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Aortic stenosis is a progressive disease that develops over decades, and once symptomatic and untreated, is associated with poor survival. Transcatheter aortic valve replacement has evolved significantly in the past decade and has expanded its indication from surgically inoperable and high-risk patients to patients with intermediate risk. Assessmen...
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... data have shown that the time from the onset of symptoms to death is about 2 years in patients who develop heart failure (HF) symptoms, 3 years in those who present with a syncope and 5 years in those presenting with angina. 2 The Long-term follow-up of the Placement of Aortic Transcatheter Valves (PARTNER 1B) trial showed that two-thirds of inoperable patients who followed standard treatment did not survive beyond 2 years, while transcatheter aortic valve replacement (TAVR) halved mortality. 3 Stages of cardiac damage in patients with severe AS have recently been defined ( Figure 1). 4 hospitalisation rate (17% versus 7%) and stroke rate (6% versus 2%). ...
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Acute decompensated heart failure (ADHF) due to severe aortic stenosis (AS) and concomitant left ventricular outflow tract (LVOT) obstruction is a serious condition. Treatment with medication alone is sometimes difficult, and the efficacy of further interventional strategies has not been fully elucidated. In patients with high surgical risks, combi...
Citations
... Clinical data research has found that the incidence of severe aortic stenosis is about 3% in people over 75 years old (Lindroos et al., 1993). Aortic stenosis leads to a decrease in cardiac output and may be accompanied by aortic regurgitation, resulting in systemic hypoperfusion, long-term consequences may include cardiac hypertrophy, dilation, and severe heart failure (Kanwar et al., 2018;Pibarot et al., 2019;Spitzer et al., 2019). Transcatheter aortic valve replacement (TAVR) is a minimally invasive surgery developed in recent years for the treatment of aortic stenosis, mainly suitable for patients who are inoperable or at high risk. ...
Transcatheter aortic valve replacement (TAVR) is a minimally invasive interventional solution for treating aortic stenosis. The complex post-TAVR complications are associated with the type of valve implanted and the position of the implantation. The study aimed to establish a rapid numerical research method for TAVR to assess the performance differences of self-expanding valves released at various positions. It also aimed to calculate the risks of postoperative paravalvular leak and atrioventricular conduction block, comparing these risks to clinical outcomes to verify the method’s effectiveness and accuracy. Based on medical images, six cases were established, including the aortic wall, native valve and calcification; one with a bicuspid aortic valve and five with tricuspid aortic valves. The parameters for the stent materials used by the patients were customized. High strain in the contact area between the stent and the valve annulus may lead to atrioventricular conduction block. Postoperatively, the self-expanding valve maintained a circular cross-section, reducing the risk of paravalvular leak and demonstrating favorable hemodynamic characteristics, consistent with clinical observations. The outcomes of the six simulations showed no significant difference in valve frame morphology or paravalvular leak risk compared to clinical results, thereby validating the numerical simulation process proposed for quickly selecting valve models and optimal release positions, aiding in TAVR preoperative planning based on patients’geometric characteristics.
... The other cardiovascular task we consider is the detection of AS, which is a condition in which the aortic valve becomes calcified and narrowed, and is typically detected using spectral Doppler measurements [21,17]. High inter-observer variability, limited access to expert cardiac physicians, and the unavailability of spectral Doppler in many point-of-care ultrasound devices are challenges that can be addressed through the use of automatic AS detection models. ...
Echocardiography (echo) is an ultrasound imaging modality that is widely used for various cardiovascular diagnosis tasks. Due to inter-observer variability in echo-based diagnosis, which arises from the variability in echo image acquisition and the interpretation of echo images based on clinical experience, vision-based machine learning (ML) methods have gained popularity to act as secondary layers of verification. For such safety-critical applications, it is essential for any proposed ML method to present a level of explainability along with good accuracy. In addition, such methods must be able to process several echo videos obtained from various heart views and the interactions among them to properly produce predictions for a variety of cardiovascular measurements or interpretation tasks. Prior work lacks explainability or is limited in scope by focusing on a single cardiovascular task. To remedy this, we propose a General, Echo-based, Multi-Level Transformer (GEMTrans) framework that provides explainability, while simultaneously enabling multi-video training where the inter-play among echo image patches in the same frame, all frames in the same video, and inter-video relationships are captured based on a downstream task. We show the flexibility of our framework by considering two critical tasks including ejection fraction (EF) and aortic stenosis (AS) severity detection. Our model achieves mean absolute errors of 4.15 and 4.84 for single and dual-video EF estimation and an accuracy of 96.5 % for AS detection, while providing informative task-specific attention maps and prototypical explainability.
... This is in agreement with the findings by Dweck, et al, who investigated the patterns of LV hypertrophy in patients with moderate and severe AS (AV peak velocity ≥3.0 m/s and AVA <1.5 cm 2 ), and found that the degree of AS severity was unrelated to LV mass by CMR. 31 Also, although heart failure in patients with severe AS is associated with a particularly poor prognosis, HF has multiple etiologies beyond LV pressure load due to valvular obstruction, e.g. hypertension, ischemic heart disease, infiltrative myocardial disease, which can occur at any grade of AS. 32,33 Our results are limited by the lack of important clinical information such as concomitant CV disease, medications, biomarkers, or future AVR. This does not have a sizable effect on the results regarding the primary aim of this study, i.e. to compare AVAi vs. ELI, since that comparison is made with the same data, and the same limitations thus are present for both AVA measures. ...
Background: Evidence of improved risk assessment in aortic stenosis (AS) by using energy-loss index (ELI) instead of aortic valve area indexed to body surface area (AVAi) is scarce, and positive results have been driven by aortic valve replacement. We aimed to evaluate the prognostic performance of ELI and AVAi in a head-to-head comparison using large-scale, real-world data.
Methods: In the multi-center, mortality-data linked National Echocardiography Database of Australia (NEDA), patients with AS and requisite ascending aortic area measurements were identified. The prognostic value of AVAi and ELI, respectively, was analyzed using Cox regression and the C statistic.
Results: In patients with mild AS (n=3,179), moderate AS (n=4,194), and severe AS (n=3,120), there were 4,229 deaths of which 2,359 were reported as cardiovascular deaths (median [interquartile range] follow-up 2.5 [1.1-4.5] years]. Decreasing AVAi was associated with increased cardiovascular mortality (hazard ratio [95% confidence interval] 1.18 [1.16-1.20] per 0.1 cm2/m2 downward increment]. Prognostic performance for 5-year mortality did not improve by using ELI instead of AVAi (identical C statistics 0.626 [0.612-0.640]), and the relative performance did not change when analyzing 1-year cardiovascular mortality, or all-cause mortality.
Conclusion: ELI was not associated with improved prognostic performance compared to AVAi in echocardiographic assessment of AS using large-scale, real-world clinical data. AVAi remains a relevant measure for risk prediction in AS, providing information on incremental risk with decreasing area.
... Degenerative aortic stenosis (AS) is the most common valvular heart disease encountered in developed countries that requires an appropriate therapeutic approach [1,2]. The clinical picture is marked by a long-term paucisymptomatic evolution that coincides with the typical clinical picture which, in the absence of procedural valve replacement treatment (surgical or minimally invasive), leads to a poor prognosis [3,4]. ...
(1) Background: Aortic stenosis is the most common valvulopathy in elderly patients over 60 years of age. The absence of immediate surgical intervention through classic valve replacement or through a minimally invasive procedure, namely transcatheter implantation of the aortic valve (TAVI) leads to an increase in the risk of morbidity and mortality through the deterioration of the clinical condition. Since the first interventional transcatheter aortic valve implantation procedure was performed in 2012 and until now, the progression of medical technology and state-of-the-art valves have led to the refinement of the treatment strategy and the improvement of the prognosis of patients with aortic stenosis undergoing TAVI in the first 6 months after the procedure; (2) Methods: We conducted a prospective study in which 86 patients diagnosed with severe aortic stenosis underwent minimally invasive valve replacement by TAVI; (3) Results: The presence of preoperative anemia is associated with a negative prognosis both in the medium term and in evolution, and in addition to hematological parameters, we also evaluated a series of biochemical data, with special attention to renal function and lipid profile; (4) Conclusions: Biological parameters followed after TAVI may be predictors associated with a negative long-term prognosis.
... Heart failure (HF) is one of the most common comorbidities among patients who undergo transcatheter aortic valve implantation (TAVI). 1 Current literature on short-term outcomes among these high-risk patients remains limited. ...
Heart failure (HF) is one of the most common comorbidities among patients who undergo transcatheter aortic valve implantation (TAVI). Current literature on short-term outcomes among these high-risk patients remains limited. Hence, we evaluated the 30-day readmission outcomes of patients hospitalized with HF during index admission for TAVI.
... Myocardial oxygen consumption increases due to left ventricular hypertrophy, resulting in an imbalance between myocardial oxygen supply and demand, leading to an increased risk of congestive heart failure and sudden death. [1,2] To increase myocardial oxygen supply and maintain the myocardial oxygen supply-demand balance in patients with hypertrophic cardiomyopathy and aortic stenosis, it is crucial to maintain an appropriate heart rate, normal left ventricular diastolic volume (preload), and normal systemic vascular resistance (afterload), while limiting myocardial contractility and maintaining coronary blood flow. [1,3] Anaphylaxis in patients with aortic stenosis induces an acute increase in heart rate and myocardial contractility while also reducing the preload and afterload. ...
Rationale:
We present the first case of a patient with severe aortic stenosis who developed anaphylactic shock and was successfully treated with adrenaline and landiolol, a highly selective β1-receptor blocker, to prevent disruption of the myocardial oxygen supply-demand balance caused by tachycardia.
Patient concerns:
An 86-year-old woman was scheduled for simultaneous anterior-posterior fixation for a burst fracture of the 12th thoracic vertebra; 200 mg sugammadex, a neuromuscular blocking agent antagonist, was administered postoperatively, and she was extubated without complications. However, 6 min after extubation, her blood pressure decreased abruptly to 55/29 mm Hg, and her heart rate increased to 78 bpm. Then, we intervened with fluid loading, an increased dose of noradrenaline, and phenylephrine administration. However, her blood pressure did not increase.
Diagnoses:
A general observation revealed urticaria on the lower leg; thus, we suspected anaphylactic shock due to sugammadex administration.
Interventions:
We carefully administered 2 doses of 0.05 mg adrenaline and simultaneously administered landiolol at 60 μg/kg/min to suppress adrenaline-induced tachycardia. Adrenaline administration resulted in a rapid increase in blood pressure to 103/66 mm Hg and a maximum heart rate of 100 bpm, suppressing excessive tachycardia.
Outcomes:
The patient's general condition was stable after the intervention, and circulatory agonists could be discontinued the following day. She was discharged from the intensive care unit on the fourth postoperative day.
Lessons:
Landiolol may help control the heart rate of patients with aortic stenosis and anaphylactic shock. The combined use of landiolol and adrenaline may improve patient outcomes; however, their efficacy and risks must be evaluated by studying additional cases.
... The left ventricle (LV) responds to pressure overload imposed by the stenotic aortic valve, increasing wall thickness while the left atrium enlarges. 4 Over time, the LV becomes less compliant, worsening the diastolic function. Without AVI, dilation of the LV cavity occurs, leading to a worsened systolic function. ...
Aims
To study clinical phenotype, prognosis for all‐cause and cardiovascular (CV) mortality and predictive factors in patients with incident heart failure (HF) after aortic valvular intervention (AVI) for aortic stenosis (AS).
Methods and results
In this retrospective, observational study we included patients from the Swedish Heart Failure Registry (SwedeHF) recorded 2003–2016, with AS diagnosis and AVI before HF diagnosis. The AS diagnosis was established according to International Classification of Diseases 10th revision (ICD‐10) codes, thus without information concerning clinical or echocardiographical data on the aortic valve disease. The patients were divided into two subgroups: left ventricular ejection fraction (LVEF) ≥ 50% (AS‐HFpEF) and <50% (AS‐HFrEF). We individually matched three controls with HF from the SwedeHF without AS (control group) for each patient. Baseline characteristics, co‐morbidities, survival status and outcomes were obtained by linking the SwedeHF with two other Swedish registries. We used Kaplan–Meier curves to present time to all‐cause mortality, cumulative incidence function for time to CV mortality and Cox proportional hazards model to evaluate the relative difference between AS‐HFrEF and AS‐HFpEF and AS‐HF and controls. The crude all‐cause mortality was 49.0%, CV mortality 27.9% in AS‐HF patients, respectively 44.7% and 26.6% in matched controls. The adjusted risk for all‐cause mortality and CV mortality was similar in HF, regardless of LVEF vs. controls. No significant difference in factors predicting higher all‐cause mortality was observed in AS‐HFrEF vs. AS‐HFpEF, except for diabetes (only in AS‐HFrEF), with statistically significant interaction predicting death between the two groups.
Conclusions
In this nationwide SwedeHF study, we characterized incident HF population after AVI. We found no significant differences in all‐cause and CV mortality compared with general HF population. They had virtually the same predictors for mortality, regardless of LVEF.
... Degenerative aortic valve stenosis is the most common valvular cardiac disease in developed countries and affects more than 4% of North American and European citizens [1,2]. Surgical aortic valve replacement (AVR) with the use of cardiopulmonary bypass (CPB) is one of several treatment options. ...
Background
Recently adopted mini-thoracotomy approach for surgical aortic valve replacement has shown benefits such as reduced pain and shorter recovery, compared to more conventional mini-sternotomy access. However, whether limited exposure of the heart and ascending aorta resulting from an incision in the second intercostal space may lead to increased intraoperative cerebral embolization and more prominent postoperative neurologic decline, remains inconclusive. The aim of our study was to assess potential neurological complications after two different minimal invasive surgical techniques for aortic valve replacement by measuring cerebral microembolic signal during surgery and by follow-up cognitive evaluation.
Methods
Trans-cranial Doppler was used for microembolic signal detection during aortic valve replacement performed via mini-sternotomy and mini-thoracotomy. Patients were evaluated using Addenbrooke’s Cognitive Examination Revised Test before and 30 days after surgical procedure.
Results
A total of 60 patients were recruited in the study. In 52 patients, transcranial Doppler was feasible. Of those, 25 underwent mini-sternotomy and 27 had mini-thoracotomy. There were no differences between groups with respect to sex, NYHA class distribution, Euroscore II or aortic valve area. Patients in mini-sternotomy group were younger (60.8 ± 14.4 vs.72 ± 5.84, p = 0.003), heavier (85.2 ± 12.4 vs.72.5 ± 12.9, p = 0.002) and had higher body surface area (1.98 ± 0.167 vs. 1.83 ± 0.178, p = 0.006). Surgery duration was longer in mini-sternotomy group compared to mini-thoracotomy (158 ± 24 vs. 134 ± 30 min, p < 0.001, respectively). There were no differences between groups in microembolic load, length of ICU or total hospital stay. Total microembolic signals count was correlated with cardiopulmonary bypass duration (5.64, 95%CI 0.677–10.60, p = 0.027). Addenbrooke’s Cognitive Examination Revised Test score decreased equivalently in both groups ( p = 0.630) (MS: 85.2 ± 9.6 vs. 82.9 ± 11.4, p = 0.012; MT: 85.2 ± 9.6 vs. 81.3 ± 8.8, p = 0.001).
Conclusion
There is no difference in microembolic load between the groups. Total intraoperative microembolic signals count was associated with cardiopulmonary bypass duration. Age, but not micorembolic signals load, was associated with postoperative neurologic decline.
Trial registry number
clinicaltrials.gov , NCT02697786 14.
... 22 Four stages of myocardial damage can be observed with incremental impact on mortality [Stage 0: no myocardial damage, 1-year mortality 4.4%; Stage 1: reduced LV systolic function and increased LV filling pressures; Stage 2: additional damage to the left atrium and mitral valve; Stage 3: onset of pulmonary hypertension and tricuspid regurgitation (TR); Stage 4: significant right ventricular dysfunction, 25% 1-year mortality]. 23 The prevalence of a LV ejection fraction (LVEF) <50% in patients at greater than intermediate risk for aortic valve replacement is estimated between 30-50%. 23 The impact of myocardial damage on the prognosis of these patients is significant and underscores the importance of regular echocardiographic surveillance and incorporation of additional markers of myocardial injury ( Table 2). ...
... 23 The prevalence of a LV ejection fraction (LVEF) <50% in patients at greater than intermediate risk for aortic valve replacement is estimated between 30-50%. 23 The impact of myocardial damage on the prognosis of these patients is significant and underscores the importance of regular echocardiographic surveillance and incorporation of additional markers of myocardial injury ( Table 2). ...
Heart failure is an inevitable end‐stage consequence of significant valvular heart disease (VHD) that is left untreated and increasingly encountered in an ageing society. Recent advances in transcatheter procedures and improved outcomes after valve surgery mean that intervention can (and should) be considered in all patients – even the elderly and those with multiple comorbidities ‐ at earlier stages of the natural history of primary VHD, before the onset of irreversible left ventricular dysfunction (and frequently before the onset of symptoms). All patients with known VHD should be monitored carefully in the setting of a heart valve clinic and those who meet guideline criteria for surgical or transcatheter intervention referred for intervention without delay.
High quality evidence for the use of medical therapy in VHD is limited and achieving target doses in an elderly and comorbid population frequently challenging. Furthermore, determining whether the valve or ventricle is the principal disease driver is crucial (although the distinction is not always binary, and often unclear). Guideline‐directed medical therapy remains the mainstay of treatment for secondary mitral regurgitation ‐ although up to 50% of patients may fail to respond and should be considered for cardiac resynchronization, transcatheter or surgical valve intervention. Early and definitive management strategies are essential and should be overseen by a specialist Heart Team that includes a Heart Failure specialist. In this article, we provide an evidence‐based summary of approaches to the medical treatment of VHD and clinical guidance for the best management of patients in situations where high quality evidence is lacking.
... AS and mitral regurgitation). 5 Moreover, patients with untreated symptomatic AS are at an increased risk of sudden death. The true impact of this decline on patient outcomes will require future investigation. ...
