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Background: Worsening aortic insufficiency (AI) is a known sequela of prolonged continuous-flow left ventricular assist device (LVAD) support with a significant impact on patient outcomes. While medical treatment may relieve symptoms, it is unlikely to halt progression. Surgical aortic valve replacement (SAVR) and transcatheter aortic valve replace...
Context in source publication
Context 1
... total of 105 TAVR implantations and 50 SAVR procedures were performed in LVAD patients during the study period. As shown in Figure 1, there was an increase in the number of TAVR procedures performed annually during the study period, from 15 in 2015 to 30 in 2018. The small sample size limited our ability to report similar trends in SAVR. ...
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Objective: To investigate reverse cardiac remodeling in self-expandable valve (SEV) and balloon-expandable valve (BEV) in patients with low-flow, low-gradient aortic stenosis (LFLGAS) who performed transcatheter aortic valve replacement (TAVR).
Methods: Patients with classical low-flow, low-gradient aortic stenosis (CLFLGAS) and paradoxical low-flo...
Valvular heart disease can develop as a long-term side effect of radiation therapy, along with other cardiovascular complications. The timeline until clinically significant disease can be on the order of decades, with left-sided valves most commonly affected. Only a few retrospective studies have characterized the incidence and findings associated...
Background: To explore why bicuspid aortic stenosis has certain clinical differences from the tricuspid morphology, we evaluated the metabolomics profile involved in bicuspid aortic valve (BAV) aortic stenosis prior to and after transcatheter aortic valve replacement (TAVR) in comparison with tricuspid aortic valve (TAV).
![Pooled mortality proportion for MetS (4%, [95% CI: 2%, 6%]) and no‐MetS...](publication/365655063/figure/fig3/AS:11431281176294172@1690100395847/Pooled-mortality-proportion-for-MetS-4-95-CI-2-6-and-no-MetS-2-95-CI-1_Q320.jpg)
Background
The effect of metabolic syndrome (MetS), defined as insulin resistance along with two or more of: obesity, atherogenic dyslipidaemia and elevated blood pressure, on postoperative complications after isolated heart valve intervention remains controversial. We hypothesized that MetS may negatively influence the postoperative course in thes...
Citations
... Many surgeons choose to correct moderate or worse AI at the time of LVAD insertion. This is typically done through concomitant bioprosthetic aortic valve replacement, though subsequent transcatheter aortic valve replacement in those with the development of AI after initial LVAD implant has been reported with success as well [49,50]. In all cases, achieving a range of pump speeds prior to discharge that allow for sufficient AV opening may prevent fusion of the valve leaflets and has been recommended as a way to prevent de novo AI development [46]. ...
Heart transplantation and durable left ventricular assist devices (LVADs) represent two definitive therapies for end-stage heart failure in the modern era. Despite technological advances, both treatment modalities continue to experience unique risks that impact surgical and perioperative decision-making. Here, we review special populations and factors that impact risk in LVAD and heart transplant surgery and examine critical decisions in the management of these patients. As both heart transplantation and the use of durable LVADs as destination therapy continue to increase, these considerations will be of increasing relevance in managing advanced heart failure and improving outcomes.
... MACCE was reported only in one study [32], which favored TAVI (RR = 0.48; 95% CI: [0.25, 0.90], P = 0.02). ...
... TAVI demonstrated advantages over SAVR, including bleeding, AKI, pneumonia, and shorter LOS, aligning with previous research [18,19,21,32,42,43]. These benefits are consistent with the less invasive nature of TAVI, which avoids sternotomy and cardiopulmonary bypass. ...
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 (I²) 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) (I² = 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) (I² = 11%, P = 0.34), in-hospital acute kidney injury (RR = 0.56; 95% CI: [0.41, 0.76], P < 0.001) (I² = 91%, P < 0.001), major bleeding (RR = 0.23; 95% CI: [0.17, 0.32], P < 0.001) (I² = 78%, P < 0.001), and shorter hospital say (MD = − 4.76 days; 95% CI: [− 5.27, − 4.25], P < 0.001) (I² = 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) (I² = 0% P = 0.83).
Conclusion
TAVI reduces in-hospital stroke and is associated with better safety outcomes than SAVR in patients with pure AR.
... Despite these exclusions, about 3-10% of patients undergoing TAVR have a bicuspid aortic valve (BAV), a common congenital heart disease [2,3]. In addition, TAVR has been applied in severe aortic valve regurgitation cases as a compassionate/off-label use, including those with a left ventricular assist device (LVAD) [4]. ...
At present, transcatheter aortic valve replacement (TAVR) is not only used in high-surgical-risk patients with aortic stenosis (AS), but its use has also been extended to low-risk patients, resulting in its increasing utilization in patients with bicuspid aortic valve (BAV). BAV however presents unique challenges for TAVR due to its distinct valvular anatomy, and surgical aortic valve replacement (SAVR) remains the primary recommended method of aortic valve replacement in patients with BAV. Nonetheless, observational data have been quickly accumulating regarding the successful use of TAVR in BAV. Here, we present a case of a 73-year-old female who presented with heart failure symptoms and was found to have severe AS and BAV with calcified raphe (Sievers 1a). Due to her age and complicated medical history, including coronary artery disease and chronic kidney disease, she was considered to be at intermediate surgical risk (Society of Thoracic Surgeons (STS) score 5.4%) and underwent TAVR with the successful deployment of a 29 mm Edwards SAPIEN valve (Edwards Lifesciences, California, USA). A post-procedure echocardiogram confirmed the appropriate placement of the prosthesis without any valvular or paravalvular regurgitation. This case, therefore, adds to the growing body of evidence regarding the use of TAVR in patients with BAV despite anatomical challenges.
... Nevertheless, complications, length of stay, and costs were higher in the SAVR group than in the TAVI group [59]. In another study, there was a significantly higher incidence of the primary composite outcome (in-hospital mortality, stroke, transient ischemic attack, MI, pacemaker implantation, need for open aortic valve surgery, vascular complications, and cardiac tamponade) in patients undergoing SAVR (30%) compared with TAVI (14.3%; p = 0.001) [17]. ...
Patients with a clinical indication for aortic valve replacement can either undergo surgical aortic valve replacement (SAVR) or Transcatheter Aortic Valve Implantation (TAVI). There are many different factors that go into determining which type of replacement to undergo, including age, life expectancy, comorbidities, frailty, and patient preference. While both options offer significant benefits to patients in terms of clinical outcomes and quality of life, there is growing interest in expanding the indications for TAVI due to its minimally invasive approach. However, it is worth noting that there are several discrepancies in TAVI outcomes in regards to various endpoints, including death, stroke, and major cardiovascular events. It is unclear why these discrepancies exist, but potential explanations include the diversity of etiologies for aortic stenosis, complex patient comorbidities, and ongoing advancements in both medical therapies and devices. Of these possibilities, we propose that phenotypic variation of aortic stenosis has the most significant impact on post-TAVI clinical outcomes. Such variability in phenotypes is often due to a complex interplay between underlying comorbidities and environmental and inherent patient risk factors. However, there is growing evidence to suggest that patient genetics may also play a role in aortic stenosis pathology. As such, we propose that the selection and management of TAVI patients should emphasize a precision medicine approach.
Introduction: Patients with end-stage heart failure (HF) may need mechanical circulatory support such as a left ventricular assist device (LVAD). However, there are a range of complications associated with LVAD including aortic regurgitation (AR) and thrombus formation. This study assesses whether the risk of developing aortic conditions can be minimised by optimising LVAD implantation technique.
Methods: In this work, we evaluate the aortic flow patterns produced under different geometrical parameters for the anastomosis of the outflow graft (OG) to the aorta using computational fluid dynamics (CFD). A three-dimensional aortic model is created and the HeartMate III OG positioning is simulated by modifying (i) the distance from the anatomic ventriculo-arterial junction (AVJ) to the OG, (ii) the cardinal position around the aorta, and (iii) the angle between the aorta and the OG. The continuous LVAD flow and the remnant native cardiac cycle are used as inlet boundaries and the three-element Windkessel model is applied at the pressure outlets.
Results: The analysis quantifies the impact of OG positioning on different haemodynamic parameters, including velocity, wall shear stress (WSS), pressure, vorticity and turbulent kinetic energy (TKE). We find that WSS on the aortic root (AoR) is around two times lower when the OG is attached to the coronal side of the aorta using an angle of 45° ± 10° at a distance of 55 mm.
Discussion: The results show that the OG placement may significantly influence the haemodynamic patterns, demonstrating the potential application of CFD for optimising OG positioning to minimise the risk of cardiovascular complications after LVAD implantation.
Concomitant aortic stenosis (AS) in heart failure (HF) is associated with high rates of mortality and morbidity. Current guidelines recommend aortic valve replacement in patients with severe symptomatic AS and asymptomatic AS with left ventricular ejection fraction <50% and during other cardiac surgeries. Transcatheter aortic valve replacement (TAVR) has now allowed for the treatment of severe AS in previously inoperable or high-surgical-risk patients. Leveraging multimodality imaging techniques is increasingly recognized for reinforcing the rationale for intervening early, thus mitigating the risk of ongoing progression to advanced HF. There are increasing data in favor of TAVR in diverse clinical scenarios, particularly asymptomatic AS and moderate AS. Limited information is, however, available regarding the advantages of HF medical therapy before and after intervention. This review aims to comprehensively examine the phenotypes of AS in the context of HF progression, while exploring the evolving role of TAVR in specific populations.
Aortic, mitral and tricuspid valve regurgitation are commonly encountered in patients with continuous-flow left ventricular assist devices (CF-LVADs). These valvular heart conditions either develop prior to CF-LVAD implantation or are induced by the pump itself. They can all have significant detrimental effects on patients' survival and quality of life. With the improved durability of CF-LVADs and the overall rise in their volume of implants, an increasing number of patients will likely require a valvular heart intervention at some point during CF-LVAD therapy. However, these patients are often considered poor reoperative candidates. In this context, percutaneous approaches have emerged as an attractive “off-label” option for this patient population. Recent data show promising results, with high device success rates and rapid symptomatic improvements. However, the occurrence of distinct complications such as device migration, valve thrombosis or hemolysis remain of concern. In this review, we will present the pathophysiology of valvular heart disease in the setting of CF-LVAD support to help us understand the underlying rationale of these potential complications. We will then outline the current recommendations for the management of valvular heart disease in patients with CF-LVAD and discuss their limitations. Lastly, we will summarize the evidence related to transcatheter heart valve interventions in this patient population.
