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Clinical Research on Aortic Valve Replacement

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A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Cardiology".

Deadline for manuscript submissions: closed (31 August 2023) | Viewed by 9212

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Prof. Dr. Theodor J.M. Fischlein

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Guest Editor

Department of Cardiac Surgery, Klinikum Nürnberg, Paracelsus Medical University, 90471 Nuremberg, Germany
Interests: cardiac surgery; aortic valve disease; minimally invasive; translational science; aorta; heart valve disease; endothelium; coronary artery disease

Dr. Francesco Pollari

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Guest Editor

Cardiac Surgery Department, Klinikum Nürnberg-Paracelsus Medical University, 90419 Nürnberg, Germany
Interests: cardiac surgery; aortic valve disease; minimally invasive; mechanical circulatory support; aorta; heart valve disease; coronary artery disease

Special Issue Information

Dear Colleagues,

Aortic disease is the most common valvular heart disease. Additionally, while the number of procedures in Western countries has consistently dropped in favor of transcatheter aortic valve implantation (TAVI), surgical replacement (SAVR) remains the gold standard. The wide range of diseases that can be treated by SAVR (e.g., insufficiency, subvalvular stenosis, endocarditis, bicuspid degeneration, tumor) but also the evidence concerning the long-term outcomes are the main reasons SAVR remains the gold standard of the aortic valve disease. However, continuous efforts seek to minimize the burden of the surgery and to address unresolved issues, such as choice of intervention in patients with bicuspid aortic valve or the possibility to repair the valve, and also how to make TAVI and SAVR complementary and not competitive.

This Special Issue aims to address some of these gaps, including pre-procedural planning, streamlining of procedures, and post-procedural management, to improve clinical outcomes and ensure the best lifetime management for these patients. Both original research contributions and state-of-the-art reviews are welcome.

Prof. Dr. Theodor J.M. Fischlein
Dr. Francesco Pollari
Guest Editors

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Keywords

aortic valve disease
surgical aortic valve replacement
transcatheter aortic valve implantation
minimally invasive
sutureless aortic valve replacement
calcification

Published Papers (9 papers)

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Research

12 pages, 1670 KiB

Open AccessArticle

Aortic Valve Replacement: Understanding Predictors for the Optimal Ministernotomy Approach

by Francesco Giosuè Irace, Ilaria Chirichilli, Marco Russo, Federico Ranocchi, Marcello Bergonzini, Antonio Lio, Francesca Nicolò and Francesco Musumeci

J. Clin. Med. 2023, 12(21), 6717; https://doi.org/10.3390/jcm12216717 - 24 Oct 2023

Cited by 1 | Viewed by 729

Abstract

Introduction. The most common minimally invasive approach for aortic valve replacement (AVR) is the partial upper mini-sternotomy. The aim of this study is to understand which preoperative computed tomography (CT) features are predictive of longer operations in terms of cardio-pulmonary bypass timesand cross-clamp times. Methods. From 2011 to 2022, we retrospectively selected 246 patients which underwent isolated AVR and had a preoperative ECG-gated CT scan. On these patients, we analysed the baseline anthropometric characteristics and the following CT scan parameters: aortic annular dimensions, valve calcium score, ascending aorta length, ascending aorta inclination and aorta–sternum distance. Results. We identified augmented body surface area (>1.9 m²), augmented annular diameter (>23 mm), high calcium score (>2500 Agatson score) and increased aorta–sternum distance (>30 mm) as independent predictors of elongated operation times (more than two-fold). Conclusions. Identifying the preoperative predictive factors of longer operations can help surgeons select cases suitable for minimally invasive approaches, especially in a teaching context. Full article

(This article belongs to the Special Issue Clinical Research on Aortic Valve Replacement)

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10 pages, 951 KiB

Open AccessArticle

Aortic Valve Replacement in Adult Patients with Decellularized Homografts: A Single-Center Experience

by Alexandra Andreeva, Iuliana Coti, Paul Werner, Sabine Scherzer, Alfred Kocher, Günther Laufer and Martin Andreas

J. Clin. Med. 2023, 12(21), 6713; https://doi.org/10.3390/jcm12216713 - 24 Oct 2023

Viewed by 773

Abstract

Background: decellularized aortic homografts (DAH) represent a promising alternative for aortic valve replacement in young adults due to their low immunogenicity and thrombogenicity. Herein, we report our midterm, single-center experience in adult patients with non-frozen DAH from corlife. Methods: safety, durability, and hemodynamic performance were evaluated according to current guidelines in all consecutive patients who had received a DAH at our center since 03/2016. Results: seventy-three (mean age 47 ± 11 years, 68.4% (n = 50) male) patients were enrolled. The mean diameter of the implanted DAH was 24 ± 2 mm. Mean follow-up was 36 ± 27 months, with a maximum follow-up of 85 months and cumulative follow-up of 215 years. No cases of stenosis were observed, in four (5.5%) cases moderate aortic regurgitation occurred, but no reintervention was required. No cases of early mortality, non-structural dysfunction, reoperation, valve endocarditis, or thrombosis were observed. Freedom from bleeding and thromboembolic events was 100%; freedom from re-intervention was 100%; survival was 98.6% (n = 72). Conclusions: early and mid-term results showed low mortality and 100% freedom from reoperation, thromboembolic events, and bleeding at our center. However, in order for this novel approach to be established as a valid alternative to aortic valve replacement in young patients, long-term data are required. Full article

(This article belongs to the Special Issue Clinical Research on Aortic Valve Replacement)

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15 pages, 6295 KiB

Open AccessArticle

Transcatheter Aortic Valve Replacement in Degenerated Perceval Bioprosthesis: Clinical and Technical Aspects in 32 Cases

by Giovanni Concistrè, Tommaso Gasbarri, Marcello Ravani, Anees Al Jabri, Giuseppe Trianni, Giacomo Bianchi, Rafik Margaryan, Francesca Chiaramonti, Michele Murzi, Enkel Kallushi, Egidio Varone, Simone Simeoni, Alessandro Leone, Andrea Farneti, Sergio Berti and Marco Solinas

J. Clin. Med. 2023, 12(19), 6265; https://doi.org/10.3390/jcm12196265 - 28 Sep 2023

Cited by 2 | Viewed by 929

Abstract

Background: Sutureless aortic bioprostheses are increasingly being used to provide shorter cross-clamp time and facilitate minimally invasive aortic valve replacement. As the use of sutureless valves has increased over the past decade, we begin to encounter their degeneration. We describe clinical outcomes and technical aspects in patients with degenerated sutureless Perceval (CorCym, Italy) aortic bioprosthesis treated with valve-in-valve transcatheter aortic valve replacement (VIV-TAVR). Methods: Between March 2011 and March 2023, 1310 patients underwent aortic valve replacement (AVR) with Perceval bioprosthesis implantation. Severe bioprosthesis degeneration treated with VIV-TAVR occurred in 32 patients with a mean of 6.4 ± 1.9 years (range: 2–10 years) after first implantation. Mean EuroSCORE II was 9.5 ± 6.4% (range: 1.9–35.1%). Results: Thirty of thirty-two (94%) VIV-TAVR were performed via transfemoral and two (6%) via transapical approach. Vascular complications occurred in two patients (6%), and mean hospital stay was 4.6 ± 2.4 days. At mean follow-up of 16.7 ± 15.2 months (range: 1–50 months), survival was 100%, and mean transvalvular pressure gradient was 18.7 ± 5.3 mmHg. Conclusion: VIV-TAVR is a useful option for degenerated Perceval and appears safe and effective. This procedure is associated with good clinical results and excellent hemodynamic performance in our largest single-center experience. Full article

(This article belongs to the Special Issue Clinical Research on Aortic Valve Replacement)

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16 pages, 644 KiB

Open AccessArticle

Improved Early Outcomes in Women Undergoing Aortic Valve Interventions

by Pietro Giorgio Malvindi, Olimpia Bifulco, Paolo Berretta, Jacopo Alfonsi, Mariano Cefarelli, Carlo Zingaro, Filippo Capestro, Alessandro D’Alfonso and Marco Di Eusanio

J. Clin. Med. 2023, 12(17), 5749; https://doi.org/10.3390/jcm12175749 - 04 Sep 2023

Viewed by 681

Abstract

Surgical aortic valve replacement (SAVR) in female patients has been associated with higher mortality (up to 3.3–8.9%) and postoperative complication rates when compared with their male counterparts. In recent years, TAVI has been shown to provide a greater benefit than SAVR in women. We sought to assess the early outcomes of the contemporary aortic valve intervention practice (surgical and transcatheter) in patients referred to our cardiac surgery unit. The data of consecutive patients who underwent isolated aortic valve intervention for aortic valve stenosis during the 2018–2022 period were retrieved from our internal database. Several preoperative, intraoperative, and postoperative variables were analyzed, including the predicted risk of a prosthesis–patient mismatch. Nine hundred and fifty-five consecutive patients—514 women and 441 men—were included. Among them, 480 patients—276 female and 204 male—received a transcatheter procedure, and 475—238 women and 237 men—had conventional SAVR. The women were older and had higher EuroSCORE II, while the male patients presented a higher incidence of cardiovascular comorbidities. There was no difference in mortality or major postoperative complication rates after either the surgical or transcatheter procedures between the female and male populations. The availability and targeted use of different techniques and technologies have enabled the safe and effective treatment of female patients treated for severe symptomatic aortic valve stenosis with similar results when compared with their male counterparts. Full article

(This article belongs to the Special Issue Clinical Research on Aortic Valve Replacement)

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14 pages, 957 KiB

Open AccessArticle

A Machine Learning Model for the Accurate Prediction of 1-Year Survival in TAVI Patients: A Retrospective Observational Cohort Study

by Francesco Pollari, Wolfgang Hitzl, Magnus Rottmann, Ferdinand Vogt, Miroslaw Ledwon, Christian Langhammer, Dennis Eckner, Jürgen Jessl, Thomas Bertsch, Matthias Pauschinger and Theodor Fischlein

J. Clin. Med. 2023, 12(17), 5481; https://doi.org/10.3390/jcm12175481 - 24 Aug 2023

Viewed by 959

Abstract

Background: predicting the 1-year survival of patients undergoing transcatheter aortic valve implantation (TAVI) is indispensable for managing safe early discharge strategies and resource optimization. Methods: Routinely acquired data (134 variables) were used from 629 patients, who underwent transfemoral TAVI from 2012 up to 2018. Support vector machines, neuronal networks, random forests, nearest neighbour and Bayes models were used with new, previously unseen patients to predict 1-year mortality in TAVI patients. A genetic variable selection algorithm identified a set of predictor variables with high predictive power. Results: Univariate analyses revealed 19 variables (clinical, laboratory, echocardiographic, computed tomographic and ECG) that significantly influence 1-year survival. Before applying the reject option, the model performances in terms of negative predictive value (NPV) and positive predictive value (PPV) were similar between all models. After applying the reject option, the random forest model identified a subcohort showing a negative predictive value of 96% (positive predictive value = 92%, accuracy = 96%). Conclusions: Our model can predict the 1-year survival with very high negative and sufficiently high positive predictive value, with very high accuracy. The “reject option” allows a high performance and harmonic integration of machine learning in the clinical decision process. Full article

(This article belongs to the Special Issue Clinical Research on Aortic Valve Replacement)

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12 pages, 1002 KiB

Open AccessArticle

Sutureless and Rapid Deployment vs. Transcatheter Valves for Aortic Stenosis in Low-Risk Patients: Mid-Term Results

by Claudio Muneretto, Lorenzo Di Bacco, Marco Di Eusanio, Thierry Folliguet, Fabrizio Rosati, Michele D’Alonzo, Diego Cugola, Salvatore Curello, Camila Mayorga Palacios, Massimo Baudo, Francesco Pollari and Theodor Fischlein

J. Clin. Med. 2023, 12(12), 4045; https://doi.org/10.3390/jcm12124045 - 14 Jun 2023

Viewed by 1252

Abstract

Background: Recent trials showed that TAVI is neither inferior nor superior to surgical aortic valve replacement. The aim of this study was to evaluate the outcomes of Sutureless and Rapid Deployment Valves (SuRD-AVR) when compared to TAVI in low surgical risk patients with isolated aortic stenosis. Methods: Data from five European Centers were retrospectively collected. We included 1306 consecutive patients at low surgical risk (EUROSCORE II < 4) who underwent aortic valve replacement by means of SuRD-AVR (n = 636) or TAVI (n = 670) from 2014 to 2019. A 1:1 nearest-neighbor propensity-score was performed, and two balanced groups of 346 patients each were obtained. The primary endpoints of the study were: 30-day mortality and 5-year overall survival. The secondary endpoint was 5-year survival freedom from major adverse cardiovascular and cerebrovascular events (MACCEs). Results: Thirty-day mortality was similar between the two groups (SuRD-AVR:1.7%, TAVI:2.0%, p = 0.779), while the TAVI group showed a significantly lower 5-year overall survival and survival freedom from MACCEs (5-year matched overall survival: SuRD-AVR: 78.5%, TAVI: 62.9%, p = 0.039; 5-year matched freedom from MACCEs: SuRD-AVR: 64.6%, TAVI: 48.7%, p = 0.004). The incidence of postoperative permanent pacemaker implantation (PPI) and paravalvular leak grade ≥ 2 (PVL) were higher in the TAVI group. Multivariate Cox Regression analysis identified PPI as an independent predictor for mortality. Conclusions: TAVI patients had a significantly lower five-year survival and survival freedom from MACCEs with a higher rate of PPI and PVL ≥ 2 when compared to SuRD-AVR. Full article

(This article belongs to the Special Issue Clinical Research on Aortic Valve Replacement)

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12 pages, 2508 KiB

Open AccessArticle

Prognostic Impact of Psoas Muscle Mass Index following Trans-Catheter Aortic Valve Replacement

by Teruhiko Imamura, Hayato Fujioka, Ryuichi Ushijima, Mitsuo Sobajima, Nobuyuki Fukuda, Hiroshi Ueno and Koichiro Kinugawa

J. Clin. Med. 2023, 12(12), 3943; https://doi.org/10.3390/jcm12123943 - 09 Jun 2023

Cited by 1 | Viewed by 1021

Abstract

Background: Psoas muscle mass is a recently featured index of sarcopenia, which has a negative prognostic impact in patients with a variety of diseases. We investigated the prognostic impact of baseline psoas muscle mass in patients receiving a trans-catheter aortic valve replacement (TAVR). Methods: Patients who received TAVR at our center between 2015 and 2022 were included. Patients received computer tomography imaging upon admission as an institutional protocol, and psoas muscle mass was measured, which was indexed by body surface area. Patients were followed for four years or until January 2023. The prognostic impact of psoas muscle mass index on 4-year mortality following index discharge was evaluated. Results: A total of 322 patients (85 years, 95 male) were included. Median psoas muscle mass index at baseline was 10.9 (9.0, 13.5) × 10 cm³/m². A lower psoas muscle mass index tended to be associated with several index of malnutrition and sarcopenia. A psoas muscle mass index was independently associated with 4-year mortality with an adjusted hazard ratio of 0.88 (95% confidence interval 0.79–0.99, p = 0.044). Patients with lower psoas muscle mass index (below the statistically calculated cutoff of 10.7 × 10 cm³/m², N = 152) had significantly higher cumulative 4-year mortality compared with others (32% versus 13%, p = 0.008). Conclusions: A lower psoas muscle mass index, which is a recently featured objective marker of sarcopenia, was associated with mid-term mortality following TAVR in the elderly cohort with severe aortic stenosis. The measurement of psoas muscle mass index prior to TAVR could have clinical implications for shared decision-making among patients, their relatives, and clinicians. Full article

(This article belongs to the Special Issue Clinical Research on Aortic Valve Replacement)

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11 pages, 1139 KiB

Open AccessArticle

Prognostic Impact of Polypharmacy following Trans-Catheter Aortic Valve Replacement

by Teruhiko Imamura, Nikhil Narang, Ryuichi Ushijima, Mitsuo Sobajima, Nobuyuki Fukuda, Hiroshi Ueno and Koichiro Kinugawa

J. Clin. Med. 2023, 12(7), 2598; https://doi.org/10.3390/jcm12072598 - 30 Mar 2023

Cited by 1 | Viewed by 1048

Abstract

Background: Polypharmacy in elderly patients with various comorbidities is associated with mortality and morbidity. However, the prognostic impact of polypharmacy in patients with severe aortic stenosis receiving trans-catheter aortic valve replacement remains unknown. Methods: Patients with severe aortic stenosis who received trans-catheter aortic valve replacement between 2015 and 2022 and were followed up at our institute following index discharge were included in this retrospective study. The impact of polypharmacy, which was defined as medication numbers ≥10 at index discharge, upon 2-year all-cause death was investigated. Results: A total of 345 patients (median age 85 [83, 89] years old, 99 (29%) men) were included. Median medication number was 9 (7, 10) at the index discharge and 88 (26%) were classified as receiving polypharmacy. Frailty index, including mini-mental state examination and CSHA score, were not significantly different between those with and without polypharmacy (p > 0.05 for both). Polypharmacy was associated with higher 2-year cumulative mortality with an adjusted hazard ratio of 21.4 (95% confidence interval, 6.06–74.8, p < 0.001). As a sub-analysis, the number of cardiovascular medications was not associated with 2-year mortality (hazard ratio 1.12, 95% confidence interval 0.86–1.48, p = 0.46), whereas a higher number of non-cardiovascular medications was associated with an incremental increase in 2-year mortality with a hazard ratio of 1.39 (95% confidence interval, 1.15–1.63, p < 0.001). Conclusions: In elderly patients with severe aortic stenosis, polypharmacy was associated with worse short-term survival following trans-catheter aortic valve replacement. Prognostic implication of aggressive intervention to decrease the amount of medication among those receiving TAVR requires further prospective studies. Full article

(This article belongs to the Special Issue Clinical Research on Aortic Valve Replacement)

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9 pages, 1156 KiB

Open AccessArticle

Prognostic Impact of Baseline Six-Minute Walk Distance following Trans-Catheter Aortic Valve Replacement

by Teruhiko Imamura, Nikhil Narang, Ryuichi Ushijima, Mitsuo Sobajima, Nobuyuki Fukuda, Hiroshi Ueno and Koichiro Kinugawa

J. Clin. Med. 2023, 12(7), 2504; https://doi.org/10.3390/jcm12072504 - 26 Mar 2023

Cited by 4 | Viewed by 1225

Abstract

Background: The six-minute walk test is a practical tool for assessing functional capacity in patients with a variety of etiologies including pulmonary disease and heart failure. Six-minute walk distance (6MWD) is associated with mortality and morbidity in patients with a variety of comorbidities. We aimed to assess the prognostic impact of baseline 6MWD in patients with severe aortic stenosis undergoing trans-catheter aortic valve replacement (TAVR). Methods: Patients with severe aortic stenosis who underwent a six-minute walk test after index admission and underwent TAVR between 2015 and 2022 were included in this retrospective study. Patients were followed up for two years or until November 2022 following TAVR. The impact of baseline 6MWD on the primary composite outcome, defined as all-cause death and all-cause readmission during the 2-year observation period following index discharge, was assessed. Results: A total of 299 patients (median age 86 years old, 85 men) were included. They received a 6-min walk test prior to TAVR, underwent successful TAVR procedures, and were discharged alive. The median baseline 6MWD was 204 (143, 282) meters. Shorter baseline 6MWD was associated with higher cumulative incidence of the primary outcome with an adjusted hazard ratio of 0.76 (95% confidence interval 0.58–1.01, p = 0.055) with a cutoff 6MWD of 178 m during the 2-year observation period after index discharge. Conclusions: Overall, functional capacity was impaired in the elderly patients with severe aortic stenosis prior to TAVR. Patients with severe aortic stenosis having shorter baseline 6MWD tended to have higher rates of morbidity and mortality after successful TAVR. The clinical implication of aggressive cardiac rehabilitation to improve patients’ functional capacity and 6MWD-guided optimal patient selection remain the future concerns. Full article

(This article belongs to the Special Issue Clinical Research on Aortic Valve Replacement)

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