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   Table of Contents - Current issue
January-March 2022
Volume 23 | Issue 1
Page Nos. 1-66

Online since Monday, May 16, 2022

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Transcatheter aortic valve implantation for degenerated surgical aortic bioprosthesis: A systematic review p. 1
Abdallah El Sabbagh, Mohammed Al-Hijji, Mayra Guerrero
Background: Transcatheter aortic valve in valve (Aviv) replacement has been shown to be an effective therapeutic option in patients with failed aortic bioprosthetic valves. This review intended to evaluate contemporary 1-year outcomes of Aviv in recent studies. Methods: A systematic review on outcomes of Aviv was performed using the best available evidence from studies obtained using a MEDLINE, Cochrane database, and SCOPUS search. Endpoints of interest were survival, coronary artery obstruction, prosthesis-patient mismatch (PPM), stroke, pacemaker implantation, and structural valve deterioration. Results: A total of 3339 patients from 23 studies were included. Mean age was 68–80 years, 20%–50% were female, and Society of Thoracic Surgeons score ranged from 5.7 to 31.1. Thirty-day all-cause mortality ranged from 2% to 8%, and 1-year all-cause mortality ranged from 8% to 33%. Coronary artery obstruction risk after Aviv ranged from 0.6% to 4%. One-year stroke ranged from 2% to 8%. Moderate-severe PPM occurred in 11%–58%, and pacemaker rate at 1 year ranged from 5% to 12%. Conclusion: Transcatheter aortic ViV has emerged as an effective therapeutic option to treat patients with failed bioprostheses. The acceptable complication rate and favorable 1-year outcomes make Aviv an appropriate alternative to redo surgical aortic valve replacement.
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Antithrombotic therapy after transcatheter aortic valve replacement p. 10
Tariq A.M. Mousa, Ahmed Mahfouz, Nazar Mohammed
Transcatheter aortic valve replacement (TAVR) is a treatment option for patients with asymptomatic severe aortic stenosis who are candidates for a bioprosthesis across the entire spectrum of risk. TAVR carries a risk for thrombotic and bleeding events, focusing on the importance of defining the optimal antithrombotic regimen. Patients undergoing TAVR are mostly elderly and have many comorbidities such as atrial fibrillation (AF) requiring oral anticoagulants (OACs) or coronary artery disease requiring antiplatelet agents. After TAVR among patients without baseline indications for OAC, recent data suggest dual-antiplatelet therapy is associated with an increased risk for bleeding events, particularly early postprocedure compared with single-antiplatelet therapy with aspirin. The risk of leaflet thrombosis in patients undergoing TAVR raised concern about the use of OAC in patients without an initial indication for anticoagulation therapy. Although it showed effectiveness in modulating thrombus formation at the valve level, the bleeding hazard has shown to be unacceptably high, and the net benefit of combining antiplatelet and OAC therapy is unproven. For patients with indications for the use of long-term OAC, such as those with AF, adding antiplatelet therapy increases bleeding events. A favorable effect of new OAC agents over Vitamin K antagonists is debatable. Overall, single-antiplatelet therapy and OAC appear to be reasonable strategies in patients without and with indications for concurrent anticoagulation, respectively. This article aims to review the available published studies and recommendations in the literature regarding the use of antithrombotic therapy post-TAVR.
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Asymptomatic severe aortic stenosis: contemporary evaluation and management p. 16
Mohamed Salah Abdelghani, Sundus Sardar, Abdelhaleem Shawky Hamada
DOI:10.4103/heartviews.heartviews_34_22  PMID:d
Aortic stenosis (AS) is the most prevalent valvular heart disease in developed countries and most prevalent in the elderly. According to the current guidelines, intervention is recommended in symptomatic severe AS; however, in asymptomatic patients, aortic valve replacement (AVR) is considered when symptoms appear or the left ventricular dysfunction occurs, but the evidence supports these indications are poor. The optimal timing and modality of intervention in asymptomatic severe AS (ASAS) remain controversial. Earlier AVR in certain scenarios has been increasingly supported by some groups before subclinical irreversible myocardial damage occurs. In addition, the continuous advancement of percutaneous and surgical approaches where associated with a substantial decrease in mortality and perioperative complications which made many authors advocate for early intervention in those patients. Our review highlights the contemporary evaluation and management of ASAS and summarizes the current scientific evidence regarding optimal timing for intervention and indications for early AVR in such patients.
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Multimodality imaging in aortic stenosis p. 22
Sabir Abdul Karim, Sherif Mahmoud Helmy
Aortic stenosis (AS) is the most common cardiac valve lesion in the adult population, with an incidence increasing as the population ages. Accurate assessment of AS severity is necessary for clinical decision-making. Echocardiography is currently the diagnostic method of choice for assessing and managing AS. Transthoracic echocardiography is usually sufficient in most situations. Transesophageal echocardiography and stress echocardiography may also be utilized when there is inadequate image quality and/or discordance in the results and the clinical presentation. There is a role for other imaging modalities such as cardiac computed tomography, magnetic resonance imaging, and catheterization in selected cases. The following describes in some detail the role of these modalities in the diagnosis and assessment of AS.
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Stress echocardiogram in asymptomatic severe aortic stenosis p. 33
Asad I.I. Abusweireh, Hakam Abdallah Alzaeem
Aortic stenosis (AS) is one of the most common adult valve diseases. Therefore, current guidelines recommend prompt aortic valve intervention once symptoms occur. However, AS is predominantly a disease of the elderly, and these people may be underreporting their symptoms, have other comorbidities, or have a low level of exertion at the baseline or they might make a subconscious adjustment of their activities. Hence, stress testing can be a vital and objective tool to uncover their symptoms and prognosticate.
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Low-Gradient aortic stenosis; the diagnostic dilemma p. 39
Osama Alkhalaila, Mansour Al Shehadat
Low-gradient (LG) aortic valve stenosis (AS) constitutes a significant subset among patients with severe aortic stenosis. This entity represents one of the most challenging heart conditions when it comes to diagnosis and management, mainly because of the discrepancy between the small aortic valve area (≤1.0 cm2) that is considered a severe AS, and low mean transvalvular pressure gradient (<40 mmHg), which is one of the criteria for nonsevere AS. LG AS is divided according to transvalvular aortic flow rate into normal-flow LG AS and low-flow LG (LFLG) AS; the latter category can be divided further according to left ventricular ejection fraction (LVEF) into classical LFLG AS if LVEF is depressed or paradoxical LFLG AS if LVEF is preserved. The primary diagnostic challenge in patients with LG AS is to confirm that AS is truly severe and not pseudosevere, which is assessed mainly by either dobutamine stress echocardiography or multidetector computed tomography. The management of symptomatic true severe LG AS is mainly by aortic valve replacement (AVR), whether surgical or transcatheter approach. Patients with LG severe AS have a generally worse prognosis and higher mortality compared with patients with high-gradient severe AS. Despite the survival benefit of AVR in patients with true severe LG AS, these patients have higher surgical risk post-AVR compared with high-gradient AS patients. Early recognition and correct diagnosis of a patient with LG AS is crucial to improve their mortality and morbidity.
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Diagnosis and therapeutic cardiac catheterization of symptomatic bicuspid aortic stenosis in the pediatric population p. 47
Haytham Yassin, Hesham Al-Saloos
Bicuspid aortic valve (BAV) is the most common congenital heart disease with a prevalence of 0.5%–1.3% of the population. Many children with BAV are asymptomatic. Clinically relevant abnormal valve function usually occurs in adulthood. However, in rare cases, children can fail to thrive which requires valvular intervention. In this review, we will explore in more detail the anatomy of the BAV, clinical presentation of BAV, diagnosis of BAV, and its function by echocardiography, and indications for transcatheter intervention in the pediatric population.
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Coronary artery occlusion during transcatheter aortic valve implantation: Early recognition have better outcome p. 55
Mohamed Abdunasser M. Baghi, Khaled Taufek Othman, Abdu Rahman H. Alnabti, Salem M Abujalala
Transcatheter aortic valve implantation (TAVI) is one of the rapidly evolving treatment strategies for severe aortic stenosis. Included in this category are inoperable, high, intermediate, and low surgical risk patients. It has varying types of complications that may require urgent surgical or transcatheter interventions to prevent procedural mortality and morbidity. Coronary artery occlusion is a rare and dreaded complication of TAVI. Here, we report a 73-year-old man who was diagnosed with severe aortic stenosis and underwent transfemoral TAVI. Unfortunately, during preimplantation balloon valvuloplasty, the patient developed severe hypotension along with ischemic changes on the electrocardiographic monitor. Promptly, coronary angiography was performed which revealed complete occlusion of the left anterior descending artery secondary to embolic debris. He was successfully rescued by manual aspiration thrombectomy (MAT). MAT results in restoration of coronary flow and reversal of shock condition before completing TAVI procedure.
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Severe subvalvular aortic stenosis in a pregnant woman p. 60
Ahmed Abdalla Elyas, Ahmed Mohamed Al Maghraby
A 35-year-old pregnant female in her second trimester presented with heart failure manifestations with evidence of very severe fixed left ventricular outflow tract obstruction. The peak systolic gradient was 132 mmHg, which is the highest reported in the literature, secondary to congenital subaortic membrane. Similar case reports that we could find in the literature were reviewed to highlight the importance of such anomaly.
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