Annulus Instead of LVOT Diameter Improves Agreement Between Echocardiography Effective Orifice Area and Invasive Aortic Valve Area

Abstract Aims Severe aortic valve stenosis (AS) is defined by an aortic valve area (AVA) <1 cm2 or an AVA indexed to body surface area (BSA) <0.6 cm/m2, despite little evidence supporting the latter approach and important intrinsic limitations of BSA indexation. We hypothesized that AVA indexed to height (H) might be more applicable to a wide range of populations and body morphologies and might provide a better predictive accuracy. Methods and results In 1298 patients with degenerative AS and preserved ejection fraction from three different countries and continents (derivation cohort), we aimed to establish an AVA/H threshold that would be equivalent to 1.0 cm2 for defining severe AS. In a distinct prospective validation cohort of 395 patients, we compared the predictive accuracy of AVA/BSA and AVA/H. Correlations between AVA and AVA/BSA or AVA/H were excellent (all R2 > 0.79) but greater with AVA/H. Regressions lines were markedly different in obese and non-obese patients with AVA/BSA (P < 0.0001) but almost identical with AVA/H (P = 0.16). AVA/BSA values that corresponded to an AVA of 1.0 cm2 were markedly different in obese and non-obese patients (0.48 and 0.59 cm2/m2) but not with AVA/H (0.61 cm2/m for both). Agreement for the diagnosis of severe AS (AVA < 1 cm2) was significantly higher with AVA/H than with AVA/BSA (P < 0.05). Similar results were observed across the three countries. An AVA/H cut-off value of 0.6 cm2/m [HR = 8.2(5.6–12.1)] provided the best predictive value for the occurrence of AS-related events [absolute AVA of 1 cm2: HR = 7.3(5.0–10.7); AVA/BSA of 0.6 cm2/m2 HR = 6.7(4.4–10.0)]. Conclusion In a large multinational/multiracial cohort, AVA/H was better correlated with AVA than AVA/BSA and a cut-off value of 0.6 cm2/m provided a better diagnostic and prognostic value than 0.6 cm2/m2. Our results suggest that severe AS should be defined as an AVA < 1 cm2 or an AVA/H < 0.6 cm2/m rather than a BSA-indexed value of 0.6 cm2/m2.

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Incidence and predictors of prosthesis–patient mismatch after TAVI using SAPIEN 3 in Asian: differences between the newer and older balloon-expandable valve

Open Heart ◽

10.1136/openhrt-2020-001531 ◽

2021 ◽

Vol 8 (1) ◽

pp. e001531

Author(s):

Masaki Miyasaka ◽

Norio Tada ◽

Masataka Taguri ◽

Shigeaki Kato ◽

Yusuke Enta ◽

...

Keyword(s):

Aortic Valve ◽

Strong Predictor ◽

Multivariate Logistic Regression Analysis ◽

Asian Population ◽

Effective Orifice Area ◽

Aortic Valve Area ◽

Complication Rates ◽

Number Of Patients ◽

Transcatheter Heart Valve ◽

Sapien 3

BackgroundThe balloon-expandable SAPIEN 3 (S3) is superior to the older-generation balloon-expandable SAPIEN XT (XT) in a lower incidence of paravalvular aortic regurgitation, lower complication rates and better survival in transcatheter aortic valve implantation (TAVI). However, prosthesis–patient mismatch (PPM) more frequently occurs in S3 than XT. Further, little information is available on PPM after TAVI using S3 in Asians. This study aims to determine the incidence and predictors of PPM in S3 by focusing on the difference between S3 and XT using data from a Japanese multicentre registry.MethodsFrom the Optimised transCathEter vAlvular iNtervention-TAVI (OCEAN-TAVI) registry, 2134 patients undergoing TAVI using S3 or XT were included. PPM was defined as moderate if ≧0.65 but ≦0.85 cm2/m2 or severe if <0.65 cm2/m2 at the indexed effective orifice area by postprocedural echocardiography.ResultsThe incidence of moderate and severe PPM in S3 was 13.3% and 1.3%, respectively. The 20 mm transcatheter heart valve (THV) was more frequently used in S3 than XT (7.4% vs 2.4%, p<0.0001). PPM was more frequently observed in S3 than XT (14.7% vs 8.8%, p<0.0001). Multivariate logistic regression analysis revealed S3 predicted PPM (OR 1.92 (95% CI 1.35 to 2.74), p=0.0003). The mutual predictors for PPM between S3 and XT were younger age, larger body surface area, smaller aortic valve area, no balloon postdilatation and the use of 20 mm and 23 mm THV. When comparing 23 mm, 26 mm and 29 mm S3, the ORs of 20 mm S3 were 5.67 (95% CI 2.88 to 11.12), 19.24 (95% CI 8.13 to 46.86) and 51.03 (95% CI 12.28 to 280.77), respectively.ConclusionsThe incidence of PPM after TAVI using S3 was 14.6% overall in this Asian population. PPM was more frequently observed in S3 than XT. A considerable number of patients were treated by the 20 mm S3 in an Asian cohort. The 20 mm THV was identified as a strong predictor for PPM.

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Impact of the Trifecta bioprosthetic valve in patients with low-flow severe aortic stenosis

Heart and Vessels ◽

10.1007/s00380-021-01802-5 ◽

2021 ◽

Author(s):

Tohru Takaseya ◽

Atsunobu Oryoji ◽

Kazuyoshi Takagi ◽

Tomofumi Fukuda ◽

Koichi Arinaga ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Stenosis ◽

Severe Aortic Stenosis ◽

Stroke Volume Index ◽

Low Flow ◽

Volume Index ◽

Effective Orifice Area ◽

Aortic Valve Area ◽

Hemodynamic Performance ◽

Mid Term Results

AbstractAortic stenosis (AS) is the most common valve disorder in advanced age. Previous reports have shown that low-flow status of the left ventricle is an independent predictor of cardiovascular mortality after surgery. The Trifecta bioprosthesis has recently shown favorable hemodynamic performance. This study aimed to evaluate the effect of the Trifecta bioprosthesis, which has a large effective orifice area, in patients with low-flow severe AS who have a poor prognosis. We retrospectively evaluated 94 consecutive patients with severe AS who underwent aortic valve replacement (AVR). Patients were divided into two groups according to the stroke volume index (SVI): low-flow (LF) group (SVI < 35 ml/m2, n = 22) and normal-flow (NF) group (SVI ≥ 35 ml/m2, n = 72). Patients’ characteristics and early and mid-term results were compared between the two groups. There were no differences in patients’ characteristics, except for systolic blood pressure (LF:NF = 120:138 mmHg, p < 0.01) and the rate of atrial fibrillation between the groups. A preoperative echocardiogram showed that the pressure gradient was higher in the NF group than in the LF group, but aortic valve area was similar. The Trifecta bioprosthesis size was similar in both groups. The operative outcomes were not different between the groups. Severe patient–prosthesis mismatch (PPM) (< 0.65 cm2/m2) was not observed in either of the groups. There were no significant differences in mid-term results between the two groups. The favorable hemodynamic performance of the Trifecta bioprosthesis appears to have the similar outcomes in the LF and NF groups. AVR with the Trifecta bioprosthesis should be considered for avoidance of PPM, particularly in AS patients with LV dysfunction.

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The Usefulness of [18F]F-Fluorodeoxyglucose and [18F]F-Sodium Fluoride Positron Emission Tomography Imaging in the Assessment of Early-Stage Aortic Valve Degeneration after Transcatheter Aortic Valve Implantation (TAVI)—Protocol Description and Preliminary Results

Journal of Clinical Medicine ◽

10.3390/jcm10030431 ◽

2021 ◽

Vol 10 (3) ◽

pp. 431

Author(s):

Danuta Sorysz ◽

Rafał Januszek ◽

Anna Sowa-Staszczak ◽

Anna Grochowska ◽

Marta Opalińska ◽

...

Keyword(s):

Aortic Valve ◽

Emission Tomography ◽

Effective Orifice Area ◽

Orifice Area ◽

Transcatheter Aortic Valve ◽

Positron Emission ◽

Pet Ct ◽

Transvalvular Gradient ◽

Valve Implantation

Transcatheter aortic valve implantation (TAVI) is now a well-established treatment for severe aortic stenosis. As the number of procedures and indications increase, the age of patients decreases. However, their durability and factors accelerating the process of degeneration are not well-known. The aim of the study was to verify the possibility of using [18F]F-sodium fluoride ([18F]F-NaF) and [18F]F-fluorodeoxyglucose ([18F]F-FDG) positron emission tomography/computed tomography (PET/CT) in assessing the intensity of TAVI valve degenerative processes. In 73 TAVI patients, transthoracic echocardiography (TTE) at initial (before TAVI), baseline (after TAVI), and during follow-up, as well as transesophageal echocardiography (TEE) and PET/CT, were performed using [18F]F-NaF and [18F]F-FDG at the six-month follow-up (FU) visit as a part of a two-year FU period. The morphology of TAVI valve leaflets were assessed in TEE, transvalvular gradients and effective orifice area (EOA) in TTE. Calcium scores and PET tracer activity were counted. We assessed the relationship between [18F]F-NaF and [18F]F-FDG PET/CT uptake at the 6 = month FU with selected indices e.g.,: transvalvular gradient, valve type, EOA and insufficiency grade at following time points after the TAVI procedure. We present the preliminary PET/CT ([18F]F-NaF, [18F]F-FDG) results at the six-month follow-up period as are part of an ongoing study, which will last two years FU. We enrolled 73 TAVI patients with the mean age of 82.49 ± 7.11 years. A significant decrease in transvalvular gradient and increase of effective orifice area and left ventricle ejection fraction were observed. At six months, FU valve thrombosis was diagnosed in four patients, while 7.6% of patients refused planned controls due to the COVID-19 pandemic. We noticed significant correlations between valve types, EOA and transaortic valve gradients, as well as [18F]F-NaF and [18F]F-FDG uptake in PET/CT. PET/CT imaging with the use of [18F]F-FDG and [18F]F-NaF is intended to be feasible, and it practically allows the standardized uptake value (SUV) to differentiate the area containing the TAVI leaflets from the SUV directly adjacent to the ring calcifications and the calcified native leaflets. This could become the seed for future detection and evaluation capabilities regarding the progression of even early degenerative lesions to the TAVI valve, expressed as local leaflet inflammation and microcalcifications.

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P1692 The past returns after 20 years: a case report

European Heart Journal - Cardiovascular Imaging ◽

10.1093/ehjci/jez319.1055 ◽

2020 ◽

Vol 21 (Supplement_1) ◽

Author(s):

S Habjan ◽

D Cantisani ◽

I S Scarfo` ◽

M C Guarneri ◽

G Semeraro ◽

...

Keyword(s):

Heart Disease ◽

Coronary Artery ◽

Aortic Valve ◽

Aortic Stenosis ◽

Valvular Heart Disease ◽

Radiation Treatment ◽

Severe Aortic Stenosis ◽

Aortic Valve Area ◽

Radiation Induced ◽

Valve Area

Abstract Introduction Radiation therapy is one of the cornerstones of treatment for many types of cancer. These patients can later in life develop cardiovascular complications associated with radiation treatment. Late cardiovascular effects of radiation treatment include coronary artery disease (CAD), valvular heart disease, congestive heart failure, pericardial disease and sudden death. The most common sign of radiation-induced valvular heart disease is the calcification of the intervalvular fibrosa between the aortic and mitral valve. Case presentation A 71-year-old male patient with a history of Non-Hodgkin lymphoma treated with radiotherapy and chemotherapy 20 years ago, CAD, arterial hypertension, diabetes type II, dyslipidemia, obesity and currently smoking presented in the emergency room in our medical facility with acute pulmonary edema. The patient had unstable angina pectoris in 2018, the coronary angiography showed two-vessel disease with a non-significant stenosis of the left main coronary artery (LMCA) and 70% stenosis of the left anterior descending artery (LAD), for which he refused the percutaneous coronary intervention. At the same time, a transthoracic echocardiography (TTE) showed severe aortic stenosis and moderately severe mitral stenosis, at that time the patient refused the operation. After the initial treatment for pulmonary edema, TTE and transesophageal echocardiography (TEE) were performed and showed a tricuspid aortic valve with calcification of the cusps and a very severe aortic stenosis (planimetric aortic valve area 0.74 cm², functional aortic valve area 0.55 cm², indexed functional aortic valve area 0.25 cm²/m², mean gradient 61 mmHg, peak gradient 100 mmHg, stroke volume (SV) 69 ml, stroke volume index (SVI) 31 ml/m², flow rate 221 ml/s, aortic annulus 20x26 mm). The left ventricle was severely dilated (end diastolic volume 268 ml) with diffuse hypokinesia and severe systolic dysfunction (ejection fraction 32%). We appreciated a calcification of the mitral-aortic intervalvular fibrosa and the mitral annulus, without mitral stenosis but with moderate mitral regurgitation. The calcification of the intervalvular fibrosa suggested our final diagnosis of radiation-induced valvular heart disease with a severe aortic stenosis in low-flow conditions. The patient was successfully treated with transcatheter aortic valve implantation (TAVI). Conclusion Radiation-induced heart disease is a common reality and is destinated to raise due to the increasing number of cancer survivors. Effects are seen also many years after the radiation treatment. The exact primary mechanism of radiation injury to the heart is still unknown. The treatment of radiation-induced valve disease is the same as the treatment of valve disease in the general population. Abstract P1692 Figure. Radiation-induced valvular heart disease

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