-
JACC. Advances Mar 2024FAV is offered to fetuses with severe aortic valve stenosis and evolving hypoplastic left heart syndrome. An inferential analysis of TS and SAE in a large series has not...
BACKGROUND
FAV is offered to fetuses with severe aortic valve stenosis and evolving hypoplastic left heart syndrome. An inferential analysis of TS and SAE in a large series has not been reported.
OBJECTIVES
The purpose of this study was to determine factors associated with fetal aortic valvuloplasty (FAV) technical success (TS) and serious adverse events (SAEs).
METHODS
Retrospective, single-center, cohort analysis of attempted FAV from March 1, 2000, to December 31, 2020. The primary outcome was the TS of FAV, and the secondary outcome was the presence of an SAE.
RESULTS
A total of 165 FAVs were attempted in 163 patients with a median gestational age of 24.6 weeks (IQR: 22.9-27.1 weeks). FAV TS was 85% (141/165) and was higher in the 2010 to 2020 era (94% [85/90] vs 75% [56/75]; < 0.001). Pre-FAV echocardiographic left ventricle (LV) long axis dimension z-score >-0.10 ( < 0.001) and higher LV ejection fraction ( = 0.037) were independently associated with a higher odds of TS. There were 117 SAEs in 67 attempted FAVs (41%), 13 of which were fetal deaths (7.9%). By classification and regression tree analysis, gestational age <21 weeks or in older fetuses, a procedure time of ≥39.6 minutes was associated with higher SAE rate. In the multivariable logistic regression model correcting for gestational age, fetuses with an LV end-diastolic volume <4.09 mL had an age-adjusted OR of 4.71 (95% CI: 1.67-13.29; = 0.004) for experiencing an SAE.
CONCLUSIONS
TS of FAV has improved over time, and failure is associated with smaller fetal left heart sizes. SAEs are common and are associated with smaller left hearts and longer procedure times.
PubMed: 38938833
DOI: 10.1016/j.jacadv.2024.100835 -
JACC. Advances Mar 2024
PubMed: 38938831
DOI: 10.1016/j.jacadv.2024.100836 -
JACC. Advances Mar 2024
PubMed: 38938827
DOI: 10.1016/j.jacadv.2024.100826 -
JACC. Advances Mar 2024International guidelines recommend aortic valve replacement (AVR) as Class I triggers in high-gradient severe aortic stenosis (HGSAS) patients with symptoms and/or left...
BACKGROUND
International guidelines recommend aortic valve replacement (AVR) as Class I triggers in high-gradient severe aortic stenosis (HGSAS) patients with symptoms and/or left ventricular ejection fraction (LVEF) <50%. The association between waiting for these triggers and postoperative survival penalty is poorly studied.
OBJECTIVES
The purpose of this study was to examine the impact of guideline-based Class I triggers on long-term postoperative survival in HGSAS patients.
METHODS
2,030 patients operated for HGSAS were included and classified as follows: no Class I triggers (no symptoms and LVEF >50%, n = 853), symptoms with LVEF >50% (n = 965), or LVEF <50% regardless of symptoms (n = 212). Survival was compared after matching (inverse probability weighting) for clinical differences. Restricted mean survival time was analyzed to quantify lifetime loss.
RESULTS
Ten-year survival was better without any Class I trigger than with symptoms or LVEF <50% (67.1% ± 3% vs 56.4% ± 3% vs 53.1% ± 7%, respectively, < 0.001). Adjusted death risks increased significantly in operated patients with symptoms (HR: 1.45 [95% CI: 1.15-1.82]) or LVEF <50% (HR: 1.47 [95% CI: 1.05-2.06]) than in those without Class I triggers. Performing AVR with LVEF >60% produced similar outcomes to that of the general population, whereas operated patients with LVEF <60% was associated with a 10-year postoperative survival penalty. Furthermore, according to restricted mean survival time analyses, operating on symptomatic patients or with LVEF <60% led to 8.3- and 11.4-month survival losses, respectively, after 10 years, compared with operated asymptomatic patients with a LVEF >60%.
CONCLUSIONS
Guideline-based Class I triggers for AVR in HGSAS have profound consequences on long-term postoperative survival, suggesting that HGSAS patients should undergo AVR before trigger onset. Operating on patients with LVEF <60% is already associated with a 10-year postoperative survival penalty questioning the need for an EF threshold recommending AVR in HGSAS patients.
PubMed: 38938822
DOI: 10.1016/j.jacadv.2024.100830 -
JACC. Advances Nov 2023Prior studies of aortic valve replacement (AVR) in patients with normal-flow, low-gradient aortic stenosis (NF-LG AS) have demonstrated conflicting results regarding the...
BACKGROUND
Prior studies of aortic valve replacement (AVR) in patients with normal-flow, low-gradient aortic stenosis (NF-LG AS) have demonstrated conflicting results regarding the survival benefit of AVR. Changes in quality of life (QoL) after transcatheter AVR (TAVR) have not been reported in this population.
OBJECTIVES
The purpose of this study was to compare changes in QoL after TAVR for patients with NF-LG AS to patients with high-gradient aortic stenosis (HG-AS).
METHODS
Patients who underwent TAVR for severe aortic stenosis (AS) were divided into 4 hemodynamic profiles of AS, including NF-LG AS. Changes in Kansas City Cardiomyopathy Questionnaire-12 score from baseline to 1 year were compared between AS groups. The primary composite outcome indicating clinical improvement consisted of survival to 1 year and improved Kansas City Cardiomyopathy Questionnaire overall summary score of ≥5 points while adjusting for relevant baseline factors.
RESULTS
Out of 860 patients who underwent TAVR, high gradient AS was present in 368 (42.8%) patients and NF-LG AS in 245 (28.5%). HG-AS and NF-LG AS groups had a similar proportion of patients who met the primary unadjusted outcome of clinical improvement (70.4% vs 63.9%, respectively; = 0.189). One-year Kaplan-Meier mortality estimates were higher for NF-LG AS patients than HG-AS patients (12.9% vs 5.8%, < 0.001). In the primary adjusted analysis, there was no significant difference in the composite outcome between HG and NF-LG AS groups (adjusted OR: 0.72, 95% CI: 0.47-1.11).
CONCLUSIONS
Selected patients with NF-LG AS experienced similar improvement in QoL after TAVR compared with HG-AS. Further investigation of patients with NF-LG AS will help to inform optimal selection for treatment with TAVR.
PubMed: 38938726
DOI: 10.1016/j.jacadv.2023.100641 -
JACC. Advances Nov 2023Extent and progression of coronary artery calcification (CAC) are strong predictors of myocardial infarction and mortality.
BACKGROUND
Extent and progression of coronary artery calcification (CAC) are strong predictors of myocardial infarction and mortality.
OBJECTIVES
This study aims to investigate if vitamin K2 and D supplementation can reduce CAC progression.
METHODS
A total of 389 participants were randomized to supplementation with vitamin K2 (720 μg/day) and D (25 μg/day) vs placebo in a multicenter double-blinded randomized controlled trial. The primary endpoint (progression of aortic valve calcification) has been reported. This study reports CAC progression in participants with no ischemic heart disease. CT scans were performed at baseline, 12, and 24 months. ΔCAC and coronary plaque volume were evaluated in the entire group and in 2 subgroups. A safety endpoint was the composite of myocardial infarction, coronary revascularization, and all-cause mortality.
RESULTS
In total, 304 participants (male, mean age 71 years) were identified. The intervention and placebo group both increased in mean CAC scores from baseline to 24-month follow-up (Δ203 vs Δ254 AU, = 0.089). In patients with CAC scores ≥400 AU, CAC progression was lower by intervention (Δ288 vs Δ380 AU, = 0.047). Plaque analyses showed no significant difference in progression of noncalcified plaque volume (Δ-6 vs Δ46 mm, = 0.172). Safety events were fewer in participants receiving supplementation (1.9% vs 6.7%, = 0.048).
CONCLUSIONS
Patients with no prior ischemic heart disease randomized to vitamin K2 and D supplementation had no significant reduction in mean CAC progression over a 2-year follow-up compared to placebo. Although the primary endpoint is neutral, differential responses to supplementation in those with CAC scores ≥400 AU and in safety endpoints are hypothesis-generating for future studies.
PubMed: 38938724
DOI: 10.1016/j.jacadv.2023.100643 -
JACC. Advances Nov 2023
PubMed: 38938711
DOI: 10.1016/j.jacadv.2023.100640 -
European Heart Journal. Case Reports Jun 2024The surface of the aorta generally does not show motion unless mobile atheroma, thrombi, vegetations, or intimal flaps are present. We previously described unusual...
BACKGROUND
The surface of the aorta generally does not show motion unless mobile atheroma, thrombi, vegetations, or intimal flaps are present. We previously described unusual mobile filamentous structures in the carotid artery. Here, we describe similar findings in the aorta and their possible cause.
CASE SUMMARY
An 88-year-old female with progressive exertional dyspnoea and severe aortic stenosis had a successful transcatheter aortic valve replacement (TAVR). A filamentous structure was noted on the focused pre-operative 2D transoesophageal echocardiography in the proximal descending aorta and post-TAVR as long strand-like structures attached to the thickened intimal wall with a planar component on 3D imaging. These findings were not associated with symptoms or clinical sequelae on short- and long-term follow-up.
DISCUSSION
The mobile structures that we describe are atypical for atheroma, thrombi, vegetations, and dissections in terms of their form and clinical presentation. 2D imaging showed that the filaments had focal thickening and emerged from the aortic surface. These findings suggest a relationship with the intima, perhaps from atherogenesis or injury with disruption or lifting of the intimal surface. No clinical sequelae were detected that may also relate to their position in the descending aorta and not the arch.
PubMed: 38938470
DOI: 10.1093/ehjcr/ytae263 -
European Heart Journal. Case Reports Jun 2024Left ventricular assist devices (LVADs) are increasingly utilized in cardiogenic shock and high-risk percutaneous coronary interventions (PCIs). These devices aspirate...
BACKGROUND
Left ventricular assist devices (LVADs) are increasingly utilized in cardiogenic shock and high-risk percutaneous coronary interventions (PCIs). These devices aspirate and expel blood from the left ventricle (LV) into the aorta, consequently reducing left ventricular end-diastolic pressure (LVEDP). We report a case of unexpected LVEDP rise under LV-to-aorta LVAD in the context of transcatheter aortic valve implantation (TAVI) and concomitant multi-vessel PCI.
CASE SUMMARY
A patient with acute heart failure, severely depressed systolic LV function, severe aortic stenosis, and multi-vessel coronary artery disease underwent TAVI and concomitant PCI under pulsatile LVAD. Notably, the patient experienced unexpected shortness of breath and elevated LVEDP while under LVAD, which normalized immediately upon LVAD removal.
DISCUSSION
Pulsatile LVAD enhances cardiac output by providing pulsatile support through a percutaneous bi-directional flow catheter. Despite expectations of reduced LVEDP and improved myocardial oxygen supply under LVAD support, we observed high LVEDP and clinical complaints of shortness of breath following TAVI and multi-vessel PCI. This case illustrates that an LVAD across the aortic valve may immobilize aortic leaflets and generate acute aortic regurgitation.
PubMed: 38938469
DOI: 10.1093/ehjcr/ytae291 -
JACC. Advances Oct 2023Traditional methods of risk assessment for thoracic aortic aneurysm (TAA) based on aneurysm size alone have been called into question as being unreliable in predicting...
BACKGROUND
Traditional methods of risk assessment for thoracic aortic aneurysm (TAA) based on aneurysm size alone have been called into question as being unreliable in predicting complications. Biomechanical function of aortic tissue may be a better predictor of risk, but it is difficult to determine in vivo.
OBJECTIVES
This study investigates using a machine learning (ML) model as a correlative measure of energy loss, a measure of TAA biomechanical function.
METHODS
Biaxial tensile testing was performed on resected TAA tissue collected from patients undergoing surgery. The energy loss of the tissue was calculated and used as the representative output. Input parameters were collected from clinical assessments including observations from medical scans and genetic paneling. Four ML algorithms including Gaussian process regression were trained in Matlab.
RESULTS
A total of 158 patients were considered (mean age 62 years, range 22-89 years, 78% male), including 11 healthy controls. The mean ascending aortic diameter was 47 ± 10 mm, with 46% having a bicuspid aortic valve. The best-performing model was found to give a greater correlative measure to energy loss (R = 0.63) than the surprisingly poor performance of aortic diameter (R = 0.26) and indexed aortic size (R = 0.32). An echocardiogram-derived stiffness metric was investigated on a smaller subcohort of 67 patients as an additional input, improving the correlative performance from R = 0.46 to R = 0.62.
CONCLUSIONS
A preliminary set of models demonstrated the ability of a ML algorithm to improve prediction of the mechanical function of TAA tissue. This model can use clinical data to provide additional information for risk stratification.
PubMed: 38938360
DOI: 10.1016/j.jacadv.2023.100637