVA, eran mayores (86 ± 7 vs 83 ± 7 años), con mayor EUROSCORE II (6,2, IC95% 5,7-6,6 vs 5,6, IC95% 4,4-6,5) y más frágiles (1,62 ± 1 vs 0,91 ± 1), en todos los casos p <0,01. La sobrevida actuarial (IC 95%) a 1 y a 2 años fue, para TAVI 88% (84-91%) y 82% (77-86%), para CRVA 83% (76-88%) y 78% (70-84%) y para TMC 70% (60-87%) y 59% (48-68%) respectivamente (p <0,001). Conclusiones: Durante los primeros 10 años de establecido un Heart Team para la toma de decisiones en EAo, se asignaron a TAVI aproximadamente la mitad y el resto se asignó por mitades a cirugía u observación. La sobrevida de los pacientes intervenidos fue similar a 2 años y mayor que la de los no intervenidos.

ABSTRACT As transcatheter aortic valve implantation (TAVI) for aortic stenosis (AS) became widespread, the need for a Heart Team (HT) arose to choose the best treatment. There are few reports regarding its usefulness. Objectives: To analyze treatment outcomes in patients with AS evaluated by a HT for 10 years. Methods: Consecutive enrollment of all patients with AS who were candidates for TAVI between January 2012 and July 2021 to choose the best treatment, including surgical aortic valve replacement (SAVR) and conservative medical management (CMM). Results: Out of 841 patients, 455 were assigned to TAVI (53%), 213 to SAVR (24%), and 183 to CMM (23%). The percentage assigned to TAVI has increased from 48% to 62% over time (p <0.05). Patients who underwent TAVI versus those who underwent SAVR were older (86 ± 7 vs. 83 ± 7 years), had a higher EUROSCORE II (6.2, 95% CI 5.7-6.6 vs. 5.6; 95% CI 4.4-6.5) and were frailer (1.62 ± 1 vs. 0.91 ± 1), in all cases p <0.01. Actuarial survival (95% CI) at 1 and 2 years was 88% (84-91%) and 82% (77-86%) for TAVI, 83% (76-88%) and 78% (70-84%) for SAVR, and 70% (60-87%) and 59% (48-68%) for CMM, respectively (p <0.001). Conclusions: For the first 10 years after a Heart Team was established for AS decision-making, approximately half of the patients were assigned to TAVI, and the rest were equally assigned in halves to either surgery or observation. Survival for patients who received interventions was similar at 2 years and higher than in those who did not.

Manejo anestésico perioperatorio en histerectomía total abdominal por fibroma uterino en paciente con estenosis aórtica severa. Presentación de un caso

Se presenta el caso de una paciente de 35 años, femenina, con antecedentes de presentar un soplo desde la infancia y que debía ser intervenida quirúrgicamente por fibroma uterino. El anestesiólogo, durante la consulta preoperatoria, constató el soplo ya mencionado por lo que se decidió posponer la cirugía e interconsultar con un cardiólogo. El examen ecocardiográfico demostró que la paciente era portadora de una estenosis aórtica severa con fracción de eyección conservada, prueba ergométrica: clase funcional I, sin isquemia. Mediante anestesia general orotraqueal, se realizó histerectomía total abdominal sin complicaciones. Es de vital importancia para el anestesiólogo el manejo perioperatorio de la estenosis aórtica.

The case of a 35-years-old female patient with a history of presenting a murmur since childhood and who had to undergo surgery for uterine fibroid is presented. The anesthesiologist, during the preoperative consultation, verified the aforementioned murmur, so it was decided to postpone surgery and consult with a cardiologist. The echocardiographic examination showed that the patient had severe aortic stenosis with preserved ejection fraction, stress test: functional class I, without ischemia. Using orotracheal general anesthesia, a total abdominal hysterectomy was performed without complications. The perioperative management of aortic stenosis is of vital importance for the anesthesiologist.

Aortic valve reconstruction surgery with Ozaki technique: initials results from a single center / Cirugía de reconstrucción de válvula aórtica con técnica de Ozaki: resultados iniciales en un centro de referencia

Abstract Background: Aortic valve (AV) replacement is the gold standard treatment for severe symptomatic AV disease. Recently, AV reconstruction surgery (Ozaki procedure) emerges as a surgical alternative with good results in the medium term. Methods: We retrospectively analyzed 37 patients who underwent AV reconstruction surgery between January 2018 and June 2020 in a national reference center in Lima, Peru. The median age was 62 years, interquartile range (IQR: 42-68). The main indication for surgery was AV stenosis (62.2%), in most cases due to bicuspid valve (19 patients, 51.4%). Twenty-two (59.4%) patients had another pathology with surgical indication associated to AV disease, 8 (21.6%) had dilatation of the ascending aorta with indication for replacement. Results: One in-hospital death occurred (1/38, 2.7%) due to perioperative myocardial infarction. There was a significant reduction in the medians of the peak (70 mmHg, CI 95% = 50.03-79.86 vs. 14 mmHg, CI 95% = 11.93-17.5, p < 0.0001) and mean (45.5 mmHg CI 95% = 30.6-49.68 vs. 7 mmHg, CI 95% = 5.93-9.6, p < 0.0001) AV gradients when we compared baseline characteristics with first 30-days results. In an average of 19 (± 8.9) months of follow-up, survival, reoperation-free survival for valve dysfunction, and survival free of AV insufficiency ≥ II were 97.3%, 100% and 91.9%, respectively. Significant reduction in the medians of the peak and mean AV gradients was maintained. Conclusions: AV reconstruction surgery showed optimal results in term of mortality, reoperation-free survival, and hemodynamic characteristics of the neo-AV.

Resumen Introducción: El reemplazo de la válvula aórtica es el tratamiento de elección para la valvulopatía aórtica severa sintomática. Recientemente, la cirugía de reconstrucción valvular aórtica (procedimiento de Ozaki) emerge como una alternativa quirúrgica con buenos resultados a mediano plazo. Métodos: Analizamos retrospectivamente 37 pacientes intervenidos de reconstrucción de válvula aórtica entre enero de 2018 y junio de 2020 en un centro de referencia nacional en Lima, Perú. La mediana de edad fue de 62 años (rango intercuartílico: 42-68). La estenosis de la válvula fue la principal indicación de cirugía (62.2%), en la mayoría de los casos por válvula bicúspide (19 pacientes, 51.4%). 22 (59.4%) pacientes presentaban otra patología con indicación de cirugía, 8 (21.6%) presentaban dilatación de la aorta ascendente con indicación de reemplazo. Resultados: La mortalidad intrahospitalaria fue de 1/38, 2.7%, por infarto de miocardio perioperatorio. Hubo una reducción significativa en las medianas del gradiente máximo (70 mmHg, IC 95% = 50.03-79.86 vs. 14 mmHg, IC 95% = 11.93-17.5, p < 0.0001) y gradiente medio (45.5 mmHg IC 95% = 30.6-49.68 vs. 7 mmHg, IC 95% = 5.93-9.6, p < 0.0001) de la válvula aórtica cuando comparamos las características basales con los resultados de los primeros 30 días. En una media de 19 (± 8.9) meses de seguimiento la sobrevida fue del 97.3%; la sobrevida libre de reoperación por disfunción valvular, 100% y la sobrevida libre de insuficiencia aórtica ≥ II, 91.9%, respectivamente. Se mantuvo una reducción significativa en las medianas de los gradientes máximo y medio de la válvula aórtica. Conclusiones: La cirugía de reconstrucción de válvula aórtica con pericardio autólogo mostró resultados óptimos en términos de mortalidad, supervivencia libre de reoperación y características hemodinámicas de la neo-válvula.

Resultados intrahospitalarios tras tratamiento percutáneo frente a quirúrgico en pacientes con estenosis aórtica y enfermedad arterial coronaria concomitante / In-hospital outcomes following percutaneous versus surgical intervention in the treatment of aortic stenosis and concomitant coronary artery disease

Introducción y objetivos: La enfermedad coronaria (EC) es frecuente en pacientes con estenosis aórtica; sin embargo, la estrategia terapéutica óptima sigue siendo objeto de debate. Investigamos los resultados periprocedimiento en pacientes sometidos a implante percutáneo de válvula aórtica con intervención coronaria percutánea (TAVI/ICP) frente al recambio valvular aórtico con injerto de derivación de arteria coronaria (RVAo/CABG) en pacientes con estenosis aórtica con EC.Métodos: Con los datos de alta del Sistema Nacional de Salud Español, se identificaron 6.194 pacientes (5.217 RVAo/CABG y 977 TAVI/ICP) entre 2016 y 2019. Se realizó un análisis emparejado por puntuación de propensión ajustado por características basales. El objetivo primario fue la mortalidad hospitalaria, Los objetivos secundarios fueron las complicaciones hospitalarias y rehospitalización cardiovascular a 30 días.Resultados: Tras el emparejamiento, se seleccionaron 774 parejas de pacientes. La mortalidad total hospitalaria fue más frecuente en el grupo quirúrgico (3,4 frente a 9,4%, p <0,001), al igual que el ictus periprocedimiento (0,9 frente a 2,2%, p=0,004), fallo renal agudo (4,3 frente a 16,0%, p <0,002), transfusión (9,6 frente a 21,1%, p <0,001) y neumonía intrahospitalaria (0,1 frente a 1,7%, p=0,001). La implantación de marcapasos permanente fue más frecuente en el tratamiento percutáneo (12,0 frente a 5,7%, p <0,001). Los centros de menor volumen (< 130 procedimientos por año) tuvieron mayor mortalidad hospitalaria para ambos procedimientos: TAVI/ICP (3,6 frente a 2,9%, p <0,001) y RVAo/CABG (9,3 frente a 6,8%, p <0,001). La rehospitalización cardiovascular a 30 días no difirió entre los grupos.(AU)

Introduction and objectives: Concomitant coronary artery disease (CAD) is prevalent among aortic stenosis patients; however the optimal therapeutic strategy remains debated. We investigated periprocedural outcomes among patients undergoing transcatheter aortic valve implantation with percutaneous coronary intervention (TAVI/PCI) vs surgical aortic valve replacement with coronary artery bypass grafting (SAVR/CABG) for aortic stenosis with CAD.Methods: Using discharge data from the Spanish National Health System, we identified 6194 patients (5217 SAVR/CABG and 977 TAVI/PCI) between 2016 and 2019. Propensity score matching was adjusted for baseline characteristics. The primary outcome was in-hospital all-cause mortality. Secondary outcomes were in-hospital complications and 30-day cardiovascular readmission.Results: Matching resulted in 774 pairs. In-hospital all-cause mortality was more common in the SAVR/CABG group (3.4% vs 9.4%, P <.001) as was periprocedural stroke (0.9% vs 2.2%; P=.004), acute kidney injury (4.3% vs 16.0%, P <.001), blood transfusion (9.6% vs 21.1%, P <.001), and hospital-acquired pneumonia (0.1% vs 1.7%, P=.001). Permanent pacemaker implantation was higher for matched TAVI/PCI (12.0% vs 5.7%, P <.001). Lower volume centers (< 130 procedures/y) had higher in-hospital all-cause mortality for both procedures: TAVI/PCI (3.6% vs 2.9%, P <.001) and SAVR/CABG (8.3 vs 6.8%, P <.001). Thirty-day cardiovascular readmission did not differ between groups.Conclusions: In this large contemporary nationwide study, percutaneous management of aortic stenosis and CAD with TAVI/PCI had lower in-hospital mortality and morbidity than surgical intervention. Higher volume centers had less in-hospital mortality in both groups. Dedicated national high-volume heart centers warrant further investigation.(AU)

Encuesta multinacional y transversal sobre las controversias del reemplazo de la raíz aórtica con conservación valvular / Multinational and Cross-Sectional Survey on Valve-Sparing Aortic Replacement Controversies

RESUMEN Introducción : El reemplazo de la raíz aórtica con conservación valvular (valve-sparing aortic root replacement, VSAR) se ha consolidado como un procedimiento eficaz para el tratamiento del aneurisma de la raíz aórtica, el síndrome de Marfan, la válvula bicúspide y la disección aórtica. Sin embargo, es necesario llegar a una opinión unánime sobre los aspectos clave del VSAR. Material y métodos : Se realizó una revisión bibliográfica de los debates y controversias más frecuentes del VSAR. A partir de esta información se elaboró una encuesta en línea que se envió a cirujanos con experiencia comprobada en VSAR para conocer su opinión sobre los factores relacionados con los pacientes, los aspectos técnicos, la ecocardiografía, la investigación, la formación y el futuro del VSAR. Resultados : Veinte cirujanos completaron la encuesta. Según 14 de cada 20 encuestados, la fracción de eyección grave se consideró una contraindicación para el llevar a cabo este procedimiento. El límite del diámetro del anillo aórtico para la remodelación fue heterogéneo entre los participantes. Todos ellos consideraron que el VSAR es un procedimiento seguro para los pacientes con síndrome de Marfan y válvula bicúspide. En el caso de disección de tipo A, 11 de cada 20 prefirieron este procedimiento solo para los pacientes jóvenes. En lo que respecta al tamaño del injerto, la altura del triángulo intervalvar (8/20) y el diámetro sinotubular (7/20) fueron los más frecuentes. Los cirujanos informaron una tasa de fracaso del 7% en la conversión al procedimiento de Bentall, y un cambio de estrategia intraoperatoria del 26%. No se consideró que un abordaje mínimamente invasivo mejorara los resultados. La mayoría de los cirujanos coincidieron en que el VSAR lo deben realizar cirujanos con mucha experiencia. Conclusiones : El VSAR ha sido aceptado como una opción terapéutica para el aneurisma de la raíz aórtica, y, aunque todavía no es posible llegar a un consenso definitivo, se presenta la valiosa experiencia de los cirujanos más destacados en este campo.

ABSTRACT Background : The valve-sparing aortic root replacement (VSAR) has been established as a successful procedure for aortic root aneurysms, Marfan's syndrome, bicuspid valves, and aortic dissections. However, there is a need for a consensus opinion regarding key aspects of VSAR. Methods : A literature review was performed regarding the most frequent debates and controversies in VSAR. An online survey was developed based on this information, and sent to surgeons with known expertise in VSAR regarding their opinion on patient-related factors, technical aspects, echocardiography, research, training, and the future of VSAR. Results : Twenty surgeons completed the survey. The reduction of left ventricular ejection fraction was considered a contra indication to VSAR when severe by 14/20 surveyed. The aortic annulus diameter cutoff point for the remodeling was heterogenous among participants. All of them felt that VSAR is safe for the Marfan´s syndrome population and bicuspid valves. For type A dissections, 11/20 preferred this procedure only in young patients. Regarding to graft sizing, the height of the interleaflet triangle (8/20) and the sino-tubular diameter (7/20) were the more frequent considered parameters. Surgeons reported a 7% of failure rate, leading to conversion to Bentall surgery, and a 26% change of strategy intraoperatively. A minimally invasive approach was not considered to improve results. Most of the surgeons agreed that VSAR should be performed by high-experienced surgeons. Conclusions : The VSAR has been accepted as a treatment option for the aortic root´s aneurysms, and even though there is still not possible to reach a final consensus, a valuable experience from the most relevant surgeons in the field is presented.

Angina in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement.

INTRODUCTION AND OBJECTIVES: To evaluate the prevalence, clinical characteristics, and outcomes of patients with angina undergoing transcatheter aortic valve replacement (TAVR) for severe aortic stenosis. METHODS: A total of 1687 consecutive patients with severe aortic stenosis undergoing TAVR at our center were included and classified according to patient-reported angina symptoms prior to the TAVR procedure. Baseline, procedural and follow-up data were collected in a dedicated database. RESULTS: A total of 497 patients (29%) had angina prior to the TAVR procedure. Patients with angina at baseline showed a worse New York Heart Association (NYHA) functional class (NYHA class> II: 69% vs 63%; P=.017), a higher rate of coronary artery disease (74% vs 56%; P <.001), and a lower rate of complete revascularization (70% vs 79%; P <.001). Angina at baseline had no impact on all-cause mortality (HR, 1.02; 95%CI, 0.71-1.48; P=.898) and cardiovascular mortality (HR, 1.2; 95%CI, 0.69-2.11; P=.517) at 1 year. However, persistent angina at 30 days post-TAVR was associated with increased all-cause mortality (HR, 4.86; 95%CI, 1.71-13.8; P=.003) and cardiovascular mortality (HR, 20.7; 95%CI, 3.50-122.6; P=.001) at 1-year follow-up. CONCLUSIONS: More than one-fourth of patients with severe aortic stenosis undergoing TAVR had angina prior to the procedure. Angina at baseline did not appear to be a sign of a more advanced valvular disease and had no prognostic impact; however, persistent angina at 30 days post-TAVR was associated with worse clinical outcomes.

Presencia de regurgitación moderada o grave luego del implante percutáneo de la válvula aórtica con la estrategia de "Cusp Overlap" / Presence of Moderate or Severe Regurgitation after Transcatheter Aortic Valve Implant with the Cusp Overlap Strategy

RESUMEN Objetivo : Analizar si la estrategia del implante alto usando superposición de las cúspides derechas e izquierdas (Cusp Overlap, COVL) en el implante percutáneo de la válvula aórtica (TAVI) se relaciona con menor incidencia de regurgitación paravalvular (RPV) moderada o grave, comparada con la estrategia convencional (CON). Material y métodos : Se analizaron 206 pacientes consecutivos que recibieron TAVI con válvulas autoexpandidles entre agosto de 2019 y mayo de 2022. Se utilizó una estrategia CON en 101 pacientes (49%) y COVL en 105 (51%). El Punto Final Primario (PFP) fue la presencia de regurgitación paravalvular moderada y grave a 30 días. Resultados : No hubo diferencia clínica entre los grupos en cuanto a la edad media, sexo ni comorbilidades; excepto una tendencia a más diabetes y angioplastia coronaria previa en el grupo COVL. El STS score fue mayor en el grupo de COVL (6,9 ± 2,2 vs. 5,8 ± 2,4 en CON, p = 0,01). A 30 días no hubo diferencia en el PFP (RPV moderada en 2% en CON, y 0,9% en COVL; ninguno presentó RPV grave). Tampoco hubo diferencia en mortalidad, infarto, oclusión coronaria, accidente cerebrovascular, sangrado mayor y complicación vascular. La necesidad de marcapasos definitivo fue menor con la estrategia de COVL (6,7% vs. 17,8%, p = 0,01) y un nuevo bloqueo de rama izquierda ocurrió en 5,7% vs. 12,9% (p = 0,07). Conclusiones : En esta serie de un solo centro, la estrategia del implante alto de la válvula aórtica percutánea usando la técnica de COVL no demostró diferencia en la presencia de regurgitaciones moderadas o graves comparada con la estrategia convencional, sin presentar diferencia en las complicaciones, y se asoció a una menor necesidad de marcapasos definitivo y a una tendencia de menos bloqueos de rama izquierda a 30 días.

ABSTRACT Objective : The aim of this study is to whether higher transcatheter aortic valve implantation (TAVI) with self-expandable valves using the right and left cusp overlap strategy (Cusp Overlap, COVL) is associated with a lower incidence of moderate or severe paravalvular regurgitation, compared with the conventional strategy (CON). Methods : A total of 206 consecutive patients undergoing TAVI with self-expandable valves between August 2019 and May 2022 were analyzed. The CON technique was used in the first 101 patients (49%) and COVL was used in 105 (51%). The primary endpoint (PEP) was the presence of moderate or severe paravalvular regurgitation at 30 days. Results : There were no clinical differences between the groups in terms of mean age, sex or comorbidities, except for a trend towards more patients with diabetes and previous percutaneous coronary intervention in the COVL group. The STS score was greater in the COVL group (6.9 ± 2.2 vs. 5.8 ± 2.4 in the CON group; p = 0.01). There was no difference in the PEP at 30 days with 2% incidence of moderate PVR in the CON group and 0.9% in the COVL group, and none of them presented severe PVR. There were no differences in mortality, myocardial infarction, coronary artery obstruction, stroke, major bleeding or vascular complications. The need for permanent pacemaker was lower with the COVL strategy (6.7% vs. 17.8%, p = 0.01) and a new left bundle branch block occurred in 5.7% vs. 12.9% (p = 0.07). Conclusions : In this single-center series, the strategy of high transcatheter aortic valve implantation using the COVL strategy showed no difference in the presence of moderate or severe regurgitation compared with the conventional strategy, with no differences in complications, and was associated with a lower need for definitive pacemaker and with a trend towards lower incidence of left bundle branch block at 30 days.

Utilidad del NT-proBNP en la evaluación pronóstica de pacientes con estenosis aórtica grave asintomáticos, con fracción de eyección ventricular izquierda preservada / Prognostic Value of NT-proBNP in Asymptomatic Patients with Severe Aortic Stenosis and Preserved Left Ventricular Ejection Fraction

RESUMEN Introducción : La indicación de reemplazo valvular aórtico (RVA) en pacientes con estenosis aórtica (EA) grave asintomáticos con función conservada es motivo de creciente debate. Objetivos : Evaluar si la elevación de la fracción aminoterminal del pro-péptido natriurético tipo B (NT-proBNP) predice la aparición de síntomas y la indicación de reemplazo valvular en pacientes inicialmente asintomáticos, con EA grave y fracción de eyección ventricular izquierda (FEVI) conservada. Material y métodos : Se incluyeron en forma prospectiva pacientes con EA grave, FEVI conservada (≥55%) que fueron considerados asintomáticos, sin indicación inicial de RVA. A todos se les realizó laboratorio con medición de NT-proBNP en forma basal y ecocardiograma con Doppler tisular consignando la onda S de la pared lateral (S lat) y la relación E/e´. Se consideró como punto final el requerimiento de reemplazo valvular durante el seguimiento. Resultados : Se incluyeron 133 pacientes con una edad de 69 ± 8 años, 49% mujeres. Luego de un seguimiento de 570 (rango intercuartilo 380-680) días, el 23,3% (n = 31) de los pacientes presentaron requerimiento de reemplazo valvular. En el aná lisis multivariado, el NT-proBNP y la relación E/e´ fueron predictores independientes de requerimiento de cirugía (HR 1,02, IC95% 1,001-1,03, p <0,001; y HR 1,42, IC95% 1,21-2,45, p<0,001, respectivamente). El NT-proBNP presentó un Área Bajo la Curva (ABC) mayor que la relación E/e´ (0,88 versus 0,64, p = 0,02). Se estableció como mejor punto de corte de NT-proBNP un valor >350 pg./mL (HR ajustado 1,55, IC95% 1,38-2,01, p <0,001). Conclusiones : El NT-proBNP y la relación E/e´ fueron predictores independientes de requerimiento de cirugía. El NT-proBNP presentó una muy buena capacidad de discriminación, mayor que la relación E/e´.

ABSTRACT Background : The aortic valve replacement (AVR) indication in asymptomatic patients with severe aortic stenosis (AS) and preserved function is being increasingly discussed. Objective : The aim of this study was to evaluate whether the elevation of the N-terminal fraction of the pro-B-type natriuretic peptide (NT-proBNP) predicts the occurrence of symptoms and the AVR indication in patients with severe AS and preserved left ventricular ejection fraction (LVEF), initially asymptomatic. Methods : Asymptomatic patients with severe AS, preserved EF (≥55%) and no initial AVR indication were prospectively included. All patients underwent laboratory tests measuring NT-proBNP at baseline and an echocardiogram with tissue Doppler recording the lateral wall S wave (lat. S) and the E/e´ ratio. The endpoint was the aortic valve replacement indication at follow-up. Results : We included 133 patients aged 69 ± 8 years, 49% of which were women. After a follow-up of 570 (interquartile range 380-680) days, 23.3% (n=31) of them required aortic valve replacement. In the multivariate analysis, NT-proBNP value and the E/e´ ratio were 2 independent predictors of surgery (HR 1.02, 95% CI 1.001-1.03) p<0.001 and HR 1.42, 95% CI 1.21- 2.45, p< 0.001, respectively). NT-proBNP presented an area under the curve (AUC) greater than the E/e' ratio (0.88 versus 0.64, p=0.02). The best NT-proBNP cut-off point was determined >350 pg/mL (adjusted HR 1.55, 95% CI 1.38-2.01, p<0.001) Conclusion : NT-proBNP value and the E/e´ ratio were independent predictors of the AVR requirement. NT-proBNP had a very good discrimination capacity, greater than the E/e´ ratio.

Reemplazo endovascular aórtico en un paciente con enfermedad de válvula aórtica bicúspide / Endovascular aortic replacement in a patient with bicuspid aortic valve disease

Resumen Un varón de 49 años ingresó en la unidad de cuidados coronarios, con antecedentes de miocardiopatía dilatada, con función sistólica del ventrículo izquierdo gravemente deteriorada y estenosis aórtica grave de origen bicúspide, sintomático para síncope, ángor y disnea de reciente diagnóstico. Durante la internación evolucionó con shock cardiogénico que requirió doble soporte inotrópico. Por presentar alto riesgo quirúrgico y elevada probabilidad de rechazo ante un eventual trasplante cardiaco, según sus estudios de histocompatibilidad, se procedió al reemplazo transcatéter de la válvula aortica, con evolución favorable.

Abstract A 49-year-old male with a history of left ventricular systolic function dilated cardiomyopathy and severe symptomatic bicuspid aortic stenosis recently diagnosed (syncope, chest pain and dyspnea) was admitted to the coronary care unit. During hospitalization, he developed cardiogenic shock requiring double inotropic support. High surgical risk and an elevated chance of graft rejection contraindicated surgical replacement or heart transplant. We performed a transcatheter aortic valve replacement with a favorable evolution.

The roadmap to transcatheter aortic valve implantation.

Nearly 300 years after the first description of aortic valve obstruction, it has taken less than two decades of randomized clinical trials (RCTs) for transcatheter aortic valve implantation (TAVI) to become a recognized strategy for patients with aortic stenosis. The high density of recent publications makes it easy to ignore the history that led to the development of this procedure. Knowing the evolution of a diagnostic or therapeutic technique improves critical reasoning, prevents repeated mistakes, paves the way for future research and contributes to an insightful perspective on the subject. Nevertheless, it should not overshadow the findings of recently published RCTs, which still are the mainstay of clinical practice. In this timeline review, the authors aim to recap the development of TAVI, combining the pathophysiology of aortic stenosis and the initial concept of TAVI with the roadmap of clinical trials that led to the generalization of the TAVI procedure.