This paper discusses a female patient with severe aortic stenosis, who was preoperatively assessed to be at high risk of left coronary artery occlusion, but developed complete occlusion of the right coronary artery during the procedure of transcatheter aortic valve replacement, leading to hemodynamic disorder. Surgical treatment under emergency cardiopulmonary bypass played a critical role in rescuing the patient.
Transcatheter aortic valve replacement (TAVR) is a minimally invasive approach to treat symptomatic severe aortic stenosis with surgical taboos or high risk. With the update of the guidelines, the indication of TAVR has been extended to the intermediate-risk aortic stenosis population, and even has a tendency to further expand to the low-risk population. This review highlights the research progress and new evidence of TAVR in respects of patient selection, valve and approach selection, ethnic differences, and surgical complications such as perivalvular leakage, cardiac conduction block, vascular complications, stroke, acute kidney injury, and coronary artery occlusion.
In developed nations, aortic stenosis (AS) is the most common valvular heart disease presentation, and its prevalence is increasing due to aging populations. Accurate diagnosis of the disease process and determination of its severity are essential in clinical decision-making. Although current guidelines recommend measuring transvalvular gradients, maximal velocity, and aortic valve area in determining the disease severity, inconsistent grading of disease severity remains a common problem in clinical practice. Recent studies suggest that patients with paradoxical low-flow and/or low-gradient, severe AS are at a more advanced stage of the disease process and have a poorer prognosis. This mode of presentation may lead to an underevaluation of symptoms and inappropriate delay of AVR. Therefore, this challenging clinical situation should be carefully assessed in particular in symptomatic patients and clinical decisions should be tailored individually.
Aortic stenosis accounts for a large proportion of valvular heart disease in China. This article described an unusual case of severe aortic stenosis with severe cardiopulmonary decompensation treated by emergency transcatheter aortic valve replacement. Preoperative assessment was performed by transesophageal echocardiography. The extracorporeal membrane oxygenation team was informed to be ready. During the operation, no obvious perivalve leakage was observed after valve released. The transvalvular pressure gradient decreased to 7 mm Hg (1 mm Hg=0.133 kPa).The patient’s symptoms were completely relieved after the operation, and no adverse events occurred during the hospitalization. After discharge, color Doppler echocardiography showed that stenosis was eliminated, cardiac function was improved, no significant perivalvular leakage was observed, and pulmonary hypertension reduced to moderate. The success of this operation confirmed the efficacy of emergency transcatheter aortic valve replacement, and showed that after a rigorous evaluation, emergency transcatheter aortic valve replacement may be a reasonable choice for patients with severe aortic valve stenosis.
Transcatheter aortic valve replacement (TAVR) as a mature technology has been widely applied in Western countries. In China, with the first two domestic prostheses being approved for commercial use, the technology now is expecting a fast development. In this article, we reviewed the features of Chinese aortic stenosis patients, the early Chinese experience of TAVR, the application of domestic prostheses and remaining problems.
Transcatheter aortic valve replacement (TAVR) has become a well-established treatment for patients with severe aortic stenosis. At present, TAVR has already shown noninferiority and even superiority to surgical aortic valve replacement (SAVR) in patients deemed at high or intermediate risk for SAVR. However, the long-term follow-up results of the randomized controlled trials comparing the efficacy and safety between TAVR and SAVR are still lacking in those patients who are at low risk for SAVR. This paper gives an overview and reviews results of the Evolut Low Risk trial and interprets its implications for transcatheter therapy in aortic valve diseases.
This case was a 58-year-old female patient with patent ductus arteriosus (PDA) and severe aortic stenosis. Upon admission, she had severe heart failure and severe edema of both lower extremities unable to lie flat. After cardiac function adjustment and under general anesthesia, she underwent a one-stop operation of PDA occlusion and transcarotid transcatheter aortic valve replacement due to the severe aortic arch stenosis which brought high risk in transfemoral artery approach. Her symptoms improved significantly, and she was discharged only 6 days after operation. At the follow-up 3 months after operation, the aortic valve transvalvular pressure gradient improved significantly, the ductus arteriosus murmur disappeared, and the patient recovered well.
Objective To identify the heart sounds of aortic stenosis by deep learning model based on DenseNet121 architecture, and to explore its application potential in clinical screening aortic stenosis. Methods We prospectively collected heart sounds and clinical data of patients with aortic stenosis in Tianjin Chest Hospital, from June 2021 to February 2022. The collected heart sound data were used to train, verify and test a deep learning model. We evaluated the performance of the model by drawing receiver operating characteristic curve and precision-recall curve. Results A total of 100 patients including 11 asymptomatic patients were included. There were 50 aortic stenosis patients with 30 males and 20 females at an average age of 68.18±10.63 years in an aortic stenosis group (stenosis group). And 50 patients without aortic valve disease were in a negative group, including 26 males and 24 females at an average age of 45.98±12.51 years. The model had an excellent ability to distinguish heart sound data collected from patients with aortic stenosis in clinical settings: accuracy at 91.67%, sensitivity at 90.00%, specificity at 92.50%, and area under receiver operating characteristic curve was 0.917. Conclusion The model of heart sound diagnosis of aortic stenosis based on deep learning has excellent application prospects in clinical screening, which can provide a new idea for the early identification of patients with aortic stenosis.
A 69-year-old male was presented with exercise intolerance and progressive exertional dyspnea for 3 months. His main clinical diagnosis were degenerative valvular disease, severe aortic stenosis, severe aortic regurgitation, severe mitral regurgitation, severe tricuspid regurgitation, ventricular electrical storm, chronic heart failure, and New York Heart Association (NYHA) class Ⅳ heart function. He was encountered with sudden ventricular electrical storm in the emergency room. Extracorporeal membrane oxygenation (ECMO) was impanted beside during cardiopulmonary resuscitation. Emergency transcatheter aortic valve replacement (TAVR) was successfully performed under the guidance of transesophageal echocardiography when hemodynamics permitted. ECMO was withdrawn on the 5th day and discharged on the 21st day. TAVR is safe and effective for the treatment of high-risk aortic stenosis, and ECMO support is the key for the success of cardiopulmonary resuscitation.
Objective To investigate the role and mechanism of peroxisome proliferator-activated receptor gamma coactivator 1α (PGC-1α) in the activation of aortic valve interstitial cells (AVICs) in aortic stenosis. Methods Isolating primary AVICs and stimulating their activation with transforming growth factor β1 (TGF-β1, 30 ng/mL), the expression of PGC-1α was detected. The activation of AVICs induced by TGF-β1 was observed after overexpression of PGC-1α by adenovirus or inhibition of PGC-1α function by GW9662. The possible downstream molecular mechanism of PGC-1α in AVICs activation was screened. Finally, the phenotype was further verified in primary human AVICs. Results The expression of PGC-1α decreased after the activation of AVICs induced by TGF-β1 (control group: 1.00±0.18; 24 h: 0.31±0.10; 48 h: 0.32±0.06; 72 h: 0.20±0.07; P<0.05). Specific overexpression of PGC-1α by adenovirus inhibited the activation of AVICs induced by TGF-β1 stimulation (periostin: 3.17±0.64 vs. 1.45±0.54, P<0.05; α-smooth muscle actin: 0.77±0.11 vs. 0.28±0.06, P<0.05). On the contrary, inhibition of PGC-1α function by GW9662 promoted the activation of AVICs (periostin: 2.20±0.68 vs. 7.99±2.50, P<0.05). Subsequently, it was found that PGC-1α might inhibit the activation of AVICs through downregulating the expression of calcium/calmodulin-dependent protein kinase (CAMK1δ) (0.97±0.04 vs. 0.74±0.11, P<0.05), and downregulating the expression of CAMK1δ alleviated the activation of AVICs (periostin: 1.76±0.11 vs. 0.99±0.20, P<0.05). The possible mechanism was that the activation of mammalian target of rapamycin (mTOR) signaling pathway was inhibited by reducing the accumulation of reactive oxygen species (ROS) (778.3±139.4 vs. 159.3±43.2, P<0.05). Finally, the protective effect of PGC-1α overexpression was verified in the activated phenotype of human AVICs (periostin: 2.73±0.53 vs. 1.63±0.14, P<0.05; connective tissue growth factor: 1.27±0.04 vs. 0.48±0.09, P<0.05). Conclusions The expression of PGC-1α significantly decreases during the activation of AVICs induced by TGF-β1. The overexpression of PGC-1α significantly inhibites the activation of AVICs, suggesting that PGC-1α plays a protective role in the activation of AVICs. The possible mechanism is that PGC-1α can inhibit the activation of CAMK1δ-ROS-mTOR pathway. In conclusion, interventions based on PGC-1α expression levels are new potential therapeutic targets for aortic stenosis.