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The bicuspid aortic valve and associated aortic disease

Key points The bicuspid aortic valve (BAV) is the most common congenital heart condition, affecting approximately 1% of the population. Familial BAV occurs in 9% to 10% of first-degree relatives. Familial aortic aneurysm with or without BAV may occur in certain families; it is inherited as an autosomal dominant condition with incomplete penetrance and inconsistent expression. BAV may accompany other congenital cardiovascular defects and conditions, including…

Aortic regurgitation: Clinical Presentation, Disease Stages, and Management

Key points Aortic regurgitation (AR) may be caused by abnormalities of the aortic leaflets, aortic root, or ascending aorta. Evaluation of AR should include valve morphology, regurgitation mechanism, and severity and aortic dilation assessment. Color Doppler proximal jet width with measurement of the vena contracta and diastolic flow reversal in the descending aorta are the most useful echocardiographic methods to assess AR severity in clinical practice.…

Aortic stenosis: Clinical presentation, disease stages, and timing of intervention

Key points Aortic stenosis is an active, progressive disease that involves inflammatory and bone mineralization pathways. The stages of aortic stenosis combine hemodynamic assessment, anatomic findings, symptomatic status, and ejection fraction measurements to help categorize management strategies. Echocardiography is the gold standard for evaluating aortic stenosis. Stress testing is considered for patients with severe aortic stenosis when the symptom history is equivocal or hemodynamic severity is…

Imaging the aortic valve

Key points Echocardiography is the primary modality for determining the morphology of the aortic valve and the cause and severity of dysfunction. In addition to symptoms, quantitative echocardiographic evaluation of left ventricular size and systolic function is key in clinical decision making for adults with aortic valvular heart disease. Aortic stenosis severity is defined by maximum aortic jet velocity, mean gradient, and continuity equation valve area.…

Surgical and procedural risk assessment of patients with valvular heart disease

Key points Accurate risk assessment is a critical component of informed consent. Risk scores are predicted probabilities calculated from a multivariable logistic regression model that is calibrated using data on a specific treatment from a fixed period. They are accurate only for a specific population and treatment over the time frame in which they are developed and validated. The Society of Thoracic Surgeons’ Predicted Risk of…

Principles of medical therapy for patients with valvular heart disease

Key points Patients with valvular heart disease (VHD) are best cared for in the context of a multidisciplinary heart valve clinic. Many adverse outcomes for adults with VHD are caused by sequelae of the disease process, including atrial fibrillation (AF), embolic events, left ventricular (LV) dysfunction, pulmonary hypertension, and endocarditis. Medical treatment of adults with VHD focuses on prevention and treatment of complications because there are…

Left ventricular and vascular changes in valvular heart disease

Key points In patients with significant valve disease, symptom onset, morbidity, and mortality after fixing the valve lesion are influenced by ventricular and vascular factors. The structure and function of the left ventricle adapt differently over time to pressure overload (e.g., aortic stenosis) and volume overload (e.g., mitral regurgitation). Changes to ventricular structure and function can be both adaptive and maladaptive and reverse to various degrees…

Clinical and genetic risk factors for calcific valve disease

Key points Despite a large burden of disease, understanding of the clinical and genetic risk factors for the development and calcific valve disease remains incomplete, and no medical treatment exists to prevent disease progression. In addition to the traditional atherosclerotic risk factors that have been associated with the development of calcific valve disease, emerging risk factors include lipoprotein(a), mineral metabolism (e.g. phosphate levels), and osteoporosis. Genetic…

Molecular mechanisms of calcific aortic valve disease

Key points Calcific aortic valve disease is an active, highly regulated process. The initiation phase has several similarities to atherosclerosis, including endothelial injury, inflammatory cell infiltration, and lipid oxidation. Valve interstitial cell activation leads to pathologic extracellular matrix remodeling and valvular fibrosis. Procalcific processes occur in the valve under the control of highly regulated osteoblast-like signaling (osteogenic) or passive calcium deposition and accumulation (dystrophic). The propagation…

Three-dimensional anatomy of the aortic and mitral valves

Key points Mitral Valve Three-dimensional echocardiography (3DE) provides real-time, detailed, nonplanar images of the complex mitral valve (MV) apparatus, including the annulus, leaflets, chordae, and papillary muscles. Quantitative analysis of MV anatomy, function, and motion using 3DE is significantly more accurate and reproducible than two-dimensional echocardiographic (2DE) planar imaging. Assessment of degenerative MV disease with 3DE helps guide the optimal surgical strategy and improve postoperative outcome.…

Epidemiology of valvular heart disease

Key points Valve disease is globally common, affecting approximately 2.5% of the population. In industrially underdeveloped countries, rheumatic disease (RhD) is the most common cause. Endomyocardial fibrosis is an underresearched disease common in equatorial Africa. In industrially developed regions, diseases of old age predominate, particularly calcific aortic stenosis and secondary mitral regurgitation. In the United States, valve disease is most common among the elderly, with a…

Long-term outcomes and valve durability

Background Early data for transcatheter aortic valve implantation (TAVI) was limited to inoperable and high surgical risk patients and as such the life span of the implanted prosthesis may be expected to exceed the life expectancy of these high-risk recipients. This has limited the data on longer-term outcomes available to date. In recent years, as TAVI has been expanded as a treatment option for both intermediate…

Antithrombotic therapy and recommended follow-up

Antithrombotic therapy after TAVI Prosthetic valves have known thromboembolic complications, especially in the short term, with an incidence observed to be <1% to almost 8% in the first year after transcatheter aortic valve implantation (TAVI). However, the prevention of these complications with routine use of antithrombotic therapy is challenging in this patient population. Risk factors that have been reported for stroke in the early period after…

Arrhythmias and pacemaker implantation

Although most complications of transcatheter aortic valve implantation (TAVI) have decreased over time, the rate of arrhythmic complications and conduction abnormalities seems to remain stable. Indeed, the introduction of newer-generation devices has not resulted in a reduction of these complications, which remains the main limitation of TAVI compared with surgery. This chapter highlights key data regarding arrhythmias and pacemaker implantation associated with TAVI. Epidemiology and predictors…

Transcatheter aortic valve implantation–related procedural and device complications

Since its introduction into clinical practice, transcatheter aortic valve implantation (TAVI) has proven to be a transformational technology, where the implantation of the new valve is done without the need for complex surgery, usually via the femoral artery under local anesthesia, which results in a quicker patient recovery time and lower hospital costs. Management of severe aortic stenosis is moving quickly toward TAVI for lower-risk patients,…

Advanced indications for transcatheter valve implantation

Transcatheter aortic valve implantation (TAVI) may be performed for conditions that are outside the currently labeled indication of symptomatic severe stenosis of trileaflet aortic valve. TAVI in bicuspid aortic stenosis was excluded from the major commercial randomized controlled trials and instead has been investigated in single-arm registries. There is limited experience with TAVI in pure native aortic regurgitation, though dedicated devices are in development. TAVI for…

Vascular closure

Introduction Over the past decade there have been huge advances in transfemoral (TF) transcatheter aortic valve implantation (TAVI), including changes to both the prosthesis and delivery systems. This evolution has resulted in lower profile delivery systems thus enabling TF TAVI to be performed completely percutaneously. Whereas previously access was achieved predominantly via the femoral artery using a surgical cutdown technique, the use of a vascular closure…

Transcatheter aortic valve implantation: Procedural details

Introduction After the first-in-human transcatheter aortic valve implantation (TAVI) more than 15 years ago, this procedure continues to be developed and refined. This chapter aims to provide the reader with knowledge about TAVI implantation from finding the optimal coplanar view to guidewire placement into the left ventricle, valvuloplasty, and deployment of more used transcatheter aortic valves (TAVs). Alignment of the three cusps and implant projections To…

Cerebral protection

Introduction Aortic stenosis is the most common valvular heart disease in the geriatric age group. Transcatheter aortic valve implantation (TAVI) has become the standard of care and is superior to conventional surgery. The indication for TAVI has extended from prohibitive risk to low-risk individuals. TAVI has a survival benefit compared with conventional surgery with a hazard ratio (HR) of 0.88 (95% confidence interval [CI] 0.78–0.99, Fig.…

Sedation and anesthetic support

Conscious sedation The first-in-man transcatheter aortic valve implantation (TAVI) was performed percutaneously by a French team led by Alain Cribier under conscious sedation (CS). Despite this precedent, the majority of subsequent early TAVI cases were performed under general anesthesia (GA) with guidance using transesophageal echocardiography (TEE). This was in part due to the time-consuming early learning curve, bulky early TAVI devices, and the need to assess…