Search Results (15)

Background: Surgical bioprosthetic aortic valve replacement is a ubiquitous procedure, with several factors identified in affecting outcomes. We hypothesize that smaller valves may be associated with worse outcomes and decreased freedom from clinical events, and a shift in implanting larger valves whenever possible may confer benefit to the patient. Methods: A narrative review of the literature was conducted using a systematic search strategy to evaluate studies examining the relationship between bioprosthetic valve size and outcomes. Inclusion criteria focused on studies reporting paired data on valve size and clinical endpoints in surgical AVR. Results: Among the 15 reviewed studies, smaller valve sizes were consistently associated with higher post-operative transvalvular gradients (6/7 studies) and increased reintervention rates (5/8 studies). Associations with accelerated structural valve degeneration (SVD) (3/5 studies) and reduced survival (8/11 studies) were also observed, although heterogeneity in study design and follow-up durations limited definitive conclusions. Conclusion: Our findings suggest that larger valve sizes may improve freedom from SVD, reduce reintervention rates, and enhanced survival. This may also justify the slight increased risk of enlarging the aortic root to accommodate a larger bioprosthetic valve prosthesis. Further high-quality, controlled studies are needed to clarify the independent impact of valve size on long-term outcomes and guide surgical decision-making. Full article

Background: Infective endocarditis after transcatheter aortic valve replacement (TAVR-IE) is a rare but severe complication associated with high morbidity and mortality. The optimal treatment strategy—surgical explantation versus medical therapy—remains uncertain, particularly given the technical demands of TAVR removal and the advanced age of many affected patients. Methods: We conducted a systematic review and meta-analysis of studies comparing the surgical and medical management of TAVR-IE. Primary outcomes included 30-day mortality and 1-year survival. Secondary analyses explored microbiological profiles, patient demographics, prosthesis type, postoperative complications, and surgical indications. A qualitative synthesis of surgical explantation techniques and reconstructive strategies was also performed based on recent consensus recommendations. Results: Three studies comprising 1557 patients with TAVR-IE were included; 155 (10.0%) underwent surgical treatment. Thirty-day mortality was comparable between groups (surgical: 9.7%; medical: 8.4%), while the pooled odds ratio for one-year survival did not reach statistical significance (OR: 1.91, 95% CI: 0.36–10.22; I² = 88%). However, single-center outcomes demonstrated markedly improved survival with surgery (96% vs. 51%). The most common surgical indications included severe valvular dysfunction (50.3%), aortic root abscess (26.5%), and large vegetations (21.3%), in line with current guideline recommendations. Postoperative complications included acute renal failure (10%) and longer hospitalizations (19.8 vs. 18 days), although these were not statistically different. Contemporary explant strategies—such as the Double Kocher, Tourniquet, and Y-incision aortic enlargement techniques—were highlighted as critical tools for surgical success. Conclusions: While underutilized, surgical intervention for TAVR-IE may offer significant survival benefits in select patients, particularly when guided by established indications and performed at high-volume centers. Outcomes depend heavily on timing, surgical expertise, and appropriate patient selection. As TAVR expands to younger populations, TAVR-IE will become increasingly relevant, necessitating early multidisciplinary involvement and broader familiarity with advanced explant techniques among cardiac surgeons. Full article

Background: Aortic stenosis (AS) is one of the most common valvular heart diseases, particularly in the elderly, with a prevalence of approximately 3% in individuals over 75 years of age. Aortic valve replacement (AVR) remains the standard treatment, yet postoperative hemodynamic assessment is often complicated by variations in prosthetic valve size, left ventricular ejection fraction (LVEF), effective orifice area (EOA), and body surface area (BSA). These factors significantly influence prosthetic valve function and contribute to patient–prosthesis mismatch (PPM), which has been associated with worse clinical outcomes. Traditional transvalvular gradient measurements often fail to account for these patient-specific variables. This study introduces a novel approach to standardized gradient calculations, aiming to enhance the accuracy and comparability of prosthetic valve assessments. Methods: A retrospective analysis was conducted on 115 patients who underwent mechanical AVR at a single center. Patients were categorized into three groups based on the prosthetic valve type: St. Jude Medical (SJM) HP (n = 31); SJM Regent (n = 54); and those who underwent aortic root enlargement (ARE) (n = 30). Preoperative and postoperative transthoracic echocardiography (TTE) was performed to measure conventional and standardized transvalvular gradients. Four novel standardized gradient calculations were developed to adjust for individual hemodynamic differences, improving the accuracy of prosthetic valve function assessment. Results: Standardized gradient calculations demonstrated significant differences between prosthesis types. Postoperative standardized gradients were significantly higher in the SJM HP group compared to the SJM Regent and aortic-root-enlargement groups (p < 0.001, p < 0.05). The lowest standardized gradients were observed in patients who received the SJM Regent prostheses (p < 0.05). Although conventional measurements showed no significant differences, standardized calculations revealed that patients with 19 mm prostheses exhibited significantly higher transvalvular gradients than those with 21 mm prostheses (p < 0.05), emphasizing the clinical importance of prosthesis size in postoperative hemodynamics. Conclusions: Standardized gradient calculations provide a more objective, reliable, and patient-specific assessment of prosthetic valve function by minimizing interpatient variability. This approach improves the detection of patient–prosthesis mismatch and optimizes postoperative hemodynamic evaluation, potentially leading to better prosthesis selection and surgical decision-making. However, further validation is required in larger cohorts before these methods can be widely adopted into clinical practice. Future studies should assess their impact on long-term clinical outcomes, including left ventricular remodeling and patient survival. Full article

Background: Valve-sparing root replacement surgery is an alternative strategy for patients with aortic regurgitation with or without aortic root enlargement. A detailed understanding of the mechanisms of regurgitation and the morphology of the aortic root would be beneficial for predicting the feasibility and success of valve-sparing surgery. This is an exploratory study of the measurement of geometric height in 3D transesophageal echocardiography as a predictor of valve-sparing root replacement for aortic regurgitation. Methods: Transesophageal echocardiographic findings and long-term outcomes were compared in 124 patients undergoing either valve-sparing root replacement (VSRR group) or composite valve graft replacement (Bentall group) from September 2014 to March 2019. Results: The VSRR group was younger and had better left ventricular function than the Bentall group. Three-dimensional transesophageal echocardiography showed that geometric height was significantly larger in the VSRR group. In receiver-operating curve analysis, the cutoff values of geometric height for the feasibility of valve-sparing surgery were 15.9 mm and 19.8 mm in the tricuspid and bicuspid aortic valve, respectively. The overall survival was 98.6% and the freedom from reoperation rate was 89.7% at 5 years in the VSRR group. Conclusions: Appropriate patient selection and adequate GH may contribute to the success of VSSR and improve long-term outcomes. Full article

Objectives: To analyze Heart Team decisions and outcomes following failure of surgical aortic valve replacement (SAVR) prostheses. Methods: Patients undergoing re-operations following index SAVR (Redo-SAVR) and those undergoing valve-in-valve transcatheter aortic valve replacement (ViV-TAVR) following SAVR were included in this study. Patients who underwent index SAVR and/or Redo-SAVR for endocarditis were excluded. Data are presented as medians and 25th–75th percentiles, or absolute numbers and percentages. Outcomes were analyzed in accordance to the VARC-3 criteria. Results: Between 01/2015 and 03/2021, 53 patients underwent Redo-SAVR, 103 patients ViV-TAVR. Mean EuroSCORE II was 5.7% (3.5–8.5) in the Redo-SAVR group and 9.2% (5.4–13.6) in the ViV group. In the Redo-SAVR group, 12 patients received aortic root enlargement (22.6%). Length of hospital and ICU stay was longer in the Redo-SAVR group (p < 0.001; p < 0.001), PGmax and PGmean were lower in the Redo-SAVR group as compared to the ViV-TAVR group (18 mmHg (10–30) vs. 26 mmHg (19–38), p < 0.001) (9 mmHg (6–15) vs. 15 mmHg (9–21), p < 0.001). A higher rate of paravalvular leakage was seen in the ViV-TAVR group (p = 0.013). VARC-3 Early Safety were comparable between the two populations (p = 0.343). Survival at 1 year and 5 years was 82% and 36% in the ViV-TAVR cohort and 84% and 77% in the Redo-SAVR cohort. The variables were patient age (OR 1.061; [95% CI 1.020–1.104], p = 0.004), coronary heart disease (OR 2.648; [95% CI 1.160–6.048], p = 0.021), and chronic renal insufficiency (OR 2.711; [95% CI 1.160–6.048], p = 0.021) showed a significant correlation to ViV-TAVR. Conclusions: Heart Team decisions are crucial in the treatment of patients with degenerated aortic bioprostheses and lead to a low mortality in both treatment paths thanks to patient-specific therapy planning. ViV-TAVR offers a treatment for elderly or intermediate-risk profile patients with comparable short-term mortality. However, this therapy is associated with increased pressure gradients and a high prevalence of paravalvular leakage. Redo-SAVR enables the surgical treatment of concomitant cardiac pathologies and allows anticipation for later VIV-TAVR by implanting the largest possible valve prostheses. Full article

This review explores the use of bioprosthetic valves for the lifetime management of patients with aortic stenosis, considering recent advancements in surgical (SAV) and transcatheter bioprostheses (TAV). We examine the strengths and challenges of each approach and their long-term implications. We highlight differences among surgical bioprostheses regarding durability and consider novel surgical valves such as the Inspiris Resilia, Intuity rapid deployment, and Perceval sutureless bioprostheses. The impact of hemodynamics on the performance and durability of these prostheses is discussed, as well as the benefits and considerations of aortic root enlargement during Surgical Aortic Valve Replacement (SAVR). Alternative surgical methods like the Ross procedure and the Ozaki technique are also considered. Addressing bioprosthesis failure, we compare TAV-in-SAV with redo SAVR. Challenges with TAVR, such as TAV explantation and considerations for coronary circulation, are outlined. Finally, we explore the potential challenges and limitations of several clinical strategies, including the TAVR-first approach, in the context of aortic stenosis lifetime management. This concise review provides a snapshot of the current landscape in aortic bioprostheses for physicians and surgeons. Full article

Prosthesis–patient mismatch (PPM) is defined as implanting a prosthetic that is insufficiently sized for the patient receiving it. PPM leads to high residual transvalvular gradients post-aortic valve replacement and consequently results in left ventricular dysfunction, morbidity and mortality in both the short and long term. Younger patients and patients with poor preoperative left ventricular function are more vulnerable to increased mortality secondary to PPM. There is debate over the measurement of valvular effective orifice area (EOA) and variation exists in how manufacturers report the EOA. The most reliable technique is using in vivo echocardiographic measurements to create tables of predicted EOAs for different valve sizes. PPM can be prevented surgically in patients at risk through aortic root enlargement (ARE). Established techniques include the posterior enlargement through Nicks and Manouguian procedures, and aortico-ventriculoplasty with the Konno–Rastan procedure, which allows for a greater enlargement but carries increased surgical risk. A contemporary development is the Yang procedure, which uses a Y-shaped incision created through the non- and left-coronary cusp commissure, undermining the nadirs of the non- and left-coronary cusps. Early results are promising and demonstrate an ability to safely increase the aortic root by up to two to three sizes. Aortic root enlargement thus remains a valuable and safe tool in addressing PPM, and should be considered during surgical planning. Full article

Thoracic aortic aneurysms involving the root and/or the ascending aorta enlarge over time until an acute tear in the intimal layer leads to a highly fatal condition, an acute aortic dissection (AAD). These Stanford type A AADs, in which the tear occurs above the sinotubular junction, leading to the formation of a false lumen in the aortic wall that may extend to the arch and thoracoabdominal aorta. Type B AADs originate in the descending thoracic aorta just distal to the left subclavian artery. Genetic variants and various environmental conditions that disrupt the aortic wall integrity have been identified that increase the risk for thoracic aortic aneurysms and dissections (TAD). In this review, we discuss the predominant TAD-associated risk factors, focusing primarily on the non-genetic factors, and discuss the underlying mechanisms leading to TAD. Full article

Thoracic aortic dilatation is a progressive condition that results from aging and many pathological conditions (i.e., connective tissue, inflammatory, shear stress disorders, severe valvular heart disease) that induce degenerative changes in the elastic properties, leading to the loss of elasticity and compliance of the aortic wall. Mild aortic root enlargement may be also observed in athletes and is considered as a normal adaptation to regular exercise training. On the other hand, high-intensity physical activity in individuals with a particular genetic substrate, such as those carrying gene variants associated with Marfan syndrome or other inherited aortopathies, can favor an excessive aortic enlargement and trigger an acute aortic dissection. The evaluation of the aortic valve and aortic root diameters, as well as the detection of a disease-causing mutation for inherited aortic disease, should be followed by a tailored decision about sport eligibility. In addition, the risk of aortic complications associated with sport in patients with genetic aortic disease is poorly characterized and is often difficult to stratify for each individual athlete. This review aims to describe the relationship between regular physical activity and aortic dilation, focusing on patients with bicuspid aortic valve and inherited aortic disease, and discuss the implications in terms of aortic disease progression and sport participation. Full article

Assessment of left atrial (LA) sizes in dogs informs clinical staging, risk assessment, treatment decisions, and prognosis. The objective of this study was to assess the diagnostic performance of observers with different levels of experience measuring the LA with three different techniques. Echocardiographic images from 36 dogs with different degrees of left atrial enlargement (LAE) were retrospectively retrieved, anonymized and measured in a blinded fashion by a veterinary student, a first-year cardiology resident, a third-year cardiology resident, and two board-certified veterinary cardiologists. The LA to aortic root ratio (LA:Ao), LA antero-postero diameter indexed to body weight (LAiAPD) and left atrial area were measured. Inter- and intra-observer intraclass correlation coefficients (ICCs) were calculated for all three variables. Bland–Altman plots and accuracy in identification of LAE were calculated for the three least experienced observers using LA:Ao and LAiAPD. Intra- and interobserver ICCs were greater than 0.9 for every variable. The observer with least experience had significant positive bias and a tendency to overestimate larger measurements using LA:Ao, but not using LAiAPD. The accuracy of identification of LAE also increased with the increasing level of experience and was higher for LAiAPD compared to LA:Ao. Combining both methods for identification of LAE, further increased accuracy. Full article

Over the last twenty years, we marked significant progresses in the field of tissue engineering and the development of new aortic valve structural and delivery systems. These continuous iterations on the field, have completely changed the surgical indications and approaches for AVR. Nowadays, therapeutic decisions are endorsed by international guidelines; however, new technical advances need a new integrated approach. The clinical scenarios issued from the interaction between the Guidelines and the newest approaches and technologies are regularly on debate by the Heart Team. We will present some of our most encountered situations and the pattern of our therapeutic decisions. To easily navigate through Guidelines and clinical scenarios, we reported in this review a simplified and easy to use Clinical decision-making algorithm that may be a valuable tool in our daily practice. Full article

The aim of this study was to evaluate all-cause mortality and aortic reoperations after surgery for Stanford type A aortic dissection (TAAD). We evaluated the late outcome of patients who underwent surgery for acute TAAD from January 2005 to December 2017 at the Helsinki University Hospital, Finland. We studied 309 patients (DeBakey type I TAAD: 89.3%) who underwent repair of TAAD. Aortic root repair was performed in 94 patients (30.4%), hemiarch repair in 264 patients (85.4%) and partial/total aortic arch repair in 32 patients (10.4%). Hospital mortality was 13.6%. At 10 years, all-cause mortality was 34.9%, and the cumulative incidence of aortic reoperation or late aortic-related death was 15.6%, of any aortic reoperation 14.6%, reoperation on the aortic root 6.6%, on the aortic arch, descending thoracic and/or abdominal aorta 8.7%, on the descending thoracic and/or abdominal aorta 6.4%, and on the abdominal aorta 3.8%. At 10 years, cumulative incidence of reoperation on the distal aorta was higher in patients with a diameter of the descending thoracic aorta ≥35 mm at primary surgery (cumulative incidence in the overall series: 13.2% vs. 4.0%, SHR 3.993, 95%CI 1.316–12.120; DeBakey type I aortic dissection: 13.6% vs. 4.5%, SHR 3.610, 95%CI 1.193–10.913; patients with dissected descending thoracic aorta: 15.8% vs. 5.9%, SHR 3.211, 95%CI 1.067–9.664). In conclusion, surgical repair of TAAD limited to the aortic segments involved by the intimal tear was associated with favorable survival and a low rate of aortic reoperations. However, patients with enlarged descending thoracic aorta at primary surgery had higher risk of late reoperation. Half of the distal aortic reinterventions were performed on the abdominal aorta. Full article

Loss-of-function mutations of the gene encoding Krev interaction trapped protein 1 (KRIT1) are associated with the pathogenesis of Cerebral Cavernous Malformation (CCM), a major cerebrovascular disease characterized by abnormally enlarged and leaky capillaries and affecting 0.5% of the human population. However, growing evidence demonstrates that KRIT1 is implicated in the modulation of major redox-sensitive signaling pathways and mechanisms involved in adaptive responses to oxidative stress and inflammation, suggesting that its loss-of-function mutations may have pathological effects not limited to CCM disease. The aim of this study was to address whether KRIT1 loss-of-function predisposes to the development of pathological conditions associated with enhanced endothelial cell susceptibility to oxidative stress and inflammation, such as arterial endothelial dysfunction (ED) and atherosclerosis. Silencing of KRIT1 in human aortic endothelial cells (HAECs), coronary artery endothelial cells (HCAECs), and umbilical vein endothelial cells (HUVECs) resulted in increased expression of endothelial proinflammatory adhesion molecules vascular cell adhesion molecule 1 (VCAM-1) and intercellular adhesion molecule 1 (ICAM-1) and in enhanced susceptibility to tumor necrosis factor alpha (TNF-α)-induced apoptosis. These effects were associated with a downregulation of Notch1 activation that could be rescued by antioxidant treatment, suggesting that they are consequent to altered intracellular redox homeostasis induced by KRIT1 loss-of-function. Furthermore, analysis of the aorta of heterozygous KRIT1^+/− mice fed a high-fructose diet to induce systemic oxidative stress and inflammation demonstrated a 1.6-fold increased expression of VCAM-1 and an approximately 2-fold enhanced fat accumulation (7.5% vs 3.6%) in atherosclerosis-prone regions, including the aortic arch and aortic root, as compared to corresponding wild-type littermates. In conclusion, we found that KRIT1 deficiency promotes ED, suggesting that, besides CCM, KRIT1 may be implicated in genetic susceptibility to the development of atherosclerotic lesions. Full article

Obesity is caused by an excess storage of body fat, resulting from a chronic imbalance between energy intake and expenditure. Gentiana lutea L. (GL) root has been reported to reduce lipid accumulation in the aortic wall of diabetic rats. Here, we performed fractionation and isolation of the bioactive constituent(s) that may be responsible for the antiadipogenic effects of the GL root extract. A single compound, loganic acid, was identified as a candidate component in the 30% ethanol extract of GL. Loganic acid treatment significantly decreased the adipocyte differentiation of 3T3-L1 preadipocytes in a dose-dependent manner. The expression of key adipogenesis-related genes such as adiponectin (Adipoq), peroxisome proliferator-activated receptor gamma (Pparg), lipoprotein lipase (Lpl), perilipin1 (Plin1), fatty acid binding protein 4 (Fabp4), glucose transporter type 4 (Slc2a4), CCAAT/enhancer-binding protein alpha (Cebpa), and tumor necrosis factor-alpha (Tnf) were significantly reduced following treatment with loganic acid. In vivo experiments in an ovariectomy-induced obesity mouse model showed that loganic acid (oral administration with 10 and 50 mg/kg/day) significantly inhibited body weight gain, total fat increase, fatty hepatocyte deposition in the liver, and adipocyte enlargement in the abdominal visceral fat tissues. These results suggest that loganic acid in the GL root extract has antiadipogenic effects in vitro and in vivo. Loganic acid may be beneficial for the prevention and treatment of obesity, particularly in menopausal obese women. Full article

Marfan syndrome is the most common inherited disorder of connective tissue affecting multiple organ systems. Identification of the facial, ocular and skeletal features should prompt referral for aortic imaging since sudden death by aortic dissection and rupture remains a major cause of death in patients with unrecognized Marfan syndrome. Echocardiography is recommended as the initial imaging test, and once a dilated aortic root is identified magnetic resonance or computed tomography should be done to assess the entire aorta. Prophylactic aortic root replacement is safe and has been demonstrated to improve life expectancy in patients with Marfan syndrome. Medical therapy for Marfan syndrome includes the use of beta blockers in older children and adults with an enlarged aorta. Addition of angiotensin receptor antagonists has been shown to slow the progression of aortic root dilation compared to beta blockers alone. Lifelong and regular follow up in a center for specialized care is important for patients with Marfan syndrome. We present a case of a patient with clinical features of Marfan syndrome and discuss possible therapeutic interventions for her dilated aorta. Full article