Search Results (859)

Background: Although less frequently encountered, aortic valve stenosis is associated with complications separate from its hemodynamic burdens, such as infective endocarditis. Case Summary: We report the case of a 77-year-old female patient with regular cardiac follow-up in the setting of an asymptomatic severe aortic stenosis, who presented to the emergency department with signs and symptoms of sepsis and acute decompensated heart failure. Echocardiography revealed two vegetations attached to the tricuspid valve, an abscess of the anterior aortic ring, and a high-velocity ventricular septal defect. The patient was started on adequate antibiotic therapy. Surgical treatment in an urgent manner (within a few days) was decided by the Heart Team, in accordance with the ESC guidelines on the management of infective endocarditis. Whilst awaiting surgery, the patient presented with a sudden hemodynamic deterioration a few days after diagnosis, with cardiopulmonary arrest and subsequent death. Discussion: We hypothesize that the patient developed an infective endocarditis of the degenerated stenotic aortic valve with extension from left to right via a ventricular septal defect, the development of which was facilitated by the high trans-aortic valve gradient. Some reported cases describe a ventricular septal defect as a complication of native aortic valve endocarditis, though not all involve concomitant aortic stenosis. In conclusion, our case illustrates a very rare scenario of infective endocarditis complicating aortic stenosis with fulminant development. This case highlights a rare, albeit severe complication associated with aortic stenosis and therapeutic challenges in managing the dismal evolution of endocarditis in this setting. Full article

Background: Hypoplastic left heart syndrome (HLHS) is defined as “a spectrum of congenital cardiovascular malformations with normally aligned great arteries without a common atrioventricular junction, characterized by underdevelopment of the left heart with significant hypoplasia of the left ventricle including atresia, stenosis, or hypoplasia of the aortic or mitral valve, or both valves, and hypoplasia of the ascending aorta and aortic arch”. Without treatment, HLHS is usually lethal in the neonate. Many hypotheses have been advanced to explain the etiology of HLHS; however, no single theory appears to fully explain the phenotypic variability seen in HLHS. Furthermore, many of these theories offer no explanations regarding the precipitating events which lead to the development of HLHS. Objective: This review considers and critically evaluates the strengths and weaknesses of the leading theories proposed to explain the pathogenesis of HLHS—including hemodynamic disturbances, primary myocardial structural defects, valvar malformations, and genetic or epigenetic alterations that may provoke developmental and anatomic abnormalities. After presenting each model, we propose a novel, comprehensive, and data-driven framework which may assist researchers in developing models for the pathogenesis of the various subtypes of HLHS. Methods: Key findings from human fetal imaging, histopathology, genetic studies, and animal models were considered, as well as the hypothetical contribution of each in observed HLHS phenotypes. The rationales for these findings as causal factors initiating individual HLHS patterns, as well as how they might contribute to HLHS in general, were critically analyzed. Results: The flow theory is strongly supported by animal models and in utero interventions that demonstrate the impact of altered hemodynamics on cardiac morphogenesis. However, the flow theory fails to identify initial causes of disturbed flow or related histological features of HLHS like endocardial fibroelastosis. The myocardial and valve-first models suggest an important role in developmental defects, but do not necessarily have a strong experimental basis that provides explanations for how they mediate HLHS. Genetic studies in patients with HLHS have identified several candidate causal mutations. However, such genetic causes of HLHS exhibit incomplete phenotypic penetrance and clinical impact. A multifactorial framework attempts to integrate these diverse mechanisms and may provide the most coherent explanation that can accommodate the heterogeneity and variable presentation of HLHS. Such a framework may identify multiple forces that drive disease but does not provide useful pathways for future research about HLHS. Conclusions: No single hypothesis has fully explained how HLHS is initiated, progresses, and presents with the clinical conditions that are encountered by cardiac surgeons and cardiologists. The most current models suggest that the spectrum of HLHS reflects acomplex interaction between genetic susceptibility, flow-dependent cardiac remodeling, and environmental factors in utero. A multifactorial model integrates these diverse mechanisms and may provide the most coherent explanation for the various phenotypic variations in HLHS. Based on our analysis of the most current data and the strengths and weaknesses of the current theoretical frameworks, we propose a novel research strategy aimed at identifying specific cardiac progenitor cell populations whose dysregulation may represent a unifying explanation for the etiology of the various phenotypes of HLHS. Based on the arguments made throughout this manuscript that evaluate the various genetic, structural, and hemodynamic models of initiation of disease, we believe that the significant phenotypic variability across the spectrum of HLHS (i.e., the different anatomic subtypes for “classic” HLHS) most likely reflects different underlying etiologies and mechanisms. At the very least, it is very likely that the timing of the insult is critical in determining anatomic subtype. Based on the published data and the arguments within this manuscript, it seems naive to think that there is a single unifying mechanism explain all forms of HLHLS. Full article

Background: Coronary computed tomography angiography (cCTA) is now indicated as a non-invasive tool for ruling out obstructive coronary artery disease (O-CAD) in patients who are candidates for transcatheter aortic valve implantation (TAVI) showing low-intermediate pre-test probability of O-CAD. In elderly and comorbid TAVI candidates, the safety and accuracy of cCTA as an alternative to invasive coronary angiography (ICA) for ruling out O-CAD remain to be established. Aim: To assess the feasibility, diagnostic accuracy, and clinical safety of cCTA for ruling out proximal O-CAD in elderly, comorbid, high-risk patients undergoing TAVI. Methods: We conducted a retrospective, single-center study including all consecutive patients with severe symptomatic aortic stenosis who underwent TAVI between January 2019 and December 2020. All patients underwent pre-TAVI cCTA. Patients with positive or non-diagnostic cCTA underwent ICA selectively (ICA group). In patients with no-O-CAD, ICA was omitted and proceeded directly to TAVI (no-ICA group). Accordingly, patients were divided into two groups: no-ICA and ICA group. Clinical follow-up was extended up to 5 years, with assessment of major adverse cardiovascular events (MACEs), mortality, heart failure hospitalizations, and unplanned revascularization. Results: Among 355 patients enrolled, 210 were included in the study. Among them, 140 (66.7%) had negative cCTA for O-CAD, and ICA was safely omitted in 132 patients (62.8%). cCTA was inconclusive in 43 patients (20.5%) and positive in 27 (12.9%). ICA confirmed O-CAD in 53 of 78 patients (67.9%) and PCI was performed in 35 of 53 (66.0%). The accuracy of cCTA for ruling in O-CAD was low (66.28%). During the follow-up period (1513 ± 508 days), the no-ICA group showed comparable outcomes to the ICA group in terms of periprocedural complications and long-term results—at both 1 and 5 years—for MACEs, heart failure hospitalizations, mortality and unplanned revascularization. Outcomes remain comparable between the two groups after performing matched-pair analyses. Conclusions: Our data show that cCTA may provide a reliable, safe, and effective alternative to ICA for ruling out obstructive CAD in elderly patients undergoing TAVI when image quality is diagnostic. A cCTA-based strategy allows deferral of ICA in most cases without compromising procedural safety or long-term clinical outcomes, enabling a personalized and tailored clinical pathway. Whether advanced CT techniques, such as CT-FFR and photon-counting CT, may help refine patient selection for invasive coronary assessment remains to be demonstrated. Full article

Background: Because of demographic changes, the number of older patients undergoing cardiac interventions has increased. The most common indication in this group is aortic valve stenosis, treated with either surgical aortic valve replacement (SAVR) or transcatheter aortic valve implantation (TAVR), with good outcomes. Our study investigated whether the heart team’s choice of intervention (TAVI, SAVR, or conservative) is influenced by geriatric assessment results. Methods: This study was a single-centre, prospective, longitudinal case–control study conducted over 12 months and did not affect routine diagnostic examinations or clinical decisions. After risk stratification and clinical evaluation, patients were assigned to undergo TAVI, SAVR, or conservative management. Cardiological evaluation and geriatric assessment were performed for up to 12 months. Results: Of 135 patients (mean age 81 ± 4.6 years), 60% underwent TAVI, 29% SAVR, and 11% conservative therapy. Age, Frailty Score, cognition, and nutritional status were significantly associated with the heart team’s decision, whereas EuroSCORE II remained the only independent predictor of one-year mortality (OR 1.58, 95% CI 1.13–2.19, p = 0.007). One-year mortality was 9.9% (n = 11). Compared to the literature, one-year mortality was lower than expected, particularly in the intervention group. Conclusions: Single assessment tools did not have the power to predict mortality. Similar to other trials, a combination of different scores can assess the risk of mortality. Full article

Background: In elderly, multimorbid patients, renal function changes are frequent following transcatheter aortic valve implantation. However, the early renal recovery following the relief of aortic stenosis is not sufficiently characterized. Methods: This retrospective single-center study comprised 410 consecutive patients who underwent TAVI. Serum creatinine and estimated glomerular filtration rate (eGFR) were measured prior to and within 72 h of TAVI to evaluate renal function. Primary outcomes were defined as absolute alterations (Δcreatinine and ΔeGFR). Spearman’s correlation and multivariable regression were implemented to assess associations. Results: The mean age was 82.0 ± 8.7 years, and 46.9% of the participants were female. The eGFR demonstrated modest improvement (mean ΔeGFR +3.83 mL/min/1.73 m²), while creatinine showed minimal change (mean Δ −0.015 mg/dL). Renal function exhibited bidirectional alterations. Baseline creatinine was inversely associated with Δcreatinine (ρ = −0.127, p = 0.010), which was consistent with regression to the mean. Conversely, baseline eGFR was not associated with ΔeGFR (ρ = 0.004, p = 0.934). There were no significant correlations between renal changes and BMI (ρ = −0.041 and ρ = 0.047; both p > 0.30). In multivariable analysis, baseline creatinine remained independently associated with Δcreatinine (β = −0.279, p < 0.001), whereas ejection fraction exhibited a modest association (β = 0.012, p = 0.020). Acute kidney injury was observed in 13.9% of the population (57/410) and was not independently correlated with baseline variables. Conclusions: Early renal alterations following TAVI are frequent and frequently favorable; however, they are primarily indicative of baseline renal function, with limited independent predictive value of other variables. The results should be regarded as hypothesis-generating. Full article

Aortic stenosis (AS) and mitral stenosis (MS) are progressive valvular heart diseases associated with substantial morbidity and mortality once symptoms develop. Over the past decade, the management of isolated AS has undergone profound evolution, driven by refinements in surgical aortic valve replacement, the adoption of minimally invasive techniques, and the rapid expansion of transcatheter aortic valve replacement across all surgical risk categories. In contrast, patients with concomitant AS and MS represent a complex and understudied population, frequently excluded from randomized trials and only marginally addressed in contemporary clinical practice guidelines. The management requires individualized guideline-directed decision-making led by a multidisciplinary Heart Team. The paucity of high-quality data in combined AS–MS underscores the need for dedicated prospective studies and international registries. The aim of this narrative review is to describe current strategies to treat AS both when isolated and concomitant with MS. We also discuss the need for updated, specific guidelines. Full article

Coronary artery disease (CAD) often coexists with severe aortic stenosis (AS) in patients undergoing transcatheter aortic valve implantation (TAVI), posing a complex diagnostic and therapeutic challenge. As TAVI is increasingly used for younger, lower-risk patients, managing CAD is becoming a personalized, long-term clinical concern. This narrative review summarizes the current evidence on coronary assessment and revascularization strategies in individuals with severe AS. Invasive coronary angiography remains the leading method for anatomical coronary imaging, but coronary computed tomography angiography is emerging as a reliable alternative that may reduce unnecessary invasive procedures in certain patients. The routine performance of PCI before TAVI is under increasing scrutiny, and available data support a more selective approach based on lesion significance, CAD complexity, procedural timing, and anticipated need for future coronary access. Significant uncertainties remain concerning the physiological evaluation of lesions, the timing and completeness of revascularization, and the treatment of left main or multivessel disease. Additional phenotype-specific and longitudinal studies are needed to improve management algorithms for this population. Full article

The coarctation of the aorta is a congenital anomaly characterized by a local narrowing of the aortic lumen localized near the ductus arteriosus. Typically diagnosed in childhood, but it can remain until symptoms become evident. This aortic anomaly can also coexist with aortic valve stenosis. In our case report, we present a 46-year-old male with chest pain, dyspnea, and a significant blood pressure gradient between upper and lower extremities. Diagnostic examination included transthoracic echocardiography and computerized tomography. This diagnostic imaging showed narrowing of the aortic lumen with a residual lumen dimension of 3 mm and severe aortic stenosis. The patient underwent a complex surgical procedure, replacement of the aortic valve and reconstruction of the aorta. An extra-anatomic ascending-to-descending aortic bypass was constructed using a 20 mm Dacron graft, combined with mechanical aortic valve replacement. The operation was performed through median sternotomy with two arterial canula in the femoral artery and in the aorta, and one venous canula in the right atrium. Two canulae are placed for the safe performance of cardiopulmonary bypass. The patient was discharged at home without complication. This case highlights that a single surgical procedure may represent a definitive treatment of a complex problem with good short-term results. Full article

Transcatheter Aortic Valve Replacement (TAVR) has transformed aortic stenosis management across the full risk spectrum, but expansion into younger populations makes valve failure and reintervention central to lifetime planning. There are two pathways to follow when TAVR fails: redo transcatheter implantation and surgical explantation with surgical aortic valve replacement (SAVR), termed TAVR-SAVR. This narrative review synthesizes evidence from four studies (35,677 patients, 2011–2024) examining the association between prior valve type and redo SAVR outcomes versus redo SAVR after prior surgical prosthesis (SAVR-SAVR). TAVR-SAVR volume grew at up to 144.6% annually, projected to surpass SAVR-SAVR by approximately 2029 based on linear extrapolation from limited registry and single-center data. Operative mortality was 12.3–17% in TAVR-SAVR versus 1.1–9% in SAVR-SAVR, persisting after propensity matching in both comparative studies (11.3% vs. 6.7%, OR 1.7; and 12.0% vs. 1.1%, OR 12.5). Observed-to-expected mortality ratios exceeded 1.0 across all risk strata, including low-risk patients (O/E up to 5.48), while SAVR-SAVR demonstrated a remarkably low ratio of 0.22–0.33. Renal failure, failure to rescue, and prolonged ventilation were significantly higher following TAVR-SAVR; stroke and pacemaker rates were comparable. Paradoxically, shorter bypass and cross-clamp times in TAVR-SAVR despite worse outcomes are consistent with cumulative organ injury, rather than operative complexity, as a predominant contributor to excess mortality, though this mechanistic explanation remains hypothetical. STS risk models, developed for standard surgical populations, showed limited applicability in this population, with observed mortality consistently exceeding predicted values. These findings raise important considerations regarding TAVR-first strategies in operable patients aged 65–80 years, although causality cannot be established from observational data alone. In the era of expanding TAVR indications, the legacy of the first valve cannot be ignored. Full article

Background/Objectives: Nowadays, transcatheter aortic valve implantation (TAVI) is widespread in patients with severe aortic valve stenosis. New prosthesis designs are becoming available to address the shortcomings of their predecessors and improve clinical outcomes. Methods: Electronic databases were screened for studies comparing outcomes of TAVI with Portico and SAPIEN 3. In a random-effects meta-analysis the pooled incidence rates of procedural, clinical and functional outcomes, according to VARC-2 definitions, were assessed. Results: Thirteen observational studies and one multi-center randomized clinical trial enrolling 20,522 patients (Portico N = 3001 and SAPIEN 3 N = 17,521) were included in the analysis. The need for more than one prosthesis during initial implantation was significantly higher among Portico recipients compared to SAPIEN 3 recipients: (RR 2.72 [1.36, 5.45] p = 0.005). Pre- and post-dilatation were performed more frequently in the Portico group (RR 1.53 [1.12, 2.09], p = 0.008 and RR 4.21 [2.83, 6.26], p < 0.00001, respectively). Moderate-to-severe paravalvular leak (PVL) was significantly more common in the Portico arm (RR 3.27 [1.80, 5.91] p < 0.0001). In contrast, the mean gradient and rate of prosthesis–patient mismatch (PPM) was significantly lower in the Portico group (MD −31.58 [−37.02; −26.14] mmHg and RR 0.42 [0.32, 0.55], p < 0.00001). Recipients of Portico demonstrated over 60% higher risk of permanent pacemaker implantation (PPI) compared to SAPIEN 3 (RR 1.62 [1.25, 2.10], p = 0.0002). Other procedural and short-term clinical outcomes, including neurologic events, major vascular complications, life threatening or major bleeding, acute kidney injury, myocardial infarction and mortality did not differ between the devices. A difference in mortality was observed at the 1-year follow-up (RR 1.26 [1.06, 1.51], p = 0.01; I² = 5%). Conclusions: The evidence shows good short-term outcomes for both valves. Compared to SAPIEN 3, Portico was associated with a significantly higher rate of moderate-to-severe PVL and PPI, but a lower mean gradient and incidence of PPM. A significantly higher 1-year mortality was observed in the Portico group. Full article

Background and Objectives: Recent studies have focused on evaluating the hemodynamic results in patients undergoing transcatheter aortic valve implantation (TAVI) with small aortic annuli. There is limited data on the incidence, clinical characteristics, and mortality of prosthesis–patient mismatch (PPM) in patients undergoing TAVI with large aortic annuli. Materials and Methods: This is a retrospective analysis of consecutive patients with severe aortic stenosis and large annuli who underwent TAVI at a single UK center. PPM was defined according to the Valve Academic Research Consortium (VARC-3) criteria and identified using echocardiography within 4–6 weeks following TAVI. Measurements were analyzed by an experienced operator who was blinded to the type of valve platform and clinical outcomes. Results: A total of 447 patients were screened, of whom 353 patients were included in the analysis. The incidence of any PPM or severe PPM was 38% and 15% of patients, respectively. Patients with severe PPM were younger, had larger body surface area, and were more likely to receive a balloon-expandable valve (BEV). At a mean follow-up of 35 months, mortality was numerically higher in patients with severe PPM (46% vs. 36%, p = 0.20) but this did not reach statistical significance. Similar mortality rates were observed among patients with or without severe PPM in those who received SEV as well as BEV. There was a differential role of body surface area in mortality in patients who developed severe PPM versus non-severe PPM. Conclusions: Severe PPM was evident in patients with large aortic annuli undergoing TAVI, particularly those who received BEV. Nonetheless, severe PPM did not impact mortality rate at three-year follow-up. Longer-term follow-up may be required to assess the impact of severe PPM on mortality. Full article

Transcatheter aortic valve replacement (TAVR) has transformed the management of severe aortic stenosis and is now widely used across a broad spectrum of surgical risk. With expanding indications and increasing use in younger patients, contemporary practice increasingly emphasizes lifetime management of aortic valve disease, a shift further supported by recent developments including findings from the EARLY TAVR trial and the May 2025 U.S. Food and Drug Administration approval of TAVR for asymptomatic severe aortic stenosis. This narrative review summarizes recent developments in TAVR, including advances in device technology, procedural techniques, and patient selection. Focus is placed on the importance of optimal first valve selection, prevention of prosthesis–patient mismatch (PPM), and planning for future reintervention such as valve-in-valve (ViV) TAVR. Emerging procedural strategies including bioprosthetic valve fracture and leaflet modification techniques have expanded treatment options for patients at risk of elevated gradients or coronary obstruction. The review also highlights evolving approaches to TAVR in complex clinical scenarios and discusses future directions in device design and imaging-based procedural planning. As TAVR continues to evolve, careful procedural planning and multidisciplinary heart team collaboration remain essential to optimizing long-term outcomes. Full article

Asymptomatic severe aortic stenosis (AS) is characterized by a prolonged latent phase during which progressive valvular obstruction and myocardial remodeling may occur despite preserved left ventricular ejection fraction and the absence of overt clinical symptoms. Historically, management has favored watchful waiting until symptom onset or guideline-defined triggers emerge; however, recent randomized data challenge this conservative paradigm. This review summarizes the natural history, risk stratification, and contemporary management of asymptomatic severe AS, with a focus on emerging insights that inform the timing of intervention. We propose an individualized, contemporary framework for managing asymptomatic severe AS that integrates multimodal risk assessment, procedural risk, and shared decision-making, and we outline future directions aimed at refining patient selection and optimizing the personalized timing of intervention. Full article

Death rates related to heart failure amount to approximately 50% of deaths globally, and one of the leading causes of heart failure is aortic valve failure, which is treated using prosthetic aortic valves. Porcine pericardium is amongst the materials used to develop a potentially ideal bioprosthetic aortic valve. The mechanical properties of native porcine pericardium are necessary for enhancing a prosthetic aortic valve. The aim of this study was to determine the mechanical properties of porcine pericardium and find optimized material parameters for finite element analysis using five isotropic models. Uniaxial rupture tests were performed using Cellscale biotester to measure the force at rupture, stiffness, and deformation at rupture. Tests were done in circumferential and radial directions, and one-way Anova was used to evaluate different behaviors in both directions. The average coefficient of determination was used to find the model that performed better. Full article

Previous studies on healthy controls suggest the added value of thigh-based Electrocardiography (ECG), which collects data using sensors embedded in a toilet seat for unobtrusive signal acquisition. However, further evidence regarding its clinical feasibility is needed; with this work, we investigated three complementary aspects: signal quality, morphological correlation with standard ECG leads, and the system’s potential for heart rate variability (HRV) analysis in patients undergoing aortic valve replacement. This work was divided into two main phases. In the first, 32 healthy volunteers underwent simultaneous ECG recordings using both a standard 12-lead ECG system and the thigh-based system. Signal Quality Index (SQI) analysis revealed that 56.25% of the experimental signals were classified as excellent, and over 62.5% of recordings showed a strong correlation with Lead I of the clinical ECG. These findings extend the state of the art by further characterising the quality and relevance of the captured signals. In the second phase, two patients with severe aortic stenosis were monitored before and after surgical valve replacement. HRV metrics derived from the thigh-based ECG captured distinct autonomic responses: one patient showed significant postoperative improvement in global and parasympathetic modulation (increased SDNN, RMSSD, and Sample Entropy), while the other exhibited reduced variability and complexity, potentially indicating impaired autonomic recovery. These results highlight the feasibility of thigh-based ECG data acquisition for passive, longitudinal cardiac health monitoring in everyday environments and its applicability for pre- and postoperative autonomic assessment. Full article