Belluco E.

Besola L.

Cademartiri F.

Colli A.

Gerosa G.

English

Archivio della Ricerca - Università di Pisa

Letters J A C C V O L . 7 6 , N O . 1 5 , 2 0 2 0O C T O B E R 1 3 , 2 0 2 0 : 1 8 0 8 – 1 41810The limitations of the present study included thefollowing: 1) retrospective, observational studydesign; 2) lack of detailed data regarding the time inthe therapeutic range of warfarin; and 3) we onlyinvestigated Taiwanese patients with AF in whom thereduced dosages of DOACs were prescribed; there-fore, whether our findings can be generalized to otherpopulations is uncertain.Compared with the CG equation, the MDRD andCKD-EPI formulas overestimated eGFRs in older adultpatients with AF with low BWs. The adoptions ofMDRD or CKD-EPI, rather than CG, resulted in inap-propriate dosing of DOACs, thus attenuating the ad-vantages of DOACs compared with warfarin regardingthe composite risks of IS/SE and major bleeding.Therefore, the CG equation should be used for thecalculations of eGFRs to determine DOAC dosages, asused in pivotal randomized trials and recommendedby international guidelines.Yi-Hsin Chan, MD*Tze-Fan Chao, MDHsin-Fu Lee, MDYung-Hsin Yeh, MDChih-Hsin Yeh, MSYa-Chi Huang, MSShang-Hung Chang, MD, PhDChi-Tai Kuo, MDGregory Y.H. Lip, MDShih-Ann Chen, MD*Division of CardiologyDepartment of MedicineTaipei Veterans General HospitalNo. 201, Sec. 2, Shih-Pai RoadTaipei 112TaiwanE-mail: eyckeyck@gmail.comhttps://doi.org/10.1016/j.jacc.2020.08.025 2020 by the American College of Cardiology Foundation. Published byElsevier.This study was supported by grants 105-2628-B-182A-003-MY3 from the Min-istry of Science and Technology and grants CMRPG3E1681, CMRPG3E1682,CMRPG3E1683, and CORPG3G0351 from Chang Gung Memorial Hospital,Linkou, Taiwan. The authors have reported that they have no relationshipsrelevant to the contents of this paper to disclose. The authors acknowledge thesupport of the Maintenance Project of the Center for Big Data Analytics andStatistics (Grant CLRPG3D0045) at Chang Gung Memorial Hospital for statisticalassistance, study design and monitoring, data analysis, and interpretation.The authors attest they are in compliance with human studies committees andanimal welfare regulations of the authors’ institutions and Food and DrugAdministration guidelines, including patient consent where appropriate. Formore information, visit the JACC author instructions page.RE F E RENCE1. Chao TF, Chiang CE, Lin YJ, et al. Evolving changes of the use of oral an-ticoagulants and outcomes in patients with newly diagnosed atrial fibrillationin Taiwan. Circulation 2018;138:1485–7.What Happens to theAortic Root Morphologyand Flow WhenWe Replace theAortic Valve?Recently, Blanke et al. (1) reported the results of theEvolut low-risk leaflet thickening or immobility(LTI) subgroup study on the onset ofhypoattenuated leaflet thickening (HALT) andreduced leaflet motion (RLM) in patients undergoingtranscatheter aortic valve replacement (TAVR) withself-expandable Evolut R system (Medtronic, Inc.,Minneapolis, Minnesota) or surgical aortic valvereplacement (SAVR). They found no difference interms of HALT and RLM between the 2 techniqueseven if previous studies reported higher ratesfollowing TAVR (2). In spite of these enticingresults, we believe that caution should bemaintained toward HALT after TAVR when treatingyoung low-risk patients.Using post-operative cardiac magnetic resonance,we recently studied the morphofunctional changes ofthe aortic root after TAVR and SAVR. Significant dif-ferences have been found when analyzing SAVR withsutured prosthesis (Magna Ease, Edwards Life-sciences, Irvine, California), rapid-deployment pros-thesis (Intuity Elite, Edwards) and TAVR with Sapien 3(Edwards). With both SAVR devices, aortic rootmorphology is maintained and the sinuses of Valsalvaare preserved, whereas they are sensibly flattened af-ter TAVR. Blood flow analysis was different not onlybetween SAVR and TAVR but also between the 2 SAVRdevices (Figure 1). Blood flow turbulence increasedprogressively when moving from sutured to rapiddeployment and to transcatheter prostheses,confirming previous in vitro observations (Figure 1)(3). These findings can also partially explain the highrate of HALT and RLM after SAVR reported in thestudy, where both sutured and sutureless prostheseswhere included. Indeed, as Blanke et al. (1) point out,both conditions were strongly related with use ofsutureless prosthesis. When treating young patientswith TAVR, these noticeable alterations should notbe overlooked because they potentially could berelated to an increased risk of HALT and structuraldysfunction in the long run. Further studies arenecessary to fully understand HALT and RLM causesand evolution.FIGURE 1 Post-Operative CMR Acquisitions of the Aortic Root(Left) One-directional phase-contrast acquisitions with encoded color-scale velocity mapping shows the flow pattern. (Right) The cine–steady-state free precession acquisitions showing the morphology of the aortic root for Magna Ease and Sapien 3 prostheses. All acquisitionsare coaxial to the aortic valve, perpendicular to flow direction. Asterisks indicate the sinus of Valsalva. CMR ¼ cardiac magnetic resonance.J A C C V O L . 7 6 , N O . 1 5 , 2 0 2 0 LettersO C T O B E R 1 3 , 2 0 2 0 : 1 8 0 8 – 1 41811Laura Besola, MDFilippo Cademartiri, MD, PhDEnrica Belluco, MEng, PhDGino Gerosa, MD*Andrea Colli, MD, PhD*Department of Surgical, Medical and MolecularPathology and Critical Care MedicineUniversity of PisaVia Paradisa 256124 PisaItalyE-mail: andrea.colli@unipi.ithttps://doi.org/10.1016/j.jacc.2020.06.087 2020 by the American College of Cardiology Foundation. Published byElsevier.Dr. Besola is a current American Association for Thoracic Surgery Fellow as shereceived the 2019–2020 Evarts A. Graham Memorial Travelling Fellowship. Allother authors have reported that they have no relationships relevant to thecontents of this paper to disclose.The authors attest they are in compliance with human studies committees andanimal welfare regulations of the authors’ institutions and Food and DrugAdministration guidelines, including patient consent where appropriate. Formore information, visit the JACC author instructions page.REF ER ENCES1. Blanke P, Leipsic JA, Popma JJ, et al., for the Evolut Low RiskLTI Substudy Investigators. Bioprosthetic aortic valve leaflet thickeningFIGURE 1 Hypoattenuated Leaflet Thickening in aSurgical BioprosthesisLetters J A C C V O L . 7 6 , N O . 1 5 , 2 0 2 0O C T O B E R 1 3 , 2 0 2 0 : 1 8 0 8 – 1 41812in the Evolut low risk sub-study. J Am Coll Cardiol 2020;75:2430–42.2. Chakravarty T, Soondergard L, Friedman J, et al., for the RESOLVE; SAVORYInvestigators. Subclinical leaflet thrombosis in surgical and transcatheterbioprosthetic aortic valves: an observational study. Lancet 2017;389:2383–92.3. Midha PA, Raghav V, Sharma R, et al. The fluid mechanics of transcatheterheart valve leaflet thrombosis in the neosinus. Circulation 2017;136:1598–609.Early Valve Thrombosisin Surgical AorticBioprosthesisRare or Underestimated Event?Computed tomography showing early thrombosis on a last-generation bioprosthesis.We read with great interest the paper by Blanke et al.(1) in which subclinical valve thrombosis is welldescribed in patients screened by 4-dimensionalcomputed tomography (CT) after aortic valveintervention. If this phenomenon seems morefrequent in transcatheter procedures, the lower useof diagnostic tools with higher sensitivity canunderestimate its real incidence in surgical aorticvalve replacement (SAVR). In the paper, the use ofsutureless valves is associated with greater risk ofhypoattenuated leaflet thickening, but there is nomention of prostheses model or implantationtechnique. In our department, we recently admitteda 55-year-old patient because of endocarditis on amechanical aortic prosthesis who was treated withimplantation of a biological prosthesis (InspirisResilia, Edwards Lifesciences, Irvine, California).A post-operative echocardiogram showed an in-crease in aortic transvalvular gradients with noevident thickening or hypomobility of the cusps. A CTrevealed the presence of thickening of the non-coronary cusp (Figure 1). Warfarin anticoagulanttherapy was instituted.The present report shows the first case of HALTwith a last-generation bioprosthetic valve (2).Egbe et al. (3) demonstrated that surgical HALTwas mentioned in only 5% of transthoracicechocardiograms and that tissue valve recipientswith hypercoagulable conditions, history ofthromboembolic events, depressed left ventricularfunction, and atrial fibrillation are at greaterthrombotic risk (3).We agree with Blanke et al. (1) that the key clinicalissue regarding HALT is the association with earlystructural deterioration, especially when youngpatients may be prone to this occurrence afterSAVR. Our case teaches that last-generationbioprostheses may also be prone to subclinicalthrombosis and that it is difficult to detect withechocardiography. We believe that futureperspectives in SAVR should include the realincidence of HALT in different prostheses and itsimpact on durability, as well as whether theduration and choice of treatment of HALT should beguided by CT imaging or by clinical features.*Andrea De Martino, MDGiosuè Falcetta, MDAndrea Colli, MD, PhD*Department of Surgical, Medical, and MolecularPathology and Critical Care MedicineUniversity of Pisa, ItalyVia Paradisa 256124 PisaItalyE-mail: andrea.demartino@unipi.ithttps://doi.org/10.1016/j.jacc.2020.06.088 2020 by the American College of Cardiology Foundation. Published byElsevier.The authors have reported that they have no relationships relevant to thecontents of this paper to disclose.The authors attest they are in compliance with human studies committees andanimal welfare regulations of the authors’ institutions and Food and DrugAdministration guidelines, including patient consent where appropriate. Formore information, visit the JACC author instructions page.R EF E RENCE S1. Blanke P, Leipsic JA, Popma JJ, et al. Bioprosthetic aortic valve leafletthickening in the Evolut low risk sub-study. J Am Coll Cardiol 2020;75:2430–42.2. Puskas JD, Bavaria JE, Svensson LG, et al. The COMMENCE trial: 2-yearoutcomes with an aortic bioprosthesis with RESILIA tissue. Eur J Car-diothorac Surg 2017;52:432–9.3. Egbe A, Pislaru SV, Ali MA, et al. Early prosthetic valve dysfunction due tobioprosthetic valve thrombosis: the role of echocardiography. J Am CollCardiol Img 2018;11:951–8.

What Happens to the Aortic Root Morphology and Flow When We Replace the Aortic Valve?

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What Happens to the Aortic Root Morphology and Flow When We Replace the Aortic Valve?

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