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Contemporary Clinical Treatment Options and Outcomes of Aortic Valve Disease

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A special issue of Journal of Cardiovascular Development and Disease (ISSN 2308-3425). This special issue belongs to the section "Cardiac Surgery".

Deadline for manuscript submissions: closed (31 March 2024) | Viewed by 21868

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Dr. Mladen J. Kocica

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Guest Editor

UC Clinical Centre of Serbia, Clinics for Cardiac Surgery, Belgrade, Serbia
Interests: acute aortic dissections (Type A); aortic valve and aortic root reconstruction; surgical ventricular restoration – SVR

Dr. Igor Rudez

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Guest Editor

Department of Cardiac and Transplant Surgery, Dubrava University Hospital, Zagreb, Croatia
Interests: beating heart surgery; aortic valve repair; mitral valve repair; cardiac transplantation; aortic aneurysms

Special Issue Information

Dear Colleagues,

The aortic valve is not only anatomically located at the center of the heart, but the diseases of this valve are also becoming an important subject for cardiologists and surgeons. Diseases of the aortic valve are currently responsible for 61.1% of deaths due to valvular heart diseases. Although its function was generally thought to be entirely passive, contemporary investigations have brought completely new insight into the complex physiology of the aortic root, thus opening a new field related to the understanding, diagnosis, and treatment of aortic valve diseases. Since 1952, with the first Hufnagel aortic valve prosthesis implantation in descending thoracic aorta at Georgetown University, Washington DC, much has been accomplished in the field. Advances in science and technology, spanning from genetics and molecular biology to bioengineering and biotechnology, have opened new horizons in aortic valve disease diagnosis and treatment options. I believe that this Special Issue will help to clarify some important and current questions regarding clinical and surgical practice, and to induce inspiration and yield new insights into aortic valve disease science.

Dr. Mladen J. Kocica
Dr. Igor Rudez
Guest Editors

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Keywords

aortic valve
pharmacological treatment
transcatheter therapy
surgical treatment
outcome

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Published Papers (9 papers)

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Editorial

Jump to: Research, Review

3 pages, 196 KiB

Open AccessEditorial

Aortic Valve Repair and Early-Career Surgeons—Nothing Is Impossible

by Anze Djordjevic and Igor Rudez

J. Cardiovasc. Dev. Dis. 2023, 10(7), 284; https://doi.org/10.3390/jcdd10070284 - 1 Jul 2023

Cited by 1 | Viewed by 1108

Abstract

Aortic valve repair with either the reimplantation of the aortic valve or aortic root remodelling with the external annuloplasty procedure is the most effective means of treating aortic regurgitation and/or aortic root aneurysms [...] Full article

(This article belongs to the Special Issue Contemporary Clinical Treatment Options and Outcomes of Aortic Valve Disease)

Research

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15 pages, 1053 KiB

Open AccessArticle

Age-Specific Outcomes of Bioprosthetic vs. Mechanical Aortic Valve Replacement: Balancing Reoperation Risk with Anticoagulation Burden

by Fatimah A. Alhijab, Latifa A. Alfayez, Essam Hassan, Monirah A. Albabtain, Ismail M. Elnaggar, Khaled A. Alotaibi, Adam I. Adam, Claudio Pragliola, Huda H. Ismail and Amr A. Arafat

J. Cardiovasc. Dev. Dis. 2024, 11(7), 227; https://doi.org/10.3390/jcdd11070227 - 18 Jul 2024

Viewed by 1104

Abstract

Background: The choice of prosthesis for aortic valve replacement (AVR) remains challenging. The risk of anticoagulation complications vs. the risk of aortic valve reintervention should be weighed. This study compared the outcomes of bioprosthetic vs. mechanical AVR in patients older and younger than 50. Methods: This retrospective study was conducted from 2009 to 2019 and involved 292 adult patients who underwent isolated AVR. The patients were divided according to their age (above 50 years or 50 years and younger) and the type of valves used in each age group. The outcomes of bioprosthetic valves (Groups 1a (>50 years) and 1b (≤50 years)) were compared with those of mechanical valves (Groups 2a (>50 years) and 2b (≤50 years)) in each age group. Results: The groups had nearly equal rates of preexisting comorbidities except for Group 1b, in which the rate of hypertension was greater (32.6% vs. 14.7%; p = 0.025). This group also had higher rates of old stroke (8.7% vs. 0%, p = 0.011) and higher creatinine clearance (127.62 (108.82–150.23) vs. 110.02 (84.87–144.49) mL/min; p = 0.026) than Group 1b. Patients in Group 1a were significantly older than Group 2a (64 (58–71) vs. 58 (54–67) years; p = 0.002). There was no significant difference in the NYHA class between the groups. The preoperative ejection fraction and other echocardiographic parameters did not differ significantly between the groups. Re-exploration for bleeding was more common in patients older than 50 years who underwent mechanical valve replacement (p = 0.021). There was no difference in other postoperative complications between the groups. The groups had no differences in survival, stroke, or bleeding rates. Aortic valve reintervention was significantly greater in patients ≤ 50 years old with bioprosthetic valves. There were no differences between groups in the changes in left ventricular mass, ejection fraction, or peak aortic valve pressure during the 5-year follow-up. Conclusions: The outcomes of mechanical and bioprosthetic valve replacement were comparable in patients older than 50 years. Using bioprosthetic valves in patients younger than 50 years was associated with a greater rate of valve reintervention, with no beneficial effect on the risk of bleeding or stroke. Full article

(This article belongs to the Special Issue Contemporary Clinical Treatment Options and Outcomes of Aortic Valve Disease)

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8 pages, 691 KiB

Open AccessArticle

Aortic Valve Infective Endocarditis Complicated by Annular Abscess: Antibiotics in the Abscess Cavity

by Zaki Haidari, Shehla Ufaq Ahmad, Stephan Knipp, Iskandar Turaev and Mohamed El Gabry

J. Cardiovasc. Dev. Dis. 2024, 11(7), 189; https://doi.org/10.3390/jcdd11070189 - 24 Jun 2024

Viewed by 941

Abstract

Objectives: Infective endocarditis of the aortic valve complicated by annular abscess is a challenging problem and often requires patch reconstruction after surgical debridement of the abscess cavity. Filling the remaining cavity with antibiotics is advocated to prevent recurrent endocarditis. This study aimed at evaluating the role of local antibiotics in patients with aortic valve infective endocarditis complicated by annular abscess. Methods: Between January 2012 and December 2021, all consecutive patients with aortic valve infective endocarditis complicated by annular abscess undergoing cardiac surgery and annular patch reconstruction were included. Patients receiving local antibiotics were compared with patients without local antibiotics. The primary endpoints were the incidence of recurrent endocarditis, re-operation, and mortality during two-year follow-up. Results: A total of 41 patients with aortic valve infective endocarditis complicated by annular abscess underwent surgical patch reconstruction after radical debridement. In total, 20 patients received local antibiotics in the abscess cavity and 21 patients were treated without local antibiotics. The most common causative microorganisms were the staphylococci species and the most common location of the abscess was the non-coronary annulus. During two-year follow-up, one patient in each group developed recurrent endocarditis (p > 0.99) and both patients were reoperated (p > 0.99). Two-year mortality was 30% in the local antibiotic group and 24% in the control group (p = 0.65). Conclusions: Radical debridement and patch reconstruction of the aortic annulus in patients with aortic valve infective endocarditis complicated by annular abscess is an effective surgical strategy. Filling of the remaining abscess cavity with antibiotic seems not to affect the rate of recurrent endocarditis, reoperation, and mortality during two-year follow-up. Full article

(This article belongs to the Special Issue Contemporary Clinical Treatment Options and Outcomes of Aortic Valve Disease)

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11 pages, 1395 KiB

Open AccessArticle

Aortic Valve Repair with External Annuloplasty in Bicuspid versus Tricuspid Aortic Valve Patients

by Davor Baric, Nikola Sliskovic, Gloria Sestan, Savica Gjorgjievska, Daniel Unic, Marko Kusurin, Josip Varvodic, Zrinka Safaric Oremus, Ivana Jurin, Nikola Bulj, Dubravka Susnjar and Igor Rudez

J. Cardiovasc. Dev. Dis. 2024, 11(1), 17; https://doi.org/10.3390/jcdd11010017 - 6 Jan 2024

Viewed by 2038

Abstract

Surgical repair for regurgitant bicuspid aortic valve (BAV) is promising but underutilized due to perceived complexities and lack of long-term data. This study evaluated the efficacy of valve-sparing root remodeling (VSRR) or isolated valve repair combined with calibrated external ring annuloplasty in BAV versus tricuspid aortic valve (TAV) patients. All patients operated on for aortic regurgitation and/or aneurysm at our institution between 2014 and 2022 were included and entered into the Aortic Valve Insufficiency and ascending aorta Aneurysm InternATiOnal Registry (AVIATOR). Patients with successful repair at index surgery (100% in the BAV group, 93% in the TAV group, p = 0.044) were included in a systemic follow-up with echocardiography at regular intervals. Among 132 patients, 58 were in the BAV (44%) and 74 in the TAV group (56%). There were no inter-group differences in preoperative patient characteristics, except BAV patients being significantly younger (47 ± 18 y vs. 60 ± 14 y, p < 0.001) and having narrower aortic roots at the level of sinuses (41 ± 6 mm vs. 46 ± 13 mm, p < 0.001) and sinotubular junctions (39 ± 10 mm vs. 42 ± 11, p = 0.032). No perioperative deaths were recorded. At four years, there was no significant difference in terms of overall survival (96.3% BAV vs. 97.2% TAV, p = 0.373), freedom from valve reintervention (85.2% BAV vs. 93.4% TAV, p = 0.905), and freedom from severe aortic regurgitation (94.1% BAV vs. 82.9% TAV, p = 0.222). Surgical repair of BAV combined with extra-aortic annuloplasty can be performed with low perioperative morbidity and mortality and excellent mid-term results which are comparable to TAV repair. Full article

(This article belongs to the Special Issue Contemporary Clinical Treatment Options and Outcomes of Aortic Valve Disease)

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14 pages, 1139 KiB

Open AccessArticle

Mid-Term Clinical Outcomes and Hemodynamic Performances of Trifecta and Perimount Bioprostheses following Aortic Valve Replacement

by Francesca Toto, Laura Leo, Catherine Klersy, Tiziano Torre, Thomas Theologou, Alberto Pozzoli, Elena Caporali, Stefanos Demertzis and Enrico Ferrari

J. Cardiovasc. Dev. Dis. 2023, 10(4), 139; https://doi.org/10.3390/jcdd10040139 - 24 Mar 2023

Cited by 2 | Viewed by 1410

Abstract

Aims of the Study: We evaluated the clinical outcome and the hemodynamic and freedom from structural valve degeneration of two standard aortic bioprostheses. Methods: Clinical results, echocardiographic findings and follow-up data of patients operated for isolated or combined aortic valve replacement with the Perimount or the Trifecta bioprosthesis were prospectively collected, retrospectively analysed and compared. We weighted all the analyses by the inverse of the propensity of choosing either valves. Results: Between April 2015 and December 2019, 168 consecutive patients (all comers) underwent aortic valve replacement with Trifecta (n = 86) or Perimount (n = 82) bioprostheses. Mean age was 70.8 ± 8.6 and 68.8 ± 8.6 years for the Trifecta and Perimount groups, respectively (p = 0.120). Perimount patients presented a greater body mass index (27.6 ± 4.5 vs. 26.0 ± 4.2; p = 0.022), and 23% of them suffered from angina functional class 2–3 (23.2% vs. 5.8%; p = 0.002). Mean ejection fraction was 53.7 ± 11.9% (Trifecta) and 54.5 ± 10.4% (Perimount) (p = 0.994), with mean gradients of 40.4 ± 15.9 mmHg (Trifecta) and 42.3 ± 20.6 mmHg (Perimount) (p = 0.710). Mean EuroSCORE-II was 7 ± 11% and 6 ± 9% for the Trifecta and Perimount group, respectively (p = 0.553). Trifecta patients more often underwent isolated aortic valve replacement (45.3% vs. 26.8%; p = 0.016) and annulus enlargement (10.5% vs. 2.4%; p = 0.058). All-cause mortality at 30 days was 3.5% (Trifecta) and 8.5% (Perimount), (p = 0.203) while new pacemaker implantation (1.2% vs. 2.5%; p = 0.609) and stroke rate (1.2% vs. 2.5%; p = 0.609) were similar. Acute MACCE were observed in 5% (Trifecta) and 9% (Perimount) of patients with an unweighted OR of 2.22 (95%CI 0.64–7.66; p = 0.196) and a weighted OR of 1.10 (95%CI: 0.44–2.76, p = 0.836). Cumulative survival at 24 months was 98% (95%CI: 0.91–0.99) and 96% (95%CI: 0.85–0.99) for Trifecta and Perimount groups, respectively (log-rank test; p = 0.555). The 2-year freedom from MACCE was 94% (95%CI: 0.65–0.99) for Trifecta and 96% (95%CI: 0.86–0.99) for Perimount (log-rank test; p = 0.759, HR 1.46 (95%CI: 0.13–16.48)) in the unweighted analysis (not estimable in the weighted analysis). During the follow-up (median time: 384 vs. 593 days; p = 0.0001) there were no re-operations for structural valve degeneration. Mean valve gradient at discharge was lower for Trifecta across all valve sizes (7.9 ± 3.2 vs. 12.1 ± 4.7 mmHg; p < 0.001), but the difference did not persist during follow-up (8.2 ± 3.7 mmHg for Trifecta, 8.9 ± 3.6 mmHg for Perimount; p = 0.224); Conclusions: Postoperative outcome and mid-term follow-up were similar. An early better hemodynamic performance was detected for the Trifecta valve but did not persist over time. No difference in the reoperation rate for structural valve degeneration was found. Full article

(This article belongs to the Special Issue Contemporary Clinical Treatment Options and Outcomes of Aortic Valve Disease)

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16 pages, 2412 KiB

Open AccessArticle

Incidence and Risk Factors for Long-Term Persistence of Diastolic Dysfunction after Aortic Valve Replacement for Aortic Stenosis Compared with Aortic Regurgitation

by Luminița Iliuță, Andreea Gabriella Andronesi, Alexandru Scafa-Udriște, Bogdan Rădulescu, Horațiu Moldovan, Florentina Ligia Furtunescu and Eugenia Panaitescu

J. Cardiovasc. Dev. Dis. 2023, 10(3), 131; https://doi.org/10.3390/jcdd10030131 - 20 Mar 2023

Cited by 2 | Viewed by 1742

Abstract

(1) Background: Severe left ventricular (LV) diastolic dysfunction with a restrictive diastolic pattern (LVDFP) is generally associated with a worse prognosis. Its evolution and reversibility in the short- and medium-term after aortic valve replacement (AVR) has been little-studied. We aimed to evaluate the evolution of LV remodeling and LV systolic and diastolic function after AVR in aortic stenosis (AS) patients compared to aortic regurgitation (AR). Moreover, we tried to identify the main predictive parameters for postoperative evolution (cardiovascular hospitalization or death and quality of life) and the independent predictors for the persistence of restrictive LVDFP after AVR. (2) Methods: A five-year prospective study on 397 patients undergoing AVR for AS (226 pts) or AR (171 pts), evaluated clinically and by echocardiography preoperatively and until 5 years postoperatively. (3) Results: 1. In patients with AS, early post AVR, LV dimensions decreased and diastolic filling and LV ejection fraction (LVEF) improved more rapidly compared to patients with AR. At 1 year postoperatively, persistent restrictive LVDFP was found especially in the AR group compared to the AS group (36.84% vs. 14.16%). 2. Cardiovascular event-free survival at the 5-year follow-up was lower in the AR group (64.91% vs. 87.17% in the AS group). The main independent predictors of short- and medium-term prognosis after AVR were: restrictive LVDFP, severe LV systolic dysfunction, severe pulmonary hypertension (PHT), advanced age, severe AR, and comorbidities. 3. The persistence of restrictive LVDFP after AVR was independently predicted by: preoperative AR, the E/Ea ratio > 12, the LA dimension index > 30 mm/m², an LV endsystolic diameter (LVESD) > 55 mm, severe PHT, and associated second-degree MR (p < 0.05). (4) Conclusions: AS patients had an immediate postoperative evolution in terms of LV remodeling, and LV systolic and diastolic function were more favorable compared to those with AR. The restrictive LVDFP was reversible, especially after the AVR for AS. The main prognostic predictors were the presence of restrictive LVDFP, advanced age, preoperative AR, severe LV systolic dysfunction, and severe PHT. Full article

(This article belongs to the Special Issue Contemporary Clinical Treatment Options and Outcomes of Aortic Valve Disease)

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Review

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22 pages, 3467 KiB

Open AccessReview

Aortic Valve Embryology, Mechanobiology, and Second Messenger Pathways: Implications for Clinical Practice

by Maximiliaan L. Notenboom, Lucas Van Hoof, Art Schuermans, Johanna J. M. Takkenberg, Filip R. Rega and Yannick J. H. J. Taverne

J. Cardiovasc. Dev. Dis. 2024, 11(2), 49; https://doi.org/10.3390/jcdd11020049 - 1 Feb 2024

Cited by 1 | Viewed by 2699

Abstract

During the Renaissance, Leonardo Da Vinci was the first person to successfully detail the anatomy of the aortic root and its adjacent structures. Ever since, novel insights into morphology, function, and their interplay have accumulated, resulting in advanced knowledge on the complex functional characteristics of the aortic valve (AV) and root. This has shifted our vision from the AV as being a static structure towards that of a dynamic interconnected apparatus within the aortic root as a functional unit, exhibiting a complex interplay with adjacent structures via both humoral and mechanical stimuli. This paradigm shift has stimulated surgical treatment strategies of valvular disease that seek to recapitulate healthy AV function, whereby AV disease can no longer be seen as an isolated morphological pathology which needs to be replaced. As prostheses still cannot reproduce the complexity of human nature, treatment of diseased AVs, whether stenotic or insufficient, has tremendously evolved, with a similar shift towards treatments options that are more hemodynamically centered, such as the Ross procedure and valve-conserving surgery. Native AV and root components allow for an efficient Venturi effect over the valve to allow for optimal opening during the cardiac cycle, while also alleviating the left ventricle. Next to that, several receptors are present on native AV leaflets, enabling messenger pathways based on their interaction with blood and other shear-stress-related stimuli. Many of these physiological and hemodynamical processes are under-acknowledged but may hold important clues for innovative treatment strategies, or as potential novel targets for therapeutic agents that halt or reverse the process of valve degeneration. A structured overview of these pathways and their implications for cardiothoracic surgeons and cardiologists is lacking. As such, we provide an overview on embryology, hemodynamics, and messenger pathways of the healthy and diseased AV and its implications for clinical practice, by relating this knowledge to current treatment alternatives and clinical decision making. Full article

(This article belongs to the Special Issue Contemporary Clinical Treatment Options and Outcomes of Aortic Valve Disease)

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12 pages, 690 KiB

Open AccessReview

Prosthesis–Patient Mismatch and Aortic Root Enlargement: Indications, Techniques and Outcomes

by Ibrahim Talal Fazmin and Jason M. Ali

J. Cardiovasc. Dev. Dis. 2023, 10(9), 373; https://doi.org/10.3390/jcdd10090373 - 1 Sep 2023

Cited by 4 | Viewed by 3625

Abstract

Prosthesis–patient mismatch (PPM) is defined as implanting a prosthetic that is insufficiently sized for the patient receiving it. PPM leads to high residual transvalvular gradients post-aortic valve replacement and consequently results in left ventricular dysfunction, morbidity and mortality in both the short and long term. Younger patients and patients with poor preoperative left ventricular function are more vulnerable to increased mortality secondary to PPM. There is debate over the measurement of valvular effective orifice area (EOA) and variation exists in how manufacturers report the EOA. The most reliable technique is using in vivo echocardiographic measurements to create tables of predicted EOAs for different valve sizes. PPM can be prevented surgically in patients at risk through aortic root enlargement (ARE). Established techniques include the posterior enlargement through Nicks and Manouguian procedures, and aortico-ventriculoplasty with the Konno–Rastan procedure, which allows for a greater enlargement but carries increased surgical risk. A contemporary development is the Yang procedure, which uses a Y-shaped incision created through the non- and left-coronary cusp commissure, undermining the nadirs of the non- and left-coronary cusps. Early results are promising and demonstrate an ability to safely increase the aortic root by up to two to three sizes. Aortic root enlargement thus remains a valuable and safe tool in addressing PPM, and should be considered during surgical planning. Full article

(This article belongs to the Special Issue Contemporary Clinical Treatment Options and Outcomes of Aortic Valve Disease)

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14 pages, 1574 KiB

Open AccessReview

Contemporary Evaluation and Clinical Treatment Options for Aortic Regurgitation

by Mark Lebehn, Torsten Vahl, Polydoros Kampaktsis and Rebecca T. Hahn

J. Cardiovasc. Dev. Dis. 2023, 10(9), 364; https://doi.org/10.3390/jcdd10090364 - 25 Aug 2023

Cited by 2 | Viewed by 6315

Abstract

Aortic regurgitation (AR) is the third most frequent form of valvular disease and has increasing prevalence with age. This will be of increasing clinical importance with the advancing age of populations around the globe. An understanding of the various etiologies and mechanisms leading to AR requires a detailed understanding of the structure of the aortic valve and aortic root. While acute and chronic AR may share a similar etiology, their hemodynamic impact on the left ventricle (LV) and management are very different. Recent studies suggest current guideline recommendations for chronic disease may result in late intervention and suboptimal outcomes. Accurate quantitation of ventricular size and function, as well as grading of the severity of regurgitation, requires a multiparametric and multimodality imaging approach with an understanding of the strengths and weaknesses of each metric. Echocardiography remains the primary imaging modality for diagnosis with supplemental information provided by computed tomography (CT) and cardiac magnetic resonance imaging (CMR). Emerging transcatheter therapies may allow the treatment of patients at high risk for surgery, although novel methods to assess AR severity and its impact on LV size and function may improve the timing and outcomes of surgical intervention. Full article

(This article belongs to the Special Issue Contemporary Clinical Treatment Options and Outcomes of Aortic Valve Disease)

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