Adrien Carmona

Background: Fluoroscopic assessment enables immediate evaluation of transcatheter heart valve expansion during transcatheter aortic valve replacement (TAVR). Whether fluoroscopic asymmetric expansion of balloon‐expandable valves is associated with post‐TAVR heart failure (HF) remains uncertain. Methods: Among 607 consecutive patients undergoing balloon‐expandable valve‐TAVR in a prospective registry, 589 were analyzed. Valve asymmetry was quantified using a fluoroscopic asymmetry index (%), defined as [(longest/shortest balloon‐expandable valve height)−1]×100. The primary end point was 2‐year HF hospitalization. Results: During follow‐up, 99 patients (17%) experienced HF hospitalization. As a continuous variable, asymmetry index (%) was not independently associated with 2‐year HF (adjusted hazard ratio [HR] per 1% increase, 1.02 [95% CI, 0.98–1.06]). Restricted cubic spline analysis demonstrated no significant linear or nonlinear association (overall P =0.71; P for nonlinearity=0.89), although the risk curve suggested increased HF risk beyond moderate valve asymmetry. Exploratory threshold analysis identified an asymmetry index cutoff of 7.48%. Patients above this threshold had a higher incidence of HF hospitalization than those below it (23.6% versus 15.8%; log‐rank P =0.043), despite comparable rates of impaired valve performance at discharge. Valve asymmetry >7.48% remained independently associated with late HF occurring beyond 30 days after TAVR (adjusted HR, 1.69 [95% CI, 1.10–2.60]). Conclusions: Fluoroscopic assessment of balloon‐expandable valve expansion identified patients with marked valve asymmetry at increased risk of late HF after TAVR, despite preserved early valve performance. These findings support the potential value of intraprocedural valve geometry assessment for long‐term risk stratification and warrant further investigation.

BACKGROUND: Data on the long-term incidence and clinical impact of bioprosthetic valve failure (BVF) after transcatheter aortic valve replacement remain limited. This study aimed to assess the incidence, predictors, and clinical impact of BVF following transcatheter aortic valve replacement. METHODS: We analyzed data from an international, multicenter registry including consecutive patients undergoing transcatheter aortic valve replacement at 13 centers. The primary outcome was BVF according to Valve Academic Research Consortium-3 criteria. The cumulative incidence of BVF was estimated using a competing-risk approach. The association between BVF and clinical outcomes was assessed using competing-risk models with BVF as a time-dependent covariate. RESULTS: Among 7501 patients, BVF occurred in 380 (5.1%) patients over a median follow-up of 4 (interquartile range, 2–5) years. The cumulative incidence of BVF increased over time, reaching 1.4% at 1 year, 4.6% at 5 years, and 8.3% at 10 years. Independent predictors of BVF included younger age, smoking, balloon-expandable valve, prosthesis size P P P =0.043), and heart failure hospitalization (adjusted hazard ratio, 1.43 [95% CI, 1.03–1.98]; P =0.032). Consistent findings were observed in different sensitivity analyses. CONCLUSIONS: BVF is a clinically relevant event associated with adverse long-term outcomes. These findings support the implementation of tailored surveillance and preventive strategies to mitigate BVF-related risk.

Background: The role of plasma and its components in the progression of aortic stenosis (AS) remains insufficiently investigated. This study aimed to assess whether plasma from patients with AS induces oxidative stress and contributes to valvular endothelial cells (VECs) dysfunction. Methods: Human plasma samples were obtained from patients with severe AS (AS+, n=110), patients with cardiovascular risk factors without AS (n=30), and healthy individuals (n=15). Plasma levels of proinflammatory cytokines (IL [interleukin]‐1β, IL‐6, TNF [tumor necrosis factor]‐α, and factor Xa [FXa]) were measured. Porcine aortic VECs were then incubated with plasma (10%, 24 hours). Oxidative stress levels were assessed using dihydroethidium staining, NO formation with 4‐amino‐5‐methylamino‐2′,7′‐difluororescein diacetate, mRNA expression by quantitative reverse transcription‐polymerase chain reaction, and protein expression levels by Western blot analyses. Platelets and monocytes adhesion as well as thrombin generation were determined. Different pharmacological inhibitors were used to explore the underlying pathways. Results: Plasma from patients with AS+ exhibited elevated levels of IL‐1β, IL‐6, TNF‐α, and FXa activity. Incubation of VECs with AS+ plasma induced a pro‐oxidant response mediated by proinflammatory cytokines, the angiotensin system‐SGLT2 (sodium‐glucose transport protein 2) pathway, and FXa. AS+ plasma also triggered VEC dysfunction, inflammation, monocytes and platelets adhesion, and thrombin generation. These detrimental effects were mitigated by empagliflozin, losartan, neutralizing antibodies targeting proinflammatory cytokines, and dabigatran and rivaroxaban. Conclusions: Patients with AS displayed subclinical systemic inflammation and increased FXa activity. These processes contributed to aortic VEC dysfunction, inflammation, monocytes and platelets adhesion, and thrombin generation upon exposure to AS+ plasma.

Aims: Access to transcatheter aortic valve replacement (TAVR) is generally prioritized for symptomatic patients presenting with severe heart failure, syncope, angina, and decrease in left ventricular ejection fraction 60 mmHg [sHR, 2.37 (95% CI, 1.36–4.12); P = 0.002]. Généreux stages 3 and 4 showed a strong association with waiting-list mortality, more than doubling the risk of death [sHR, 2.12 (95% CI, 1.33–3.38); P = 0.002]. Conclusion: These findings suggest that TAVR candidates at Généreux stages 3 and 4 should receive higher priority on the waiting list.

Background: Vascular closure of the femoral artery during transcatheter aortic valve implantation (TAVI) remains a critical step prone to complications, despite advancements in introducer technology. The traditional technique involves using two ProGlide^® suture closure devices (2P), but alternative approaches, such as employing a single ProGlide^® device (1P), have emerged. Aims: We sought to evaluate the efficacy and safety of the 1P strategy compared to the standard 2P closure technique during transfemoral TAVI procedures. Methods: A registry-based study was conducted at the University Hospitals of Strasbourg, France, from January 2020 to December 2023. Consecutive patients who underwent TAVI via the transfemoral approach were deemed eligible. Results: The study cohort consisted of 1303 patients, with a mean age of 81.7 years and 47% female. The 1P strategy was used in 733 cases (56.3%), while the 2P technique was employed in 570 patients (43.7%). Hemostasis was achieved in the catheterization laboratory without additional devices in 30.4% of the single-ProGlide^® pre-closing cases. Vascular complication rates were similar in both groups, at 11.3% for the 1P technique and 11.4% for the 2P technique (p = 0.964). However, vascular closure device failure was significantly less frequent in the 1P group (1.6%) compared to the 2P group (5.3%). Conclusions: The 1P strategy for pre-closing during TAVI is as effective and safe as the conventional 2P approach. The 1P method offers potential advantages in terms of simplicity and cost-effectiveness.

Transcatheter aortic valve replacement has emerged as a valuable alternative to surgical aortic valve replacement in patients with severe aortic stenosis. Given the expansion of transcatheter aortic valve replacement to lower‐risk and younger populations with longer life expectancy, the durability of transcatheter heart valves (THVs) has become an important issue that may impact cardiovascular outcomes. THVs share similarities with surgical valves but have unique features, including a trend to larger effective orifice area and less prosthesis–patient mismatch, interactions with the native valve, and crimping process, that may all potentially influence a THV's life span. Multiple mechanisms may lead to bioprosthetic valve dysfunction, including structural valve deterioration, thrombosis, endocarditis, and nonstructural valve deterioration. With an incidence of up to 12.3% 5 years after transcatheter aortic valve replacement, structural valve deterioration represents the ultimate consequence of fibrotic remodeling and calcification within the bioprosthesis, driven by thrombotic and inflammatory processes involving the native aortic valve and influenced by patient and procedural factors. Understanding these mechanisms is crucial for improving THV durability.