Aortic valve: anatomy and structure and the role of vasculature in the degenerative process

Aortic valve stenosis is a degenerative disease affecting increasing number of individuals and characterised by thickening, calcification and fibrosis of the valve resulting in restricted valve motion. Degeneration of the aortic valve is no longer considered a passive deposition of calcium, but an active process that involves certain mechanisms, that is endothelial dysfunction, inflammation, increased oxidative stress, calcification, bone formation, lipid deposition, extracellular matrix (ECM) remodelling and neoangiogenesis. Accumulating evidence indicates an important role for neoangiogenesis (i.e. formation of new vessels) in the pathogenesis of aortic valve stenosis. The normal aortic valve is generally an avascular tissue supplied with oxygen and nutrients via diffusion from the circulating blood. In contrast, presence of intrinsic micro-vasculature has been demonstrated in stenotic and calcified valves. Importantly, presence and density of neovessels have been associated with inflammation, calcification and bone formation. It remains unclear whether neoangiogenesis is a compensatory mechanism aiming to counteract hypoxia and increased metabolic demands of the thickened tissue or represents an active contributor to disease progression. Data extracted mainly from animal studies are supportive of a direct detrimental effect of neoangiogenesis, however, robust evidence from human studies is lacking. Thus, there is inadequate knowledge to assess whether neoangiogenesis could serve as a future therapeutic target for a disease that no effective medical therapy exists. In this review, we present basic aspects of anatomy and structure of the normal and stenotic aortic valve and we focus on the role of valve vasculature in the natural course of valve calcification and stenosis. © 2020 Belgian Society of Cardiology

Multi-slice CT (MSCT) imaging in pretrans-catheter aortic valve implantation (TAVI) screening. How to perform and how to interpret

Aortic valve stenosis (AS) is the most common valvular heart disease among elderly. Trans-catheter aortic valve implantation (TAVI) has become an established and effective alternative therapeutical procedure for inoperable and high-risk patients with symptomatic AS. The procedural success is greatly dependent on a thorough pre-TAVI imaging screening. This requires a comprehensive and multi-modality approach, in which multi-slice computed tomography (MSCT) is the cornerstone in the selection of eligible patients, in choosing the appropriate prosthesis and size, and in mapping the safest access route for the intervention. From our experience of more than 400 TAVI procedures and many more MSCTs for screening purposes, we provide clinical and technical details on the use of MSCT pre-TAVI and brief review of the knowledge so far. © 2017 Hellenic Society of Cardiolog

The prognostic value of CHA2DS2-VASc and GRACE risk scores in patients with ACS

Objective: Cardiovascular diseases are the first cause of death in western societies. Therapeutic interventions in the individual patient should be guided by the so-called ischemic risk of this patient. Purpose: The aim of the study was to study the ischemic prognostic scores GRACE and CHA2DS2-VASc, in patients underwent angioplasty to highlight which best predicts better the ischemic risk. Methods: Consecutives patients who underwent Percutaneous Coronary Intervention (PCI) due to Acute Coronary Disease, or elective PCI in one centre in Athens, Greece, where included in the study. The GRACE score and the CHA2DS2-VASc score were calculated. Results: 667 patients participated in the study with an average age of 61 ± 11 years and were followed-up for 2 years. The GRACE score and its predicted incidence at 3 years, was compared to the CHA2DS2-VASc score. CHA2DS2-VASc score was able to show a marginally better prognosis of future ischemic events, with an AUC of 0.624 vs 0.608 of the GRACE score. Conclusions: In our study, The CHA2DS2-VASc score managed to predict, marginally better, the appearance of MACCE over GRACE, in patients with angioplasty. © 2018 Hellenic Society of Cardiolog

Transfemoral transcatheter aortic valve replacement in the presence of a mitral prosthesis

PurposeIn the current case series, we present our experience with the self-expanding CoreValve or Evolut R (Medtronic Inc.) in patients with severe symptomatic aortic valve stenosis and concomitant mitral valve prosthesis.MethodsTwelve patients with previous mitral valve prosthesis underwent transcatheter aortic valve replacement for severe symptomatic aortic valve stenosis and/or aortic valve regurgitation. All patients underwent evaluation with an echocardiogram, computed tomography and coronary angiogram. After the index intervention and before discharge all patients underwent transthoracic echocardiography. All outcomes were defined according to the Valve Academic Research Consortium-2 criteria. Results Eleven patients underwent transcatheter aortic valve replacement for severe symptomatic aortic valve stenosis and one patient for severe aortic valve regurgitation. There was immediate improvement of patients' hemodynamic status; no cases of procedural death, stroke, myocardial infarction, or urgent cardiac surgery occurred. There was no 30-day mortality and all patients improved, with 91.6% in functional New York Heart Association class I-II. Conclusion The current study demonstrates that in patients with severe aortic valve stenosis or regurgitation and mitral valve prosthesis, the implantation of a self-expanding aortic valve via the transfemoral route is safe and feasible, with maintained long-term results. © 2019 Italian Federation of Cardiology - I.F.C. All rights reserved