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The Annals of Thoracic Surgery Jan 2024Aortic valve-sparing operations were developed >3 decades ago and have become part of the surgical armamentarium to treat patients with aortic root and ascending aortic... (Review)
Review
Aortic valve-sparing operations were developed >3 decades ago and have become part of the surgical armamentarium to treat patients with aortic root and ascending aortic aneurysms. Although remodeling of the aortic root is physiologically sounder than reimplantation of the aortic valve, most surgeons seem to prefer the latter. This review summarizes the views of one of the pioneers of aortic valve-sparing operation and includes their development, the various modifications that occurred over the years, comparative outcomes with aortic root replacement with valved conduits, outcomes from several recently reported series, and the future directions. The author argues that comparisons between aortic valve-sparing operations and aortic root replacement with valved conduits based on retrospective studies are inappropriate because these 2 types of surgery are performed in patients with different aortic valve pathology. Late outcomes after aortic valve-sparing operations have not been consistent among various reports and raise the question of surgical expertise and patients' selection. Aortic valve-sparing operations are the best treatment for young patients with aortic root aneurysm and normal aortic cusps. Further studies are needed to define their role in the management of patients with diseased aortic cusps.
Topics: Humans; Aortic Valve; Aortic Valve Insufficiency; Retrospective Studies; Treatment Outcome; Aortic Aneurysm
PubMed: 37778432
DOI: 10.1016/j.athoracsur.2023.09.027 -
Circulation Feb 2024The optimal treatment in patients with severe aortic stenosis and small aortic annulus (SAA) remains to be determined. This study aimed to compare the hemodynamic and... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
The optimal treatment in patients with severe aortic stenosis and small aortic annulus (SAA) remains to be determined. This study aimed to compare the hemodynamic and clinical outcomes between transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) in patients with a SAA.
METHODS
This prospective multicenter international randomized trial was performed in 15 university hospitals. Participants were 151 patients with severe aortic stenosis and SAA (mean diameter <23 mm) randomized (1:1) to TAVR (n=77) versus SAVR (n=74). The primary outcome was impaired valve hemodynamics (ie, severe prosthesis patient mismatch or moderate-severe aortic regurgitation) at 60 days as evaluated by Doppler echocardiography and analyzed in a central echocardiography core laboratory. Clinical events were secondary outcomes.
RESULTS
The mean age of the participants was 75.5±5.1 years, with 140 (93%) women, a median Society of Thoracic Surgeons predicted risk of mortality of 2.50% (interquartile range, 1.67%-3.28%), and a median annulus diameter of 21.1 mm (interquartile range, 20.4-22.0 mm). There were no differences between groups in the rate of severe prosthesis patient mismatch (TAVR, 4 [5.6%]; SAVR, 7 [10.3%]; =0.30) and moderate-severe aortic regurgitation (none in both groups). No differences were found between groups in mortality rate (TAVR, 1 [1.3%]; SAVR, 1 [1.4%]; =1.00) and stroke (TAVR, 0; SAVR, 2 [2.7%]; =0.24) at 30 days. After a median follow-up of 2 (interquartile range, 1-4) years, there were no differences between groups in mortality rate (TAVR, 7 [9.1%]; SAVR, 6 [8.1%]; =0.89), stroke (TAVR, 3 [3.9%]; SAVR, 3 [4.1%]; =0.95), and cardiac hospitalization (TAVR, 15 [19.5%]; SAVR, 15 [20.3%]; =0.80).
CONCLUSIONS
In patients with severe aortic stenosis and SAA (women in the majority), there was no evidence of superiority of contemporary TAVR versus SAVR in valve hemodynamic results. After a median follow-up of 2 years, there were no differences in clinical outcomes between groups. These findings suggest that the 2 therapies represent a valid alternative for treating patients with severe aortic stenosis and SAA, and treatment selection should likely be individualized according to baseline characteristics, additional anatomical risk factors, and patient preference. However, the results of this study should be interpreted with caution because of the limited sample size leading to an underpowered study, and need to be confirmed in future larger studies.
REGISTRATION
URL: https://www.clinicaltrials.gov; Unique identifier: NCT03383445.
Topics: Humans; Female; Aged; Aged, 80 and over; Male; Aortic Valve; Heart Valve Prosthesis Implantation; Aortic Valve Insufficiency; Prospective Studies; Aortic Valve Stenosis; Treatment Outcome; Heart Valve Prosthesis; Transcatheter Aortic Valve Replacement; Risk Factors; Stroke
PubMed: 37883682
DOI: 10.1161/CIRCULATIONAHA.123.067326 -
The Journal of Invasive Cardiology Sep 2023A 56-year-old man presented with typical angina for 1 day and a prior history of exertional dyspnea of 6 months duration. Clinically, he was diagnosed with severe aortic...
A 56-year-old man presented with typical angina for 1 day and a prior history of exertional dyspnea of 6 months duration. Clinically, he was diagnosed with severe aortic regurgitation (AR). Electrocardiogram showed left ventricular hypertrophy with volume overload.
Topics: Male; Humans; Middle Aged; Quadricuspid Aortic Valve; Angina Pectoris; Aortic Valve Insufficiency; Dyspnea; Electrocardiography
PubMed: 37983112
DOI: 10.25270/jic/22.00325 -
Indian Journal of Thoracic and... Dec 2023Valve-sparing procedures have been established as a durable option for treatment of patients with aortic root pathology. Complex cases where aortic valve-sparing root... (Review)
Review
UNLABELLED
Valve-sparing procedures have been established as a durable option for treatment of patients with aortic root pathology. Complex cases where aortic valve-sparing root replacement (VSRR) is applied require specific surgical techniques to ensure good outcomes. Herein, we review main concepts of VSRR and aortic valve repair. In addition, we provide three complex clinical scenarios: treatment of neo-aortic dilation after a Ross procedure, acute aortic insufficiency in a type A dissection, and chronic aortic insufficiency with a bicuspid aortic valve. Technical suggestions to achieve a safe and durable result are set forth.
SUPPLEMENTARY INFORMATION
The online version contains supplementary material available at 10.1007/s12055-023-01587-4.
PubMed: 38093922
DOI: 10.1007/s12055-023-01587-4 -
Primary Care Mar 2024Valvular heart disease is a common abnormality seen in the primary care setting. There are many causes of valvular heart disease including congenital, degenerative,... (Review)
Review
Valvular heart disease is a common abnormality seen in the primary care setting. There are many causes of valvular heart disease including congenital, degenerative, infectious, traumatic, and many more. There is a wide variety of types of valvular heart disease with each valve having the ability to develop both regurgitation and stenosis by multiple mechanisms. All these complexities make diagnosis and management of valvular heart disease complicated, especially in the context of comorbidities. For this reason, it is important for primary care physicians to have a thorough understanding of how these diseases present and when interventions are indicated.
Topics: Humans; Heart Valve Diseases; Mitral Valve Insufficiency
PubMed: 38278576
DOI: 10.1016/j.pop.2023.08.003 -
JACC. Cardiovascular Interventions Aug 2023Transcatheter aortic valve replacement (TAVR) in patients with pure severe native aortic valve regurgitation (NAVR) has been associated with suboptimal results. The...
BACKGROUND
Transcatheter aortic valve replacement (TAVR) in patients with pure severe native aortic valve regurgitation (NAVR) has been associated with suboptimal results. The available evidence concerns mostly outdated transcatheter heart valves (THVs).
OBJECTIVES
The aim of this study was to investigate the performance of new-generation THVs in patients treated for pure severe NAVR.
METHODS
The PANTHEON (Performance of Currently Available Transcatheter Aortic Valve Platforms in Inoperable Patients With Pure Aortic Regurgitation of a Native Valve) study retrospectively included patients who underwent TAVR with currently available devices (both self-expanding [SE] and balloon expandable [BE]) for severe NAVR. Technical and device success rates as well as a composite of all-cause mortality and heart failure rehospitalization at 1 year were evaluated. The rate and clinical consequences of acute transcatheter valve embolization or migration (TVEM) were also considered.
RESULTS
A total of 201 patients were included. Overall technical and device success rates were 83.6% and 76.1%, respectively, and did not differ between SE and BE devices. These figures were due mostly to TVEM occurrence (14.6% vs 16.1%; P = 0.47) and residual moderate or greater aortic regurgitation (9.2% vs 10.1%; P = 0.87). Patients who experienced TVEM compared with those without TVEM had a significantly higher incidence of the composite endpoint at 1 year (25.7% vs 15.8%; P = 0.05).
CONCLUSIONS
Despite improved THV platforms and techniques, TAVR for pure severe NAVR remains a challenging procedure, with significant risk for TVEM. SE and BE platforms demonstrated comparable performance in this setting. (Performance of Currently Available Transcatheter Aortic Valve Platforms in Inoperable Patients With Pure Aortic Regurgitation of a Native Valve [PANTHEON]; NCT05319171).
Topics: Humans; Transcatheter Aortic Valve Replacement; Aortic Valve Insufficiency; Aortic Valve; Retrospective Studies; Treatment Outcome
PubMed: 37648345
DOI: 10.1016/j.jcin.2023.07.026