Search Results (78)

Objectives: Our goal was to assess the role of leaflet geometry on the structural deterioration of bioprosthetic aortic valves (BAVs) in a closed configuration. Methods: With a Fung-type orthotropic model, finite element modeling was used to create ten cases with parabolic, circular and spline leaflet curvatures and six leaflet angles. Results: A circular circumferential curvature led to lower von Mises and compressive stresses in both the coaptation and load-bearing areas, reduced tensile stresses in the coaptation regions, and increased tensile stresses in the load-bearing areas. A parabolic radial curvature reduced von Mises stresses in the coaptation, as well as the load-bearing regions, reduced compressive stresses in the coaptation, and reduced tensile stresses in the load-bearing regions, leading to a slight increase in the minimized tensile stress in the coaptation regions (1.794 vs. 1.765 MPa) and the minimized compressive stress in the load-bearing regions (0.772 vs. 0.768 MPa). Within a range of downward inclination of the leaflets, all stresses in the coaptation regions decreased. A parabolic circumferential curvature, a linear radial curvature, and, for most cases, upward leaflet inclinations were associated with larger contact pressures between the leaflets. Conclusions: A parabolic radial curvature and downward leaflet inclination likely lead to the longer durability of BAVs. Full article

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

Aortic stenosis (AS) is a progressive valvular heart disease marked by a restriction of blood flow through the aortic valve, resulting in considerable morbidity and mortality if not addressed. AS has historically been managed through surgical aortic valve replacement (SAVR), but there is a growing trend towards the use of transcatheter aortic valve replacement (TAVR). TAVR has transformed the management of symptomatic severe AS and is currently authorized for patients with varying levels of surgical risk. The rising application of TAVR in patients under 65 years presents a challenge for heart valve teams (HVTs) managing younger individuals whose life expectancy may surpass the durability of the valve. Patients over 65 years are typically treated with bioprosthetic tissue valves; however, there remains significant uncertainty regarding the selection between TAVR and SAVR. Full article

Background/Objectives: Valve-in-valve (ViV) transcatheter aortic valve implantation (TAVI) is a key approach for treating degenerated surgical bioprosthetic valves. The ACURATE neo2 valve, with its advanced sealing technology and optimized coronary access, represents a promising solution for the challenges of ViV TAVI. This study evaluates the procedural and 30-day and 1-year follow-up outcomes of the ACURATE neo2 valve in ViV TAVI. Methods: This single-center, single-operator prospective study included patients with symptomatic bioprosthetic valve dysfunction, classified in New York Heart Association (NYHA) class III or IV, who underwent ViV TAVI with ACURATE neo2 at our center between July 2022 and February 2024. Outcomes were assessed using VARC-3 criteria. Results: Fifty-five patients (51% females, median (IQR) age 76 (8) years) were included. The technical success rate was 98.2%. No patients experienced in-hospital mortality, stroke, MI, bleeding, vascular complications, renal failure, or new pacemaker implantation. Three patients (5.5%) underwent elective chimney stenting for coronary protection. The postprocedural mean aortic gradient was 6.7 ± 1 mmHg, with a mean aortic valve area (AVA) of 2.0 ± 0.1 cm². Over a median follow-up period of 1.2 years, no deaths (0%) were observed, heart failure hospitalization rate was 3.6%, and NYHA class improved to ≤II in 100% of patients. Conclusions: ACURATE neo2 demonstrated excellent technical success, sustained hemodynamic performance, and significant clinical improvement in ViV TAVI. The absence of major adverse events reinforces its safety, efficacy, and durability as a treatment for degenerated surgical bioprostheses. Full article

Transcatheter aortic valve replacement (TAVR) was first introduced as a minimally invasive treatment for patients with severe aortic stenosis (AS) who are at high or intermediate surgical risk. Recently, its application has expanded to include younger and lower-risk patients, establishing TAVR as a less invasive alternative to surgical aortic valve replacement (SAVR) across the entire surgical spectrum. The expanding utilization of TAVR has driven significant advancements that have greatly enhanced its safety and effectiveness, resulting in a substantial reduction in complications such as paravalvular leak, conduction abnormalities, and periprocedural strokes. Numerous trials have demonstrated the potential superiority of TAVR over conventional surgery in achieving favorable clinical outcomes. Furthermore, the increasing number of long-term trials has provided valuable insight into TAVR outcomes in previously under-studied populations, including patients with complex anatomies. However, significant challenges remain, particularly in ensuring the long-term durability of transcatheter valves, with younger patients likely to outlive their bioprosthetic valves. Consequently, the focus is shifting towards lifetime management strategies, including considerations for coronary re-access, the risk of coronary obstruction, and prosthesis–patient mismatch. This review explores key developments in the field, including TAVR for aortic regurgitation and bicuspid anatomy, the emerging role of TAVR in moderate and asymptomatic AS, and innovations in valve design and procedural planning. We also examine novel imaging tools, adjunctive technologies, and strategies to address coronary access and re-intervention. As long-term data accumulate, these evolving trends will shape the future of TAVR and its role in managing aortic valve disease across increasingly complex clinical scenarios. Full article

The aim of this study was to evaluate the effect of suture material made of polyester (PET), polypropylene (PP), and polytetrafluoroethylene (PTFE) on the calcification of a bovine pericardium (BP) consisting of collagen biopolymer preserved with an epoxy compound. Non-porous film made of the synthetic reinforced polymer REPEREN^® was chosen as a control material. Samples of the material (sutured or non-sutured with each of the three types of surgical sutures) were implanted subcutaneously in 45 young rats for 30, 60, and 90 days. The calcium content of the explants was quantified using atomic absorption spectrometry, a histological examination was performed using hematoxylin and eosin and von Kossa staining, and the structure of the calcium phosphate deposits was studied using scanning electron microscopy (SEM) and energy dispersive spectrometry (EDS) with color field mapping. The results demonstrated the absence of calcification in the non-sutured BP and in all the REPEREN^® groups. In the sutured BP samples, a dynamic increase in the Ca content and the Ca/P ratio to 1.67–1.7 (crystalline hydroxyapatite) was observed by the 90th day. The minimum Ca content among the sutured BP groups was detected in samples where the PET thread was used. The cellular reaction to BP was significantly more pronounced than the reaction to REPEREN^® throughout the entire observation period; collagen homogenization was noted near the sutures. It can be concluded that all the studied suture materials provoke BP calcification. PET has the minimal negative effect. Full article

Background/Objectives: Surgical aortic valve replacement effectively relieves left ventricular afterload and promotes reverse remodeling in patients with severe aortic stenosis. The Perceval prosthesis offers a hybrid approach, combining complete annular decalcification with sutureless deployment. This design allows for reduced operative times and potentially larger effective orifice areas. However, comparative data with conventional stented bioprosthetic valves remain limited, particularly regarding reverse remodeling, hemodynamic performance, and long-term clinical outcomes. Methods: In this retrospective cohort study, 115 patients underwent aortic valve replacement with either the Perceval valve (n = 44) or conventional stented bovine pericardial valves (n = 71). Results: The Perceval group showed a 100% procedural success rate with no in-hospital mortality, significantly shorter cardiopulmonary bypass and cross-clamp times, larger effective orifice areas, and a lower incidence of patient–prosthesis mismatch. Both groups demonstrated favorable left ventricular mass regression and reverse remodeling. The rates of paravalvular leakage, permanent pacemaker implantation, and redo aortic valve replacement were comparable between groups. Multivariate Cox regression identified the follow-up indexed left ventricular mass as an independent predictor of major adverse cardiac and cerebral events. Conclusions: In this study, the Perceval valve was associated with promising hemodynamic characteristics and procedural efficiencies, particularly in cases with small aortic annuli and during minimally invasive procedures. The valve was associated with reverse ventricular remodeling and clinical outcomes that appeared similar to those of conventional stented bioprostheses. These observations suggest it may represent a potential alternative option for surgical aortic valve replacement in appropriate clinical scenarios. However, randomized control trials are needed to confirm these associations. Full article

The Ross procedure introduced a new technique for aortic valve replacement by utilizing a pulmonary autograft to replace the diseased aortic valve. This approach provides a living, dynamic valve substitute capable of growth and adaptation to systemic pressures while addressing the limitations of mechanical valves, which require lifelong anticoagulation, and bioprosthetic valves, which lack durability and growth potential. The Ross procedure offers superior hemodynamic performance and freedom from anticoagulation. While initially popular, utilization declined due to its technical complexity and concerns regarding the potential for the failure of two valves, requiring additional operations. Advances in surgical techniques, such as reinforced autografts, improved myocardial protection, and better homograft preservation, coupled with evidence of favorable long-term outcomes, have renewed interest in the procedure. Preoperative imaging with echocardiography, cardiac magnetic resonance imaging, and computed tomography angiography ensures optimal patient selection and preparation. Intraoperatively, precise autograft harvesting, accurate implantation, and meticulous right ventricular outflow tract reconstruction are critical for success. Blood conservation techniques, such as acute normovolemic hemodilution and retrograde autologous priming, are employed to minimize transfusion-related complications. The anesthesiologist plays a critical role, including meticulous monitoring of myocardial function and hemodynamics, with intraoperative transesophageal echocardiography being essential for assessing valve integrity and ventricular function. Recent studies suggest that the Ross procedure can restore life expectancy in appropriately selected patients, reinforcing its value as a surgical option for managing aortic valve disease. Full article

Background: An extensive use of transesophageal echocardiography (TEE) has recently been suggested for the diagnosis of infective endocarditis (IE). In this study, we investigated whether among patients with negative transthoracic echocardiography (TTE), subgroups can be identified among whom TEE can be avoided/delayed. Methods: We conducted a retrospective study of 637 consecutive patients who underwent TEE for suspected IE. We selected 375 patients with negative TTE. For each patient, we obtained age, sex, blood culture (BC), blood exams, evidence of embolism, presence of moderate/severe heart valve disease, valve prostheses, and intracardiac devices. Results: IE was eventually diagnosed in 56 patients. Variables independently associated with IE at multivariate analysis included positive BC (OR 3.45; p = 0.006), evidence of embolism (OR 13.0; p < 0.001), bioprosthetic heart valves (OR 4.31; p < 0.001) and platelet count < 150,000/mL (OR 2.47; p = 0.014). In patients without any of these predictors for IE (n = 81), only 1 had a diagnosis of IE and no in-hospital IE-related deaths occurred. Among patients with negative BC (n = 127), IE prevalence increased with the number of other predictors, but IE-related mortality was 0%. IE prevalence (10.8%) and IE related in-hospital mortality (2.7%) were also rather low in patients with a positive blood culture without any other independent predictors for IE but were 20% (IE-related mortality 3.8%) and 71% (IE-related mortality 28.6%) in those with only one or 2–3 other IE predictors, respectively. Conclusions: Our data suggest that, among patients with suspected IE and negative TTE, subgroups can be identified in whom TEE might be safely avoided or delayed. Full article

With the increasing number of people suffering from heart valve diseases (e.g., stenosis and/or insufficiency), the attention paid to prosthetic heart valves has grown significantly. Developing a prosthetic device that fully replaces the functionality of the native valve remains a huge challenge. Polymeric heart valves (PHVs) represent an appealing option, offering the potential to combine the robustness of mechanical valves with the enhanced biocompatibility of bioprosthetic ones. Over the years, novel biomaterials (such as promising new polymers and nanocomposites) and innovative designs have been explored for possible applications in manufacturing PHVs. This work provides a comprehensive overview of PHVs’ evolution in terms of materials, design, and fabrication techniques, including in vitro and in vivo studies. Moreover, it addresses the drawbacks associated with PHV implementation, such as their limited biocompatibility and propensity for sudden failure in vivo. Future directions for further development are presented. Notably, PHVs can be particularly relevant for transcatheter application, the most recent minimally invasive approach for heart valve replacement. Despite current challenges, PHVs represent a promising area of research with the potential to revolutionize the treatment of heart valve diseases, offering more durable and less invasive solutions for patients. Full article

Subclinical leaflet thrombosis is an imaging phenomenon observed after transcatheter aortic valve implantation (TAVI) and characterized by hypoattenuating leaflet thickening (HALT) on computed tomography angiography. The clinical implications and underlying causes remain uncertain. Hypercoagulability, a component of Virchow’s triad, may contribute to thrombus formation on bioprosthetic leaflets, but data on hypercoagulable disorders in TAVI patients and their impact on HALT are limited. The PROSTHESIS study (Prothrombotic States in Transcatheter Heart Valve Subclinical Leaflet Thrombosis) is a single-center observational cohort study aiming to include 130 TAVI patients. This pilot study aimed to (i) assess the effect of hypercoagulable disorders on HALT prevalence and (ii) evaluate their impact on the natural history of HALT. Patients were screened for common hypercoagulable disorders using genetic and functional assays and underwent multimodal imaging one year after TAVI to detect HALT. In patients with HALT, post-implant imaging was repeated after three months to assess its progression. Early results comparing 52 TAVI patients with 52 matched controls undergoing coronary angiography showed similar thrombophilia prevalence between the groups (16% vs. 12%, p = 0.565). HALT occurred in 15% of TAVI patients, more extensively in those with thrombophilia (712 mm³ vs. 135 mm³, p = 0.036). However, thrombophilia was not an independent predictor of HALT. One-year follow-up CTA revealed spontaneous HALT resolution in 63%, stability in 25%, and progression in 12%. This study aims to provide insights into HALT and its mechanisms, which may help prevent complications and improve bioprosthesis durability. Full article

Bioprosthetic aortic valve degeneration (BAVD) is a significant clinical concern following both transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR). The increasing use of bioprosthetic valves in aortic valve replacement in younger patients and the subsequent rise in cases of BAVD are acknowledged in this review which aims to provide a comprehensive overview of the incidence, diagnosis, predictors, and management of BAVD. Based on a thorough review of the existing literature, this article provides an updated overview of the biological mechanisms underlying valve degeneration, including calcification, structural deterioration, and inflammatory processes and addresses the various risk factors contributing to BAVD, such as patient demographics, comorbidities, and procedural variables. The difficulties in early detection and accurate diagnosis of BAVD are discussed with an emphasis on the need for improved imaging techniques. The incidence and progression of BAVD in patients undergoing TAVR versus SAVR are compared, providing insights into the differences and similarities between the two procedures and procedural impacts on valve longevity. The current strategies for managing BAVD, including re-intervention options of redo surgery and valve-in-valve TAVR, along with emerging treatments are discussed. The controversies in the existing literature are highlighted to offer directions for future investigations to enhance the understanding and management of BAVD. Full article

Background: In recent years, the use of transcatheter valve-in-valve implantation in the mitral position (TMVI) for the treatment of mitral valve pathology following ring or bioprosthetic implantation has emerged as a less invasive option in comparison to repeated mitral valve surgery (RMVS). We aimed to compare the early and mid-term results of these two strategies. Method: We retrospectively analyzed all patients who underwent a mitral intervention in our institution between 2005 and 2022. Applying the exclusion criteria, 41 subjects were analyzed: 23 underwent RMVS, while 18 underwent a TMVI. The time-dependency treatment effect was approached using a landmark analysis, applying the Kaplan–Meier analysis at different time points. Results: The two study groups were comparable in terms of age (p = 0.18), gender (p = 0.78), body surface area (p = 0.33), and EuroSCORE II (p = 0.06). No patients died perioperatively or had a stroke. Two patients in each group died within the first 30 days following the procedure (RMVS 8.3% vs. TMVI 11.1%; p = 0.75). Eighteen patients had died at follow-up; two underwent re-intervention on their mitral valve (one in each group). The mean survival was not statistically different between groups (RMVS 8 ± 1.1 years, 95% CI 5.8–10.2, vs. TMVI 4.79 ± 0.82 years, 95% CI 3.1–6.4; log-rank = 0.087). A landmark analysis of survival after four years showed significantly worse survival for patients in the TMVI group in comparison with those treated surgically (log-rank = 0.047). Conclusions: TMVI and RMVS are both effective strategies with similar short-term outcomes. However, patients in the TMVI group showed a significantly lower survival rate after four years. Full article

Background: In recent years, in case of aortic valve replacement (AVR), a significant increase in the use of bioprostheses has been observed. The Perceval sutureless bioprosthesis has proven to be safe and reliable in the short and mid-term, with limited but promising long-term results. An updated systematic review with the long-term results of patients who underwent a sutureless bioprosthesis implantation with a Perceval biological valve is herewith presented. Methods: Studies published between 2015 and 2024, including the long-term outcomes—with clinical as well as echocardiographic information for up to five years—of patients who underwent a Perceval implantation for AVR were selected from the published literature. The Cochrane GRADE system was used to assess the study quality, and the risk of bias in non-randomized studies (ROBINS-I) tool was used to evaluate studies. Results: Ten studies were selected with an overall number of 5221 patients. The long-term survival ranged from 64.8 to 87.9%, freedom from structural valve degeneration (SVD) from 96.1 to 100%, freedom from significant paravalvular leak from 98.5 to 100%, freedom from prosthetic endocarditis from 90.7 to 99%, and freedom from reintervention from 94 to 100%. The long-term mortality ranged from 6.5 to 27.4%. SVD was observed in 0–4.8% patients. Significant paravalvular leak was observed in 0–3.4% patients, and infective endocarditis was observed in 0–3.4%. A bioprosthesis-related reintervention at long-term follow-up was required for 0–4.3% of patients, and 1.7–7.1% of patients required a late new pacemaker implantation. The transprosthetic mean pressure gradient ranged from 9 to 14.7 mmHg, peak pressure gradient ranged from 17.8 to 26.5 mmHg, and EOA ranged from 1.5 to 1.7 cm². Conclusions: This systematic review shows that there is still a paucity of data about sutureless bioprostheses. Nevertheless, the clinical results from prospective studies or retrospective series are encouraging. Medium- and long-term results seem to support the increasing use of this type of prosthesis. Full article

Atrial fibrillation (AF) is a common arrhythmia in clinical practice, and oral anticoagulation is the cornerstone of stroke prevention in AF. Direct oral anticoagulants (DOAC) significantly reduce the incidence of intracerebral hemorrhage with preserved efficacy for preventing stroke compared to vitamin K antagonists (VKA). However, the pivotal randomized controlled trials (RCTs) of DOAC excluded patients with valvular heart disease, especially mitral stenosis, which remains an exclusion criterion for DOAC use. The INVICTUS study was a large multicenter global RCT aimed at evaluating the role of DOAC compared to VKA in stroke prevention among patients with rheumatic valvular AF. In this study, rivaroxaban failed to prove superiority over VKA in preventing the composite primary efficacy endpoints of stroke, systemic embolism, myocardial infarction, and death. Unfortunately, the bleeding rates were not lower with rivaroxaban either. The death and drug discontinuation rates were higher in the DOAC arm. Close to the heels of the dismal results of INVICTUS, an apixaban trial in prosthetic heart valves, PROACT-Xa, was also prematurely terminated due to futility. Hence, for AF complicating moderate-to-severe mitral stenosis or prosthetic valve VKA remains the standard of care. However, DOAC can be used in patients with surgical bioprosthetic valve implantation, TAVR, and other native valve diseases with AF, except for moderate-to-severe mitral stenosis. Factor XI inhibitors represent a breakthrough in anticoagulation as they aim to dissociate thrombosis from hemostasis, thereby indicating a potential to cut down bleeding further. Multiple agents (monoclonal antibodies—e.g., osocimab, anti-sense oligonucleotides—e.g., fesomersen, and small molecule inhibitors—e.g., milvexian) have garnered positive data from phase II studies, and many have entered the phase III studies in AF/Venous thromboembolism. Future studies on conventional DOAC and new-generation DOAC will shed further light on whether DOAC can dethrone VKA in valvular heart disease. Full article