Transcatheter aortic valve implantation in low-risk tricuspid or bicuspid aortic stenosis: the NOTION-2 trial
Troels Højsgaard JørgensenHans Gustav Hørsted ThyregodMikko SavontausYannick WillemenØyvind BleieMariann TangMatti NiemeläOskar AngeråsIngibjörg GuðmundsdóttirUlrik SartipyHanna DagnegaardMika LaineAndreas RückJarkko PiuholaPétur PéturssonEvald Høj ChristiansenMarkus MalmbergPeter Skov OlsenRune HaaverstadLars SøndergaardOle De BackerTroels Højsgaard JørgensenOle De BackerLars SøndergaardHanna DagnegaardPeter Skov OlsenØyvind BleieRune HaarverstadMikko SavontausMarkus MalmbergEvald Høj ChristiansenMariann TangMatti NiemeläTuomas AhvenvaaraIngibjörg GuðmundsdóttirGunnar MýrdalOskar AngeråsPétur PéturssonMika LaineTommi VähasiltaAndreas RückUlrik Sartipy
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Transcatheter aortic valve implantation (TAVI) has become the first choice to treat older patients with severe symptomatic aortic stenosis (AS). This study aimed to compare TAVI with surgery in low-risk patients ≤75 years of age, including both tricuspid and bicuspid AS.Keywords:
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Hereditary factors may have a part to play in the development of bicuspid aortic valve. This report concerns a pair of identical twins, probably monozygotic, who required aortic valve replacement as a result of aortic stenosis occurring in bicuspid aortic valves. This supports the contention that there may be a genetic influence in the development of bicuspid aortic valve, though environmental factors may be of greater importance.
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The bicuspid aortic valve is the most frequent congenital cardiac malformation; it may be isolated or associated with other congenital heart disease. The present investigation consists of a study of bicuspid aortic valves in 1022 heart specimens belonging to the anatomical collection of the Institute of Pathological Anatomy of the University of Padua. A bicuspid aortic valve was observed in 95 specimens. It occurred as an isolated congenital cardiac defect in 28 cases, seven of which had spontaneous laceration of the aortic valve (aortic dissection). It was associated with other congenital cardiac malformations in 67 out of the remaining 994 specimens (6.7%), 41 of which (61.2%) showed obstruction of the aortic arch. The frequency of bicuspid aortic valve in specimens with complete transposition of great arteries was only 1%. Bicuspid aortic valve was particularly frequent in association with ventricular septal defect and was significantly more frequent in cases with (51.1%) than in cases without (20.5%) aortic arch obstruction (p < 0.001). There was no significant relationship between the occurrence of bicuspid aortic valves and left ventricular outflow tract obstructions or mitral valve malformations. The morphology of the pulmonary valve was also examined. Concurrence of a bicuspid aortic and pulmonary valve was detected in 11 specimens, five of these had trisomy-18. Our findings cast doubt on the assumption that altered fetal blood flow through the aortic valve may be the main factor producing the bicuspid condition. Indeed, they rather support the hypothesis that most bicuspid aortic valves are expressions of a developmental complex that affects the aortic arch and the wall of the ascending aorta as well as the aorta valve.
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To detect the expression of fibrillin-1 in congenital bicuspid aortic valves, and to investigate the molecular mechanism of congenital bicuspid aortic valves.Specimens of aortic valve were obtained from 12 pediatric patients with congenital bicuspid aortic valve, 11 boys and 1 girl, aged 16.7 (10 - 18), including 5 cases of aortic stenosis (AS), 8 of aortic insufficiency (AI), and 1 of AS and AI, undergoing valve replacement, 8 children who died accidentally without cardiovascular system and collagen system diseases, 6 boys and 2 girls, aged 9.1 (1 - 17), collected in autopsy [normal (tricuspid) aortic valve controls], and 18 pediatric patients of rheumatic valvular heart disease with diseased tricuspid aortic valves who underwent aortic valve replacement, 13 boys and 5 girls, aged 16.5 (12 - 18) (rheumatic valvular heart disease controls). HE staining and light microscopy were conducted. Immunohistochemistry was used to detect the expression of fibrillin-1 in the aortic valves.Microscopy showed that the tissue structure of the congenital bicuspid aortic valves was unclear with hyperplasia of fibrous tissue. The grey degree value of fibrillin-1 of the congenital bicuspid aortic valve group was 170 +/- 10, significantly lower than those of normal aortic valve group and diseased tricuspid aortic valve group (126 +/- 8 and 73 +/- 16 respectively, both P < 0.05). There were not significant difference in the grey degree value of fibrillin-1 among the patients of congenital bicuspid aortic valves with AS, AI, and AS + AI (167 +/- 6, 171 +/- 8, and 168 +/- 6 respectively).The expression of fibrillin-1 is significantly reduced in congenital bicuspid aortic valves which may contribute to the morphological changes of the aortic valve leaflets and their resultant functional failure in congenital bicuspid aortic valves.
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There are little data on the efficacy and safety of the Edwards Sapien valve (Edwards Lifesciences, Irvine, California, USA) in congenital, bicuspid aortic valve stenosis. Patients with bicuspid valves were excluded from the randomised PARTNER trial.1 Bicuspid valves differ from tricuspid aortic valves in that the orifice is elliptical and the leaflets are typically bulky and very heavily calcified. Bicuspid valves are considered …
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Objective: The degeneration of bicuspid aortic valve and its frequent association with ascending aortic pathology, point to a still unidentified genetic tissue defect with unknown mediators. Metalloproteinases (MMPs) are lytic enzymes that have been strongly implicated in aneurysm formation. The purpose of this study was to detect the presence of these enzymes in aortic valvular tissue in healthy and diseased aortic valves with or without the presence of synchronous ascending aortic pathology. Methods: Aortic valve specimens from 26 aortic valve replacement patients as well as 4 healthy control tricuspid aortic valves were included. 10 patients had bicuspid aortic valves, and 16 had tricuspid aortic valves. Half of our patient population had a concomitant aortic procedure for aortic pathology. The study detected MMPs 1,2 and 9 as well as their Tissue inhibitors (TIMPs) 1 and 2. MMP and TIMP detection was accomplished with the construction of a tissue micro array and immunohistochemistry. Conclusions: MMP-9 expression was significantly higher in bicuspid aortic valves compared to normal valves (P≪0.05). When compared to the tricuspid valve group, MMP-9 mean value was significantly higher in bicuspid valves (P≪0.05).When the entire rest of the valve group (n=4+16, i.e. control and tricuspid valve groups) was compared to the bicuspid valve group, bicuspid valves had significantly higher MMP-2, and MMP-9 (P≪0.01) expression. TIMP expression also changed in diseased valves, among different patient groups. This increased proteolytic presence in bicuspid aortic valves may attribute to the observed decreased elastin and collagen content, and their resultant functional failure.
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Not all patients with bicuspid aortic valves behave similarly. Some patients have early valve dysfunction and require intervention in infancy or childhood. More commonly, bicuspid valves degenerate gradually throughout adulthood and valve failure does not occur until the fifth decade or later. Some patients have primarily aortic stenosis while others have aortic regurgitation. Others have mixed valve dysfunction. The aorta dilates in some, but not all patients with bicuspid aortic valves. Furthermore, dilation can occur at the sinuses, in the mid-ascending aorta, or in both regions. Numerous authors have attempted to explain this heterogeneity in valve dysfunction and aortic morphology. However, to date, the reason for the variability in presentation remains incompletely explained.
The most common way to categorise bicuspid aortic valves is according to the morphology of leaflet fusion, since most valves are trileaflet with a fused commissure. Fusion of the right and left coronary cusps (RL fusion) is most common, followed by fusion of the right and non-coronary cusps (RN fusion). Fusion of the left and non-coronary cusps is quite rare. Some valves have no identifiable raphe and are described as ‘true’ or ‘pure’ bicuspid aortic valves.
Because the morphology of bicuspid aortic valves is usually easy to define by echocardiography, it is tempting to ascribe …
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