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The Canadian Journal of Cardiology Feb 2024In this narrative review, we aim to summarize the literature surrounding the assessment and management of the common, yet understudied combination of aortic stenosis... (Review)
Review
In this narrative review, we aim to summarize the literature surrounding the assessment and management of the common, yet understudied combination of aortic stenosis (AS) and mitral regurgitation (MR), the components of which are complexly inter-related and interdependent from diagnostic, prognostic, and therapeutic perspectives. The hemodynamic interdependency of AS and MR confounds the assessment of the severity of each valve disease, thus underscoring the importance of a multimodal approach integrating valvular and extravalvular indicators of severity. A large body of literature suggests that baseline MR is associated with reduced survival post aortic valve (AV) intervention and that regression of MR post-AV intervention confers a mortality benefit. Functional MR is more likely to regress after AV intervention than primary MR. The respective natural courses of the 2 valve diseases are not synchronized; therefore, significant AS and MR at or above the respective threshold for intervention might not coincide. Surgery is primarily a 1-stop-shop procedure because of a considerable perioperative risk of repeat interventions, whereas transcatheter treatment modalities allow for a more tailored timing of intervention with reassessment of concomitant MR after AV replacement and a potential staged intervention in the absence of MR regression. In summary, AS and MR, when combined, are interlaced into a complex hemodynamic, diagnostic, and prognostic synergy, with important therapeutic implications. Contemporary approaches should consider stepwise intervention by exploiting the advantage of transcatheter options. However, evidence is needed to demonstrate the efficacy of different timing and therapeutic options.
Topics: Humans; Mitral Valve Insufficiency; Treatment Outcome; Aortic Valve Stenosis; Aortic Valve; Transcatheter Aortic Valve Replacement; Severity of Illness Index
PubMed: 37931671
DOI: 10.1016/j.cjca.2023.11.003 -
Journal of Cardiovascular Development... Jan 2024Surgical repair for regurgitant bicuspid aortic valve (BAV) is promising but underutilized due to perceived complexities and lack of long-term data. This study evaluated...
Surgical repair for regurgitant bicuspid aortic valve (BAV) is promising but underutilized due to perceived complexities and lack of long-term data. This study evaluated the efficacy of valve-sparing root remodeling (VSRR) or isolated valve repair combined with calibrated external ring annuloplasty in BAV versus tricuspid aortic valve (TAV) patients. All patients operated on for aortic regurgitation and/or aneurysm at our institution between 2014 and 2022 were included and entered into the Aortic Valve Insufficiency and ascending aorta Aneurysm InternATiOnal Registry (AVIATOR). Patients with successful repair at index surgery (100% in the BAV group, 93% in the TAV group, = 0.044) were included in a systemic follow-up with echocardiography at regular intervals. Among 132 patients, 58 were in the BAV (44%) and 74 in the TAV group (56%). There were no inter-group differences in preoperative patient characteristics, except BAV patients being significantly younger (47 ± 18 y vs. 60 ± 14 y, < 0.001) and having narrower aortic roots at the level of sinuses (41 ± 6 mm vs. 46 ± 13 mm, < 0.001) and sinotubular junctions (39 ± 10 mm vs. 42 ± 11, = 0.032). No perioperative deaths were recorded. At four years, there was no significant difference in terms of overall survival (96.3% BAV vs. 97.2% TAV, = 0.373), freedom from valve reintervention (85.2% BAV vs. 93.4% TAV, = 0.905), and freedom from severe aortic regurgitation (94.1% BAV vs. 82.9% TAV, = 0.222). Surgical repair of BAV combined with extra-aortic annuloplasty can be performed with low perioperative morbidity and mortality and excellent mid-term results which are comparable to TAV repair.
PubMed: 38248887
DOI: 10.3390/jcdd11010017 -
Journal of the American Heart... Sep 2023Background There is little evidence about the prognostic role of mitral regurgitation (MR) in patients with low-flow, low-gradient aortic stenosis undergoing...
Background There is little evidence about the prognostic role of mitral regurgitation (MR) in patients with low-flow, low-gradient aortic stenosis undergoing transcatheter aortic valve replacement (TAVR). The aim of this study was to assess the prevalence and outcome implications of MR severity in patients with low-flow, low-gradient aortic stenosis undergoing TAVR, and to evaluate whether MR improvement after TAVR could influence clinical outcome. Methods and Results This study included consecutive patients with low-flow, low-gradient aortic stenosis undergoing TAVR at 2 Italian high-volume centers. The study population was categorized according to the baseline MR severity and to the presence of MR improvement at discharge. The primary outcome was the composite of all-cause death and hospitalization for worsening heart failure up to 1 year. The study included 268 patients; 57 (21%) patients showed MR >2+. Patients with MR >2+ showed a lower 1-year survival free from the primary outcome (<0.001), all-cause death (<0.001), and heart failure hospitalization (<0.001) compared with patients with MR ≤2+. At multivariable analysis, baseline MR >2+ was an independent predictor of the primary outcome (<0.001). Among patients with baseline MR >2+, MR improvement was reported in 24 (44%) cases after TAVR. The persistence of MR was associated with a significantly reduced survival free from the primary outcome, all-cause death, and heart failure hospitalization up to 1 year. Conclusions In this study, the presence of moderately severe to severe MR in patients with low-flow, low-gradient aortic stenosis undergoing TAVR portends a worse clinical outcome at 1 year. TAVR may improve MR severity in nearly half of the patients, resulting in a potential outcome benefit after discharge.
Topics: Humans; Mitral Valve Insufficiency; Prognosis; Transcatheter Aortic Valve Replacement; Aortic Valve Stenosis; Heart Failure
PubMed: 37646211
DOI: 10.1161/JAHA.123.029553 -
Texas Heart Institute Journal Apr 2024Quadricuspid aortic valve is a rare congenital cardiac anomaly with an incidence of 0.008% to 0.043%. Its clinical course varies depending on cusp anatomy, function, and...
Quadricuspid aortic valve is a rare congenital cardiac anomaly with an incidence of 0.008% to 0.043%. Its clinical course varies depending on cusp anatomy, function, and associated cardiac malformations. It frequently progresses to aortic valve regurgitation that may require surgical valve replacement. Detection has shifted from incidental discovery during autopsies or cardiac surgeries in the early 20th century to various cardiac imaging methods in recent decades. In addition to contributing to the literature, this report supports the use of transesophageal echocardiography more liberally to detect aortic valve abnormalities. The case presents a 48-year-old female patient with an incidentally discovered quadricuspid aortic valve.
Topics: Humans; Female; Aortic Valve; Middle Aged; Echocardiography, Transesophageal; Incidental Findings; Aortic Valve Insufficiency; Heart Defects, Congenital; Predictive Value of Tests; Heart Valve Prosthesis Implantation; Echocardiography, Doppler, Color
PubMed: 38686682
DOI: 10.14503/THIJ-23-8256 -
BMC Cardiovascular Disorders Jan 2024The published studies comparing transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR) in pure aortic regurgitation (AR) are... (Meta-Analysis)
Meta-Analysis
INTRODUCTION
The published studies comparing transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR) in pure aortic regurgitation (AR) are conflicting. We conducted this systematic review and meta-analysis to compare TAVI with SAVR in pure AR.
METHODS
We searched PubMed, Embase, Web of Science (WOS), Scopus, and the Cochrane Library Central Register of Controlled Trials (CENTRAL) from inception until 23 June 2023. Review Manager was used for statistical analysis. The risk ratio (RR) with a 95% confidence interval (CI) was used to compare dichotomous outcomes. Continuous outcomes were compared using the mean difference (MD) and 95% CI. The inconsistency test (I) assessed the heterogeneity. We used the Newcastle-Ottawa scale to assess the quality of included studies. We evaluated the strength of evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) scale.
RESULTS
We included six studies with 5633 patients in the TAVI group and 27,851 in SAVR. In-hospital mortality was comparable between TAVI and SAVR (RR = 0.89, 95% CI [0.56, 1.42], P = 0.63) (I = 86%, P < 0.001). TAVI was favored over SAVR regarding in-hospital stroke (RR = 0.50; 95% CI [0.39, 0.66], P < 0.001) (I = 11%, P = 0.34), in-hospital acute kidney injury (RR = 0.56; 95% CI: [0.41, 0.76], P < 0.001) (I = 91%, P < 0.001), major bleeding (RR = 0.23; 95% CI: [0.17, 0.32], P < 0.001) (I = 78%, P < 0.001), and shorter hospital say (MD = - 4.76 days; 95% CI: [- 5.27, - 4.25], P < 0.001) (I = 88%, P < 0.001). In contrast, TAVI was associated with a higher rate of pacemaker implantation (RR = 1.68; 95% CI: [1.50, 1.88], P < 0.001) (I = 0% P = 0.83).
CONCLUSION
TAVI reduces in-hospital stroke and is associated with better safety outcomes than SAVR in patients with pure AR.
Topics: Humans; Aortic Valve; Transcatheter Aortic Valve Replacement; Aortic Valve Insufficiency; Acute Kidney Injury; Stroke
PubMed: 38262990
DOI: 10.1186/s12872-023-03667-0 -
Journal of the American Heart... Sep 2023
Topics: Humans; Transcatheter Aortic Valve Replacement; Mitral Valve Insufficiency; Prognosis; Patients; Aortic Valve Stenosis
PubMed: 37646206
DOI: 10.1161/JAHA.123.031400 -
Circulation Jun 2024Sodium-glucose cotransporter-2 inhibitors (SGLT2i) consistently improve heart failure and kidney-related outcomes; however, effects on major adverse cardiovascular... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Sodium-glucose cotransporter-2 inhibitors (SGLT2i) consistently improve heart failure and kidney-related outcomes; however, effects on major adverse cardiovascular events (MACE) across different patient populations are less clear.
METHODS
This was a collaborative trial-level meta-analysis from the SGLT2i Meta-analysis Cardio-Renal Trialists Consortium, which includes all phase 3, placebo-controlled, outcomes trials of SGLT2i across 3 patient populations (patients with diabetes at high risk for atherosclerotic cardiovascular disease, heart failure [HF], or chronic kidney disease). The outcomes of interest were MACE (composite of cardiovascular death, myocardial infarction , or stroke), individual components of MACE (inclusive of fatal and nonfatal events), all-cause mortality, and death subtypes. Effect estimates for SGLT2i versus placebo were meta-analyzed across trials and examined across key subgroups (established atherosclerotic cardiovascular disease, previous myocardial infarction, diabetes, previous HF, albuminuria, chronic kidney disease stages, and risk groups).
RESULTS
A total of 78 607 patients across 11 trials were included: 42 568 (54.2%), 20 725 (26.4%), and 15 314 (19.5%) were included from trials of patients with diabetes at high risk for atherosclerotic cardiovascular disease, HF, or chronic kidney disease, respectively. SGLT2i reduced the rate of MACE by 9% (hazard ration [HR], 0.91 [95% CI, 0.87-0.96], <0.0001) with a consistent effect across all 3 patient populations (=0%) and across all key subgroups. This effect was primarily driven by a reduction in cardiovascular death (HR, 0.86 [95% CI, 0.81-0.92], <0.0001), with no significant effect for myocardial infarction in the overall population (HR, 0.95 [95% CI, 0.87-1.04], =0.29), and no effect on stroke (HR, 0.99 [95% CI, 0.91-1.07], =0.77). The benefit for cardiovascular death was driven primarily by reductions in HF death and sudden cardiac death (HR, 0.68 [95% CI, 0.46-1.02] and HR, 0.86 [95% CI, 0.78-0.95], respectively) and was generally consistent across subgroups, with the possible exception of being more apparent in those with albuminuria (=0.02).
CONCLUSIONS
SGLT2i reduce the risk of MACE across a broad range of patients irrespective of atherosclerotic cardiovascular disease, diabetes, kidney function, or other major clinical characteristics at baseline. This effect is driven primarily by a reduction of cardiovascular death, particularly HF death and sudden cardiac death, without a significant effect on myocardial infarction in the overall population, and no effect on stroke. These data may help inform selection for SGLT2i therapies across the spectrum of cardiovascular-kidney-metabolic disease.
Topics: Sodium-Glucose Transporter 2 Inhibitors; Humans; Cardiovascular Diseases; Renal Insufficiency, Chronic; Diabetes Mellitus, Type 2; Female; Male; Treatment Outcome; Aged
PubMed: 38583093
DOI: 10.1161/CIRCULATIONAHA.124.069568 -
Journal of Cardiothoracic Surgery Jan 2024In the current study, we aimed to report the short- and mid-term outcomes of patients undergoing valve-sparing aortic root reimplantation (VSARR) and our center's...
BACKGROUND
In the current study, we aimed to report the short- and mid-term outcomes of patients undergoing valve-sparing aortic root reimplantation (VSARR) and our center's experience with the procedure.
METHODS
Forty patients with aortic root aneurysms underwent VSARR at our center from 2010 until 2022. We retrospectively reviewed the medical records of these patients and extracted the relevant data. After carefully examining the aortic valve, the surgeon decided to perform Bentall or David's procedure during the operation.
RESULTS
The study population comprised 31 (77.5%) men and nine (22.5%) women, with a mean age of 55.35 ± 15.40. One patient developed hemodynamic instability post-surgery in the hospital and died from multi-organ failure. Another patient had severe AI in the intraoperative echocardiography, and aortic valve replacement with a prosthetic graft was performed during the same operation. In pre-operation echocardiography, 25 (62.5%) patients had severe, nine (22.5%) had moderate, and six (15%) had mild AI. In the in-hospital post-operation follow-up echo, AI was improved, and no patients had severe AI (P < 0.001). Only eight patients had moderate AI in post-one-year follow-up echo exams, while the rest had mild AI.
CONCLUSION
David's procedure showed excellent mid-term results in our center, with only one in-hospital mortality.
Topics: Male; Humans; Female; Adult; Middle Aged; Aged; Aortic Valve Insufficiency; Aorta, Thoracic; Retrospective Studies; Treatment Outcome; Aortic Valve; Heart Valve Prosthesis Implantation; Replantation
PubMed: 38297332
DOI: 10.1186/s13019-024-02546-9 -
Annals of Cardiac Anaesthesia Jan 2024The quadricuspid aortic valve is a rare congenital anomaly, usually associated with aortic regurgitation requiring surgical intervention. It may be associated with other...
The quadricuspid aortic valve is a rare congenital anomaly, usually associated with aortic regurgitation requiring surgical intervention. It may be associated with other congenital anomalies such as coronary anomalies, patent ductus arteriosus, ventricular septal defect, pulmonary stenosis, and subaortic stenosis. The diagnosis is generally established by either transthoracic or transesophageal echocardiography. Herein, we report a case of a 52-year-old woman who was diagnosed to have quadricuspid aortic valve by intraoperative transesophageal echocardiography.
Topics: Humans; Female; Aortic Valve; Middle Aged; Echocardiography, Transesophageal; Aortic Valve Insufficiency; Heart Defects, Congenital
PubMed: 38722121
DOI: 10.4103/aca.aca_110_23