Search Results (235)

Background and Objectives: Transcatheter aortic valve implantation (TAVI) has become the mainstay of treatment for symptomatic aortic stenosis (AS) in patients over 70 years of age. It is also indicated for younger patients with significant comorbidities, for valve-in-valve interventions, and in selected patients with severe aortic insufficiency. We aimed to evaluate procedural and clinical outcomes of transfemoral TAVI performed over the course of 12 years by the same operators using different bioprosthetic valves. Materials and Methods: Between 2012 and 2023, 375 patients underwent TAVI in our clinic, with six types of bioprosthetic valves (Edwards Sapien XT, Medtronic Valves [CoreValve and Evolut R], Portico, Myval, Acurate Neo, and Direct Flow Medical). A transfemoral approach was used in all patients. The procedural and clinical outcomes were defined according to Valve Academic Research Consortium-3 (VARC-3) criteria. Results: The mean age of the patients was 78.4 ± 7.3, and their median STS score was 4.2 (2.9–5.9). Of the 375 patients, 361 had severe AS, 4 had severe aortic insufficiency, 5 were valve-in-valve, and 5 were valve-in-TAVI. Seven patients required a second valve implantation: four due to embolization of the prosthetic valve and three due to deep implantation of the prosthetic valve. Based on the VARC-3 criteria, the rates of technical success and device success were 90.4% and 85.3%, respectively. Major vascular complications were observed in 18 (4.8%) patients. Also, 42 (11.2%) patients required permanent pacemaker implantation. The incidence of moderate or worse paravalvular leak was 2.9%. The peri-procedural, 30-day, 1-year, and 5-year mortality rates were 5.1%, 4.3%, 15.2%, and 45.6%, respectively. STS scores (HR:1.129, 95%CI: 1.068–1.192, p < 0.001) and post-TAVI acute kidney injury (HR:3.993, 95%CI:1.629–9.785, p = 0.002) were detected as independent predictors of mortality in Cox regression analysis. Conclusions: This registry demonstrated the evolution of TAVI procedures at a single center over 12 years. A high level of collaboration between experienced operators and innovations in devices seem to be the key features for achieving high procedural success and low complication rates. Full article

Background: Sex-based disparities in the presentation, management, and outcomes of infective endocarditis (IE) remain insufficiently characterized despite their growing recognition. This study systematically evaluates current evidence on sex differences in the presentation, treatment, and outcomes of IE. Methods: A systematic review and meta-analysis were conducted according to PRISMA and Cochrane guidelines. EMBASE, MEDLINE, PubMed, the Cochrane Library, and Google Scholar were searched up to October 2024. Twenty-four studies including 139,952 patients (79,698 men and 60,254 women) were analyzed. Primary outcomes were mortality (in-hospital, 30-day, and 1-year), stroke, and treatment modality (medical vs. surgical). Secondary outcomes included complications, procedural characteristics, and hospital course. Results: Men were younger at diagnosis and had higher rates of substance abuse and coronary artery disease, while women more often had hypertension, diabetes, chronic lung disease, and prior valvular pathology. Men more frequently had aortic and prosthetic valve IE, whereas women had mitral and tricuspid involvement. Men were about 65% more likely to undergo surgery for infective endocarditis than women, while women were predominantly managed medically. Men had lower in-hospital (OR 0.81, 95% CI 0.72–0.92) and 1-year mortality (OR 0.76, 95% CI 0.61–0.94), though 30-day mortality did not differ significantly. Women experienced shorter hospital stays but longer ICU admissions and more heart failure, whereas men had more recurrent IE. Conclusions: Men underwent surgery more often and had better short- and long-term survival. Women presented later, with greater comorbidity and higher complication rates. Enhanced recognition of sex-specific risk and equitable surgical referral may improve IE outcomes. Full article

Background: The Ross procedure provides excellent outcomes in young adults requiring aortic valve replacement, with lower rates of infective endocarditis (IE) compared to prosthetic valves. Early postoperative IE of the autograft is exceptionally rare, with only isolated cases reported in major registries. Case Summary: We report a 40-year-old man with bicuspid aortic valve and a history of two previous episodes of native valve endocarditis who underwent Ross procedure with Ozaki modification. Ten days postoperatively, he developed fever and was diagnosed with early autograft IE with perivalvular abscess formation. Despite negative blood cultures (due to prior antibiotic administration), clinical findings met modified Duke criteria for possible IE. Imaging revealed perivalvular abscess with subsequent pseudoaneurysm development, while the autograft leaflets remained functional. The patient was successfully treated with 6-week combination antibiotic therapy without requiring surgical reintervention. After one year of follow-up, he remains asymptomatic with stable pseudoaneurysm size and preserved valvular function. Conclusions: Early IE following Ross procedure, though rare, should be considered in patients presenting with postoperative fever. This case demonstrates that conservative management with appropriate antibiotic therapy can be successful even with perivalvular complications, provided there is hemodynamic stability and close multidisciplinary monitoring. Long-term surveillance remains essential given the persistent structural abnormalities. Full article

Background/Objectives: Infective endocarditis (IE) remains a severe and complex disease despite advances in diagnosis and treatment. The changing epidemiological profile, with an ageing population, has reshaped its presentation and management. This study describes the epidemiological, clinical and microbiological characteristics of IE at a Portuguese tertiary referral hospital prior to the establishment of a multidisciplinary Endocarditis Team. Methods: A retrospective analysis was conducted including all adult patients diagnosed with definite or possible IE according to the 2015 ESC criteria, admitted to ULS São João, Porto, between January 2019 and December 2023. Data were collected from electronic medical records and included demographic characteristics, comorbidities, microbiology, imaging, surgical indications and outcomes. Results: A total of 143 IE episodes were identified. Median age was 71 years, with a predominance of heterologous material-related infections (81%). Enterococcus faecalis, viridans group streptococci and coagulase-negative staphylococci were the most frequent pathogens. Surgical indication was present in 74% of cases, although surgery was not performed in 22% due to comorbidities or frailty, contributing to a high in-hospital mortality rate. Conclusions: This study provides a contemporary overview of IE in Portugal, reflecting an elderly, comorbid population and a predominance of prosthetic disease. The results highlight the need for multidisciplinary management and early surgical decisions, supporting the creation of Endocarditis Teams in tertiary centres. Full article

Background and Objectives: Infective endocarditis (IE) continues to represent a life-threatening clinical entity, particularly in patients with advanced involvement of the cardiac fibrous skeleton. This study was designed to determine the incidence and to evaluate both short- and long-term outcomes in patients undergoing complex surgical intervention necessitating patch reconstruction for extensive and destructive IE. Materials and Methods: Between January 2008 and December 2024, 678 patients underwent cardiac surgery for IE at University Hospital Frankfurt/Main. The primary endpoint was long-term survival; the secondary endpoint was freedom from reoperation. Results: Ninety-six patients (14%) required complex patch reconstruction, owing to the severe involvement of the cardiac fibrous skeleton. The median age was 68 years (interquartile range [IQR], 16.5 years). Forty-three patients underwent redo surgery following previous cardiac procedures. Abscess formation was identified in 88% of cases (n = 85). Infective endocarditis was predominantly left-sided in 97% of patients (n = 94). In 40 patients (41%), the aortomitral continuity or the left ventricular outflow tract (LVOT) was involved. Combined surgical procedures were performed in 85 patients (87.6%), including 19 commando or hemi-commando operations. Thirty-day mortality was 20% (n = 19). The estimated 5- and 10-year survival rates were 46.5 ± 5.5% and 26.1 ± 6.8%, respectively. Survival did not differ significantly between native and prosthetic valve endocarditis, nor between commando/hemi-commando procedures and cases with abscess formation but preserved aorto-mitral continuity. Conclusions: In industrialized countries, extensive IE with abscess formation or destruction of the cardiac skeleton is predominantly associated with Staphylococcus aureus. Patients undergoing commando or hemi-commando procedures do not experience inferior survival compared with other patients with extensive IE. No survival advantage was observed for native versus prosthetic valve IE in the presence of extensive abscess formation. Full article

Background and clinical significance: Primary cardiac diffuse large B-cell lymphoma (DLBCL) arising in bioprosthetic valves is exceedingly rare. Most patients present with localized disease often masquerading as suspected thrombi or vegetations. Imaging studies are inconclusive and due to the rarity of the disease, treatment and follow-up data are very limited. Case presentation: We present one such case developing 9 years after aortic valve replacement in an otherwise immunocompetent patient, who presented with minor symptoms despite significant disease burden. This tumor contained Epstein–Barr virus (EBV), was confined to the site of origin, and has behaved non-aggressively after excision with a follow-up of 59 months. Conclusions: This unique disease is classified as Fibrin-associated large B-cell lymphoma (FA-LBCL) in view of its distinct clinical-pathological features. This report also addresses the unique features of this type of lymphoma. Full article

Infective endocarditis (IE) is a life-threatening condition with a rising incidence, demanding rapid and precise diagnosis. While echocardiography remains the cornerstone of initial evaluation, its limitations in complex cases—such as those involving prosthetic valves or cardiac devices—are well-known. This review synthesizes current evidence and guidelines to outline a practical, multimodality imaging approach for IE. We emphasize that integrating advanced techniques like cardiac computed tomography (CT) and [18F]-fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) early in the diagnostic pathway, particularly in high-risk scenarios, significantly enhances diagnostic certainty, guides therapeutic decisions, and improves patient outcomes. A tailored imaging strategy, driven by clinical presentation and integrated within a multidisciplinary endocarditis team, is paramount for modern IE management. Full article

Severe aortic stenosis represents a significant prognostic burden, particularly in symptomatic patients. The advent of transcatheter aortic valve replacement (TAVR) has revolutionized the treatment of patients previously considered ineligible for surgical aortic valve replacement (SAVR). TAVR provides a relatively safe intervention that leads to improvements in survival, symptoms, and functional status within months of implantation. A major complication following TAVR is the occurrence of paravalvular leaks (PVLs), which have been associated with increased mortality and higher rates of heart failure-related hospitalizations. PVLs refer to abnormal blood flow between the implanted valve and the aortic wall, which can compromise the functionality of the device. Careful pre-procedural planning enables the identification of patients at higher risk for PVL development. Although the incidence of PVLs has decreased with the introduction of newer-generation transcatheter valves, the condition remains clinically relevant. Due to the complex anatomy of the aortic valve apparatus and interference from the prosthetic frame, accurate evaluation of PVLs requires a multimodal diagnostic approach. Current evidence on PVL management is limited. In most cases, a conservative approach is adopted, while interventional strategies (such as pre- and post-dilatation, percutaneous PVL closure, and TAVR-in-TAVR) are reserved for selected patients. We performed a systematic literature review to summarize the incidence, predictors, diagnostic techniques, and management strategies of PVLs following TAVR. Full article

Objective: Prosthesis–patient mismatch (PPM) occurs after aortic valve replacement (AVR) when the effective orifice area of the implanted prosthetic valve is small relative to the patient’s body surface area. Beyond simply elevating transvalvular gradient, PPM profoundly affects cardiac remodeling, coronary physiology, and ultimately patient survival. This comprehensive review synthesizes current evidence regarding PPM pathophysiology, clinical consequences, and therapeutic strategies. Methods: We conducted a narrative review of PPM in surgical (SAVR) and transcatheter (TAVR) aortic valve replacement. PubMed and Embase were systematically searched using terms related to AVR and PPM and reference lists of key studies and reviews were screened. Studies addressing PPM prevalence, hemodynamic impact, clinical outcomes, and mitigation strategies were included. Results: PPM, defined as an iEOA ≤ 0.85 cm²/m² (moderate) or ≤0.65 cm²/m² (severe), demonstrates variable prevalence across studies, typically ranging from 5 to 30% after SAVR and 2–35% after TAVR. It is associated with increased transvalvular gradients, reduced left ventricular mass regression, persistent coronary flow abnormalities, higher rates of heart failure, and both early and late mortality. Supra-annular self-expanding transcatheter aortic valve replacement (TAVR) devices and newer generation stentless or bovine pericardial surgical valves exhibit lower PPM rates than older stented or porcine valves. Valve-in-valve (ViV) TAVR and bioprosthetic valve fracture (BVF) can improve outcomes in failed surgical valves but are less effective in small annuli. TAVR-in-TAVR procedures are limited by anatomic and technical constraints, especially in maintaining coronary access and minimizing residual gradients. Conclusions: PPM remains a common and clinically consequential complication of AVR that compromises long-term outcomes. It is largely preventable through accurate preoperative imaging, valve sizing, and consideration of annular enlargement. Optimal outcomes require matching valve characteristics to individual patient anatomy and physiology. In an era of expanding TAVR use, preventing PPM during the index procedure is critical to optimizing survival and preserving future reintervention options. Full article

Objectives: Infective endocarditis (IE) is a feared and life-threatening complication, requiring a multidisciplinary approach. Prosthetic valve endocarditis (PVE) accounts for 20–30% of IE, is one of the most severe forms of IE, and is associated with high morbidity and mortality. We aim to compare and analyze baseline characteristics, microbiology, clinical presentation, complications, and prognosis between biological and mechanical PVE; we also carried out a subgroup analysis of patients aged 45–65 at the time of onset of prosthetic surgery. Methods: The present study is a post hoc analysis of a prospective multicenter cohort of patients with PVE between January 2008 and December 2023. Patients were divided into two groups regarding the type of prosthesis, mechanical vs. biological. Results: A total of 1544 patients were included. 733 (47.47%) patients with mechanical PVE (mPVE) and 811 (52.52) with biological PVE (bPVE). We found that bPVE appeared earlier than mPVE, had more healthcare-related infections and paravalvular complications. Both groups had similar clinical presentations; moreover, there was no difference in surgical indication and if surgery was performed. On the other hand, mPVE has a higher incidence of Staphylococcus aureus (SA) and Gram-negative bacteria, while bPVE has more coagulase-negative staphylococci. Multivariable logistic regression identified the following independent risk factors of mortality: EuroSCORE I, age, mPVE, SA, IE comprising two valves, and severe sepsis. mPVE had a higher mortality on admission, probably due to a higher incidence of septic shock and CNS embolism. The subgroup analysis of patients between 45 and 65 years at the time of prosthesis implantation showed similar results. Conclusions: The present analysis shows that bPVE appears earlier than mPVE, even in the subgroup of patients aged 45–65. bPVE has more healthcare-related infections and more paravalvular complications. After adjusting for baseline differences, mPVE had higher in-hospital mortality. Full article

Background: Aspergillus endocarditis is a rare but life-threatening form of infective endocarditis that typically occurs in patients with a history of cardiac surgery, prosthetic valve implantation, or profound immunosuppression. Native valve involvement in non-traditional hosts remains exceptionally rare and is diagnostically challenging. Case presentation: We describe a 56-year-old woman with CREST syndrome and advanced liver disease awaiting transplantation who developed native aortic valve endocarditis. Blood cultures and serum biomarkers (galactomannan and β-d-glucan) were also negative. Transthoracic echocardiography revealed vegetation on the aortic valve. Valve replacement was performed, and Aspergillus fumigatus was isolated from two valve cultures. Liposomal amphotericin B was initiated; however, the patient died of multiorgan failure two weeks later. Systematic review: To contextualise this case, we conducted a systematic review of the literature following the PRISMA guidelines. We included microbiologically confirmed cases of native valve Aspergillus endocarditis based on valve or embolic tissue analysis. Forty-three studies met the inclusion criteria, comprising 45 patients in total. Data were independently extracted by two reviewers and narratively synthesised due to clinical heterogeneity. Conclusions: This case illustrates the diagnostic and therapeutic challenges of native-valve Aspergillus endocarditis in patients without classical risk factors for the disease. Early imaging and a high index of suspicion are crucial for diagnosis. Combined surgical and antifungal therapy remains the cornerstone of management, although the mortality rate remains high. Full article

Transcatheter aortic valve implantation is rapidly emerging as the leading treatment for severe aortic valve stenosis, especially in elderly and high-risk or inoperable patients. Prosthetic embolism is a rare but serious complication of transcatheter aortic valve replacement. Patients who develop prosthetic embolism are at increased risk of mortality and morbidity. These include stroke and aortic dissection associated with manipulation of the prosthesis in the ascending aorta. Treatment of valve embolisms into the aorta may differ depending on the type of valve; however, it traditionally relies on repositioning the valve to an appropriate position. To date, there are no established pharmaceutical guidelines for the management of patients with valve prosthesis embolization. We present a case report of the implantation of a second aortic valve prosthesis after periprocedural embolization of the first transcatheter valve, resulting in residual floating in the ascending aorta and following treatment with oral anticoagulation as well as single antiplatelet therapy due to the increased risk of thrombogenesis. This case report provides an example of the management of a transcatheter valve embolization with residual floating and highlights the need for further studies to address this issue. Full article

Background: Cardiovascular disease (CVD) in pregnancy is a major cause of maternal morbidity and mortality, accounting for nearly one-third of pregnancy-related deaths worldwide. Physiological adaptations—expanded plasma volume, increased cardiac output, and a prothrombotic state—represent a natural cardiovascular stress test that may precipitate decompensation or unmask subclinical disease. Aim: This review critically examines contemporary evidence and international guidelines on the management of pregnancy-related cardiovascular disorders, focusing on pathophysiological mechanisms, diagnostic challenges, and therapeutic controversies. Content: The discussion centers on three high-impact clinical domains: (1) peripartum and preexisting cardiomyopathies, emphasizing mechanisms, prognosis, and the role of bromocriptine; (2) anticoagulation management in women with mechanical prosthetic valves, balancing maternal safety and fetal protection; and (3) hypertensive disorders of pregnancy, highlighting recent evidence from the CHAP and WILL trials and their implications for long-term cardiovascular prevention. Comparative analysis of ESC 2025 and AHA 2020 recommendations reveals broad consensus but persistent discrepancies in anticoagulation targets, postpartum surveillance, and follow-up strategies. Perspectives: Endothelial dysfunction, angiogenic imbalance, and systemic inflammation emerge as shared mechanisms linking diverse pregnancy-related cardiovascular conditions. Strengthening multidisciplinary care through Pregnancy Heart Teams, integrating obstetric and cardiologic expertise, and establishing structured postpartum follow-up pathways are essential to improve outcomes. Full article

Fungal endocarditis, despite being a rare diagnosis, has a higher morbidity and mortality rate compared to bacterial endocarditis. Candida species are the most common isolated pathogens involved in fungal endocarditis. Diagnosis is suspected in patients with underlying conditions such as cancer, myelodysplastic syndrome, diabetes, or intravascular catheters, where the modified Duke criteria apply. Management of the patient requires a multidisciplinary team (cardiologist, infectious diseases consultant, cardiac surgeon) along with antifungal treatment. We present the case of a 60-year-old male with biological prosthetic aortic valve replacement in the previous year for bicuspid aortic stenosis, admitted for a 5-day history of fever, nausea and minor urinary symptoms. The blood cultures were positive for Candida parapsilosis. Transthoracic cardiac ultrasound revealed a hypoechogenic mass attached to the aortic valve at the prosthetic fixation site. Although diagnosis was rapidly confirmed and treatment was administered shortly after first suspected, the patient developed, at first, cavernous sinus thrombosis and, later, fatal ST elevation myocardial infarction. The patient died despite efficient antifungal therapy, initially with Anidulafungin in monotherapy and later in combination with Fluconazole. The reported case emphasizes the importance of managing fungal endocarditis, the need for urgent diagnostic attention and multidisciplinary team approach by infectious diseases specialist, cardiologist, neurologist and heart surgeon. Full article

Background: Randomized controlled trials (RCTs) are the foundation of evidence-based medicine. However, the rapid pace of technological innovation in cardiovascular surgery and interventional cardiology challenges the traditional RCT framework. Observational studies may hold renewed value in fields where device evolution outpaces the time required to validate clinical outcomes. Methods: This analysis evaluates 270 randomized and non-randomized studies in transcatheter aortic valve implantation (TAVI), one of the most rapidly evolving areas in cardiovascular medicine. The investigation follows two lines: first, mapping the timeline of major RCTs against the introduction of new prosthetic models; second, comparing the prevalence, duration, and role of randomized (R) versus non-randomized (NR) studies. Results: The timeline reveals a persistent misalignment between innovation and validation. New prosthetic models frequently enter the market while RCTs for prior generations are still ongoing. For example, the Sapien 3 valve was approved, while trials on Sapien XT were still enrolling. Similarly, newer Evolut and Acurate models were introduced during ongoing studies of earlier versions, often prompting new studies before existing ones concluded. This leapfrogging effect fragments the evidence base and delays definitive comparisons. In parallel, randomized trials have increased in number and tend to be shorter in duration, reflecting a maturing field. However, non-randomized studies remain crucial for early testing and post-market surveillance. Conclusions: In a field with rapid technological evolution a sort of Zeno’s paradox occurs: long-term validation cannot keep pace with fast innovation, resetting the evidence base with each new model. To overcome this paradox, a paradigm shift in evidence generation is desirable. Future strategies must augment adaptive trial designs, leverage real-world data and use higher-level, advanced analyses to incorporate subjective variables and phenotypic diversity, to reduce confounding factors and speed up data access. Higher-level, integrative evidence analytics could help Achilles walk alongside the tortoise. Full article