Search Results (124)

Cardiogenic shock (CS) in the setting of severe aortic stenosis (AS) presents a critical and high-risk scenario with limited therapeutic options and poor prognosis. Transcatheter aortic valve implantation (TAVI), initially reserved for inoperable or high-risk surgical candidates, is increasingly being considered in patients with CS due to improvements in device technology, operator experience, and supportive care. This review synthesizes current evidence from large registries, observational studies, and meta-analyses that support the feasibility, safety, and potential survival benefit of urgent or emergent TAVI in selected CS patients. Procedural success is high, and early intervention appears to confer improved short-term and mid-term outcomes compared to balloon aortic valvuloplasty or medical therapy alone. Critical factors influencing prognosis include lactate levels, left ventricular ejection fraction, renal function, and timing of intervention. The absence of formal guidelines, logistical constraints, and ethical concerns complicate decision-making in this unstable population. A multidisciplinary Heart Team/Shock Team approach is essential to identify appropriate candidates, manage procedural risk, and guide post-intervention care. Further studies and the development of TAVI-specific risk models in CS are anticipated to refine patient selection and therapeutic strategies. TAVI may represent a transformative option for stabilizing hemodynamics and improving outcomes in this otherwise high-mortality group. Full article

Background/Objectives: Currently, the transfemoral approach is recognized as the primary method for accessing transcatheter aortic valve implantation (TAVI). However, alternative techniques are needed when the transfemoral access is not suitable. We proposed that a modified transaxillary approach through the distal left axillary artery is both viable and safe for conducting TAVI, potentially offering benefits for patients. Methods: From December 2018 to February 2024, a total of 24 patients (7 women, average age 77.9 ± 8 years) received TAVI using transaxillary access via the left axillary artery. The participants suffered from symptomatic severe aortic stenosis and were deemed TAVI candidates with iliofemoral anatomy unsuitable for a transfemoral route. The patient group displayed a high perioperative risk profile, with significant peripheral artery disease or severe obstructive infrarenal aortic conditions. The implantation of the aortic prosthesis was carried out through the left distal axillary artery. A balloon-expandable valve was used in every instance. Results: In the examined cohort, the 30-day mortality rate was 4.2%. A new pacemaker was necessary for four patients (16.7%). One case exhibited a new moderate neurological dysfunction. Additionally, one patient required surgical revision of the access point due to ischemia. Conclusions: Our findings indicate that transaxillary TAVI via the distal left axillary artery has yielded encouraging outcomes. This approach is practicable and safe, does not prolong the procedure, minimizes surgical trauma, ensures excellent access regardless of chest anatomy, and is sparing for the brachial plexus. As a single-center pilot study, our findings require confirmation in larger, prospective cohorts with extended follow-up to fully validate the safety and long-term efficacy of this technique. Full article

Aortic stenosis (AS), the most common valvular heart disease, is traditionally graded based on several echocardiographic quantitative parameters, such as aortic valve area (AVA), mean pressure gradient (MPG), and peak jet velocity (Vmax). This systematic review evaluates the clinical significance and prognostic implications of discordant high-gradient AS (DHG-AS), a distinct hemodynamic phenotype characterized by elevated MPG despite a preserved AVA (>1.0 cm²). Although often overlooked, DHG-AS presents unique diagnostic and therapeutic challenges, as high gradients remain a strong predictor of adverse outcomes despite moderately reduced AVA. Sixty-three studies were included following rigorous selection and quality assessment of the key studies. Prognostic outcomes across five key studies were discrepant: some showed better survival in DHG-AS compared to concordant high-gradient AS (CHG-AS), while others reported similar or worse outcomes. For instance, a retrospective observational study including 3209 patients with AS found higher mortality in CHG-AS (unadjusted HR: 1.4; 95% CI: 1.1 to 1.7), whereas another retrospective multicenter study including 2724 patients with AS observed worse outcomes in DHG-AS (adjusted HR: 1.59; 95% CI: 1.04 to 2.56). These discrepancies may stem from delays in intervention or heterogeneity in study populations. Despite the diagnostic ambiguity, the presence of high gradients warrants careful evaluation, aggressive risk stratification, and timely management. Current guidelines recommend a multimodal approach combining echocardiography, computed tomography (CT) calcium scoring, transesophageal echocardiography (TEE) planimetry, and, when needed, catheterization. Anatomic AVA assessment by TEE, CT, and cardiac magnetic resonance imaging (CMR) can improve diagnostic accuracy by directly visualizing valve morphology and planimetry-based AVA, helping to clarify the true severity in discordant cases. However, these modalities are limited by factors such as image quality (especially with TEE), radiation exposure and contrast use (in CT), and availability or contraindications (in CMR). Management remains largely based on CHG-AS protocols, with intervention primarily guided by transvalvular gradient and symptom burden. The variability among the different guidelines in defining severity and therapeutic thresholds highlights the need for tailored approaches in DHG-AS. DHG-AS is clinically relevant and associated with substantial prognostic uncertainty. Timely recognition and individualized treatment could improve outcomes in this complex subgroup. Full article

Background/Objectives: Aortic stenosis is a common heart disease, particularly among elderly patients. Transcatheter aortic valve implantation (TAVI) offers a minimally invasive alternative method to surgical valve replacement for high-risk patients. Although clinical guidelines for TAVI are well established, standardized nursing care pathways are lacking. This systematic review aims to clarify the nursing role in the pre-, peri-, and postoperative phases of TAVI. Methods: This review was conducted in accordance with the PRISMA guidelines. After applying the eligibility criteria, ten studies were selected from five databases: PubMed, Scopus, CINAHL, Web of Science, and the Cochrane Library. The work was registered in the PROSPERO database with the ID number CRD420251061863. Results: The analysis revealed the following: (1) a strong emphasis on preoperative patient education, often led by nurse coordinators; (2) perioperative nursing roles in conscious sedation protocols and early mobilization; (3) a lack of standardized rehabilitative protocols, especially in the preoperative phase; and (4) an emerging but insufficiently evaluated role of the TAVI nurse coordinator in multidisciplinary care. Most studies concentrated on postoperative care, outcomes, follow-up, and rehabilitation, but the small sample sizes limited the strength of the conclusions. Conclusions: Nurses play a vital role in multidisciplinary TAVI teams. There is an urgent need for evidence-based nursing guidelines to standardize care, improve clinical outcomes, and address the needs of TAVI patients. This review highlights the pivotal contribution of nursing to the success of TAVI. 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

Transcatheter aortic valve implantation (TAVI) has emerged as a transformative therapy for patients with severe aortic stenosis (AS) across all surgical risk groups. However, periprocedural cerebrovascular events (CVEs), including overt stroke and silent cerebral embolism, remain significant complications. As a result, the use of embolic protection devices (EPDs) during TAVI has been proposed to mitigate this risk. Our aim was to provide a comprehensive review of the current evidence on the efficacy, safety, and clinical utility of embolic protection devices in TAVI procedures. According to the existing literature, EPDs are effective in capturing embolic debris during TAVI and are associated with a reduction in silent cerebral lesions as detected by diffusion-weighted MRI. While some RCTs and meta-analyses demonstrate a potential benefit in reducing disabling stroke, evidence for a consistent reduction in overall stroke or mortality remains inconclusive. Subgroup analyses suggest the greatest benefit in patients at elevated stroke risk, while current-generation EPDs demonstrate high technical success and an acceptable safety profile. Subsequently, EPDs represent a promising adjunct to TAVI, particularly in high-risk populations. However, routine use in all patients is not yet supported by consistent clinical evidence. Further large-scale trials and long-term outcome data are needed to clarify their role in improving neurological outcomes and to guide selective patient application. Full article

Background: The aim of this study was to compare costs and clinical outcomes associated with transcatheter aortic valve implantation (TAVI) versus surgical aortic valve replacement (SAVR). A secondary analysis was performed in patients with coronary artery disease, and patients with TAVI and percutaneous coronary intervention (PCI) were compared with SAVR and coronary artery bypass grafting (CABG). Methods: All patients who underwent the TAVI or SAVR procedure for severe degenerative aortic stenosis between August 2013 and February 2025 at a tertiary cardiovascular center were selected for inclusion in the present study. Patients were excluded if there was no available follow-up or if there was a crossover between treatments (especially CABG undergoing TAVI or SAVR undergoing PCI within a 6-month timeframe). Results: A total of 2452 patients (1925 undergoing SAVR and 527 undergoing TAVI) were included. Of those, 400 underwent SAVR + CABG and 75 underwent TAVI + PCI. During a median follow-up of 2.88 (1.12–6.43) years, a total of 404 all-cause events occurred, corresponding to 4.18 deaths per 100 patient-years. TAVI was associated with higher hospitalization costs and fewer in-hospital deaths than SAVR. However, long-term survival was similar between TAVI and SAVR and between TAVI + PCI and SAVR + CABG. Interventional treatment was more cost-effective in patients with EuroSCORE > 10%, while surgical treatment was more cost-effective in patients with EuroSCORE < 10%. Conclusions: In patients who are at high surgical risk, TAVI is more cost-effective than SAVR, and TAVI + PCI is more cost-effective than SAVR + CABG. In patients who are not at high surgical risk, SAVR is more cost-effective than TAVI, and SAVR + CABG is more cost-effective than TAVI + PCI. Full article

Background: Aortic valve stenosis remains the most prevalent valvular pathology in Western countries. Rapid deployment bioprosthesis (RD) has emerged as a promising alternative to conventional valves for surgical aortic valve replacement (SAVR), particularly in elderly and high-risk patients. This study reports the short- and long-term outcomes of RD in patients with isolated aortic stenosis. Methods: A retrospective single-center analysis was conducted on 382 patients who underwent RD-AVR between 2014 and 2020. Data were collected from clinical files and national electronic databases. Primary outcomes included cardiopulmonary bypass (CPB) and cross-clamping (XC) times, postoperative complications, and long-term survival. Results: The mean age was 75.6 ± 5.9 years, with 29.8% of patients over 80 years old and a mean EuroSCORE II of 2.3 ± 1.5%. CPB and XC times were 36.7 ± 10.8 and 27.4 ± 8.1 min, respectively. Postoperative complications included acute kidney injury (AKI, 53.4%), de novo atrial fibrillation (31.9%), and high-grade/complete atrioventricular block with permanent pacemaker implantation (9.8%). In-hospital and 30-day mortality was 1.02% and 2.3%, respectively. The 5-year survival rate was 77%. At 6 months postoperatively, the mean transvalvular gradient was 11.1 ± 4.7 mmHg. At a median follow-up of 6.7 years, no cases of structural valve deterioration and only one case of endocarditis were reported. Conclusion: In this single-center study, RD in isolated AVR demonstrated favorable short- and long-term outcomes, including no structural valve deterioration at mid-term follow-up. These devices offer a safe and effective alternative to conventional SAVR, particularly in high-risk populations. Full article

Background: Transcatheter aortic valve replacement (TAVR) has become the preferred treatment for severe aortic stenosis in high- and intermediate-risk patients, with expanding indications for lower-risk populations. However, post-procedural complications, such as stroke, conduction disturbances, and heart failure readmissions, remain concerns. The aim of our study is to analyze the national trends in TAVR procedures, in-hospital outcomes, major readmission causes, and the association of risk factors for readmissions following TAVR. Methods: We analyzed NIS data (2018–2022) to assess TAVR utilization trends, patient demographics, and in-hospital outcomes. The NRD (2021–2022) was used to evaluate 60-day readmission rates for stroke, complete heart block, and heart failure. Multivariate regression models were employed to identify risk factors having significant association with major readmission causes. Results: TAVR utilization increased from 10,788 cases in 2018 to 17,784 in 2022, with a concurrent decrease in in-hospital mortality (1.33% to 0.90%) and length of stay (3.88 to 2.97 days). Of 123,376 TAVR index admissions in 2021, 28,654 patients had 66,100 readmission events (53.57%) in the 60 days following discharge. Heart failure (17,566 cases, 26.57% of readmissions) was the most common readmission cause, followed by complete heart block (1760 cases, 2.66% of readmissions) and stroke (284 cases, 0.42% of readmissions). Predictors of post-TAVR stroke included uncontrolled hypertension (OR 2.29, p < 0.001) and chronic heart failure (OR 2.73, p < 0.001). Left bundle branch block (LBBB) was strongly associated with complete heart block (OR 12.89, p < 0.001) and heart failure readmissions (OR 7.65, p < 0.001). Conclusions: TAVR utilization has increased with improving perioperative outcomes, but post-TAVR readmissions remain significant, particularly for heart failure, stroke, and conduction disturbances. Pre-procedural uncontrolled hypertension, hyperlipidemia, congestive heart failure, and atrial fibrillation were risk factors with significant association with stroke in the 60 days following TAVR. The presence of documented pre-procedural LBB, RBB, as well as BFB were risk factors with significant association with complete heart block following TAVR placements. Pre-procedural LBB, RBB, BFB, and atrial fibrillation were risk factors having significant association with heart failure readmissions in the 60 days following TAVR. Full article

Aortic stenosis (AS), the most prevalent valvular heart disease, is increasingly recognized as an active disease process driven by a convergence of hemodynamic stress, inflammation, oxidative injury, and metabolic remodeling. While transcatheter and surgical valve replacement remain the standard interventions for severe AS, they fail to reverse the chronic myocardial remodeling that underlies adverse outcomes in many patients. Sodium–glucose cotransporter 2 (SGLT2) inhibitors have emerged as promising cardioprotective agents, with effects extending well beyond glycemic control. Recent mechanistic studies reveal that SGLT2 is expressed in the myocardium of patients with AS and is linked to pathways of fibrosis, inflammation, and energetic dysfunction. Experimental models and translational data demonstrate that SGLT2 inhibition attenuates maladaptive remodeling through modulation of TGF-β, NF-κB, NLRP3 inflammasome, and oxidative stress signaling while enhancing mitochondrial energetics and endothelial function. Importantly, clinical evidence from randomized and real-world studies suggests that SGLT2 inhibitors improve heart failure outcomes following valve replacement and may slow AS progression. This review integrates current pathophysiological insights with emerging molecular and clinical data to delineate the therapeutic rationale for SGLT2 inhibition in AS. By targeting both myocardial and valvular components of the disease, SGLT2 inhibitors may offer a novel disease-modifying strategy with potential implications across the AS continuum—from asymptomatic stages to the post-interventional setting. Ongoing and future trials are warranted to define optimal patient selection, timing, and biomarkers for response to SGLT2 inhibitor therapy in this increasingly high-risk population. Full article

Background: Transcatheter aortic valve implantation (TAVI) has transformed the treatment of severe aortic stenosis (AS), particularly in high-risk patients. However, comorbidities such as pulmonary hypertension (PH) and secondary tricuspid regurgitation (TR) contribute to adverse outcomes. Tricuspid annulus (TA) dilatation (TAD), a key marker of right ventricular dysfunction, has been associated with PH and TR progression. While echocardiographic assessment of TA has limitations, cardiac computed tomography (CT), routinely performed before TAVI, enables precise TA measurement. This study aimed to determine clinically relevant TA and TA indexed to body surface area (TA/BSA) cut-offs and assess their prognostic significance for long-term mortality. Methods: This retrospective, single-center study included 522 patients who underwent transfemoral TAVI between 2016 and 2022. Pre-procedural CT-derived TA measurements were analyzed to establish cut-off values predictive of right ventricular dysfunction in TAVI. Receiver operating characteristic (ROC) analysis was performed, and Kaplan–Meier survival curves, log-rank tests, and Cox regression were used to assess the impact of TA dimensions on long-term survival. Results: TAD correlated moderately with right ventricular dysfunction, with optimal cut-offs identified as TA ≥ 44.50 mm and TA/BSA ≥ 23.00 mm/m². However, Kaplan–Meier and Cox regression analyses demonstrated no significant association between TA or TA/BSA and long-term survival, with area under the curve (AUC) values close to 0.50, indicating poor prognostic value. Conclusions: Despite its relevance regarding right ventricular dysfunction in TAVI patients, TAD does not independently predict long-term mortality following TAVI. These findings challenge prior assumptions and suggest that TA dimensions alone should not guide risk stratification in TAVI patients. Further research is needed to refine prognostic models integrating multiple clinical and imaging parameters. Full article

Background: Myocardial fibrosis in aortic stenosis (AS) is associated with a significant risk of poor clinical outcomes. Myocardial fibrosis can be evaluated using cardiovascular magnetic resonance (CMR) imaging and may be useful for risk-stratifying patients at high risk for poorer outcomes. A circulating biomarker of fibrosis may be a cheaper, more accessible alternative to CMR in lower-to-middle-income countries. This study evaluated the correlation between serum biomarkers of myocardial fibrosis (TGF-β1, PICP, and PIIINP) with CMR markers of myocardial fibrosis (T1 mapping, extracellular volume fraction (ECV), and late gadolinium enhancement (LGE)). Methods: Twenty-one high-gradient (mean gradient ≥ 40 mmHg) severe AS (aortic valve area < 1.0 cm²) participants underwent T1 mapping and LGE imaging using CMR. Blood serum was collected for enzyme-linked immunosorbent assays of the listed biomarkers. Results: Serum TGF-β1 was associated significantly with the global T1 relaxation time on CMR (r = 0.46 with 95% CI 0.03 to 0.74, p = 0.04). In the high T1 time group (1056 vs. 1023 ms), trends toward elevated serum TGF-β1 concentration (13,044 vs. 10,341 pg/mL, p = 0.08) and ECV (26% vs. 24%, p = 0.07) were observed. The high T1 and trend towards elevated TGF-β1 concentration in this group tracked adverse LV remodeling and systolic dysfunction. There were no significant associations between PICP/PIIINP and T1 mapping or between the biomarkers and LGE quantity. Conclusions: Serum TGF-β1 is a potential surrogate for diffuse interstitial fibrosis measured by T1 mapping and ECV on CMR. Serum PICP and PIIINP may be less appropriate as surrogate markers of fibrosis in view of their temporal trends over the course of AS. Larger studies are needed to validate the utility of TGF-β1 as a marker of diffuse fibrosis and to evaluate the utility of serial PICP/PIIINP measurements to predict decompensation. Full article

Background: Heyde syndrome is a rare condition characterized by the triad of severe aortic stenosis, gastrointestinal bleeding, and acquired type 2A von Willebrand syndrome. This case report highlights the diagnostic and therapeutic approach for a 72-year-old woman presenting with exertional chest pain, dyspnea, fatigue, and a history of melena. Methods: The diagnostic workup revealed severe microcytic anemia and a reduced vWF ristocetin-to-antigen ratio. Imaging confirmed severe degenerative aortic stenosis, while video capsule endoscopy identified angiodysplasia and telangiectasias in the small bowel as the source of gastrointestinal bleeding. Following evaluation by a multidisciplinary Heart Team, the patient underwent transcatheter aortic valve replacement (TAVR) with an Evolut Fx self-expanding prosthesis. Results: Post-procedural echocardiography showed mild paravalvular regurgitation. The patient’s clinical course was favorable, with resolution of anemia and no further gastrointestinal bleeding episodes. Conclusions: Heyde syndrome requires a high index of suspicion for diagnosis in patients with severe aortic stenosis and unexplained anemia or gastrointestinal bleeding. TAVR offers an effective treatment option that not only resolves valvular pathology, but also mitigates associated bleeding risks. Full article

Background and Objectives: Aortic stenosis (AS) is a frequent valvular disease characterized by the obstruction of left ventricular outflow. The resulting hemodynamic and structural changes create an arrhythmogenic substrate, with sudden cardiac death (SCD) often caused by ventricular arrhythmias (VAs) being a feared complication. This review examines the relationship between severe AS and VA, detailing the epidemiology, pathophysiological mechanisms, risk factors, and management approaches prior to aortic valve replacement (AVR). Materials and Methods: We conducted a comprehensive narrative review of the historical and contemporary literature investigating ventricular arrhythmias in severe aortic stenosis. Literature searches were performed in PubMed, MEDLINE, and Scopus databases using keywords, including “aortic stenosis”, “ventricular arrhythmia”, “sudden cardiac death”, and “aortic valve replacement”. Both landmark historical studies and modern investigations utilizing advanced monitoring techniques were included to provide a complete evolution of the understanding. Results: The prevalence of ventricular ectopy and non-sustained ventricular tachycardia increases with AS severity and symptom onset. Left ventricular hypertrophy, myocardial fibrosis, altered electrophysiological properties, and ischemia create the arrhythmogenic substrate. Risk factors include the male sex, concomitant aortic regurgitation, elevated filling pressures, and syncope. Diagnostic approaches range from standard electrocardiography to continuous monitoring and advanced imaging. Management centers on timely valve intervention, with medical therapy serving primarily as a bridge to AVR. Conclusions: Ventricular arrhythmias represent a consequence of valvular pathology in severe AS rather than an independent entity. Their presence signals advanced disease and a heightened risk for adverse outcomes. Multidisciplinary management with vigilant monitoring and prompt surgical referral is essential. Understanding this relationship enables clinicians to better identify high-risk patients requiring urgent intervention before life-threatening arrhythmic events occur. Full article

Background/Objectives: Transthyretin cardiac amyloidosis (ATTR-CA) is an infiltrative cardiomyopathy caused by transthyretin (TTR) amyloid deposition in the myocardium, increasingly recognized in patients with aortic stenosis (AS). This study aims to investigate the diagnostic challenges and therapeutic strategies for patients with both conditions, focusing on shared pathophysiological mechanisms and key diagnostic indicators. Methods: A multimodal diagnostic approach was applied, utilizing cardiac magnetic resonance (CMR) and bone scintigraphy with technetium-99m-labeled tracers to assess AS patients with suspected ATTR-CA. Clinical signs, such as disproportionate heart failure symptoms, conduction abnormalities, and low-flow, low-gradient AS, were evaluated. Electrocardiographic findings, including low-voltage QRS complexes and pseudo-infarction patterns, were also assessed. Treatment options, including transcatheter aortic valve replacement (TAVR) and emerging pharmacotherapies for ATTR-CA, were analyzed. Results: The study found that ATTR-CA is increasingly prevalent in AS patients, with shared mechanisms like oxidative stress and amyloid-induced tissue remodeling. Key diagnostic signs include disproportionate heart failure symptoms, conduction abnormalities, and specific electrocardiographic patterns. TAVR was effective in both isolated AS and AS with ATTR-CA, although patients with both conditions had a higher risk of heart failure hospitalization and persistent symptoms. Emerging pharmacotherapies, such as TTR stabilizers and gene-silencing agents, showed promise in slowing disease progression. Conclusions: A multimodal diagnostic approach is essential for the early detection of ATTR-CA in AS patients. Combining TAVR with emerging pharmacotherapies may improve long-term outcomes for this high-risk group, enhancing patient care in those with both conditions. Full article