Aortic insufficiency (AI) is associated with worse outcomes in patients with left ventricular assist device (LVAD). Microaxial flow pumps (mAFP) are increasingly used to stabilize cardiogenic shock pre-LVAD, but their transvalvular nature raises concerns for valvular damage. We studied AI incidence and outcomes in HeartMate 3 (HM3) recipients supported by mAFP. A single-center retrospective analysis (2014-2023) compared HM3 recipients bridged with mAFP to those supported by inotropes or other mechanical circulatory support. A secondary analysis used a propensity-matched cohort. The primary outcome was the incidence of significant (≥ moderate) AI at 6 and 12 months. Secondary outcomes were hemocompatibility-related adverse events, late right heart failure, aortic valve intervention (AVI), and mortality. A total of 170 HM3 patients were included: 27 with pre-LVAD mAFP and 143 without. Median age 58.9 years; 83.5% male; 37.6% White. More patients with pre-LVAD mAFP underwent AVI at implantation (22.9% vs. 13.2%, p = 0.130). At 1 year, significant AI was more prevalent in the mAFP group (22.2% vs. 4.2%, p = 0.003). In the propensity-matched cohort, 12 month significant AI was numerically higher with mAFP (20.8% vs. 5%, p = 0.198). Secondary outcomes did not differ. Pre-HM3 mAFP support is associated with higher rates of post-HM3 AI. Further large-scale studies are needed to validate these findings.

Left Ventricular Ejection Time (LVET) is a sensitive indicator of early cardiac dysfunction, yet its routine use in first-line population screening is hindered by the operational and time demands of operator-dependent modalities like echocardiography. In this study, we introduce a scalable, contactless approach using laser Doppler vibrometry (LDV) signals targeted at the suprasternal notch (SSN) to capture hemodynamic events without physical sensor attachment. We demonstrate in a cohort of 238 individuals that this rapid, zero-setup measurement yields LVET values statistically equivalent to pulsed-wave Doppler echocardiography (concordance within a 25 ms margin). Furthermore, an exploratory clinical analysis revealed that the LDV-derived LVET index (LVETI) was significantly prolonged in patients with aortic insufficiency and stenosis compared to low-risk controls, demonstrating the clinical plausibility of the measurement. To eliminate the bottleneck of expert interpretation, we developed and validated a deep learning model that automatically extracts LVET with high accuracy (mean absolute error of 8.08 ms). By combining easy LDV data acquisition with automated analysis, this approach may facilitate rapid, operator-independent cardiovascular assessment, potentially enhancing population-level screening and cardiovascular health management.

Objective: Self-expanding (SE) transcatheter aortic prostheses (THV) have been associated with an increased risk of new permanent pacemaker implantation (PPMI), particularly with deeper implantations in the left ventricular outflow tract (LVOT) that result in more atrioventricular conduction system damage, leading to higher rates of post-procedural conduction disturbances (CDs) and subsequently more PPMIs. The cusp-overlap technique (COT) is designed to provide better visualisation of the LVOT during implantation, aiming to achieve a shallower implantation depth (ID) and potentially reduce both post-procedural CDs and PPMIs. This study seeks to compare the traditional three-cusp coplanar view technique (3CT) with the newer COT in patients undergoing transcatheter aortic valve replacement (TAVR). Methods: From March 2018 to April 2020, a total of 586 patients underwent TAVR at the university clinic in Kiel. Among them, 226 patients who received SE prostheses were included in the study. After applying exclusion criteria, a final cohort of 203 patients was analysed. Of these, 106 patients underwent TAVR using the COT, while 97 patients underwent TAVR using the 3CT. The primary endpoints of the study were the occurrence of new CD and PPMI within 30 days post-procedure. Secondary endpoints included various post-TAVR events as defined by the Valve Academic Research Consortium 3 (VARC-3) safety criteria. A specific focus was placed on assessing the risk of high valve implantation according to VARC-3 criteria, specifically paravalvular insufficiency, valve embolisation, and coronary occlusion. Statistical analysis was conducted to compare outcomes between the COT and 3CT groups. Results: Implantation depths were significantly lower in the COT group compared to the 3CT group, with ID values from the NCC and LCC being 2.7 mm (±1.5) and 2.8 mm (±1.5) for the COT, and 5.4 mm (±3) and 6.6 mm (±2.6) for the 3CT (p < 0.001 for both). The incidence of high-grade CD, particularly Atrioventricular Block (AVB) II and III, was significantly higher in the 3CT group (26.8%) compared to the COT group (13.2%) (p = 0.023). The overall 30-day PPMI rate was 18.2% (n = 37), with a significant difference between the COT and 3CT groups (12.2% vs. 24.7%, p = 0.021). The primary indication for PPMI was permanent high-grade AVB occurring during or after TAVR, accounting for 95% of cases. No cases of TAVR embolisation, acute coronary occlusion or related syndromes were observed within the first 30 days post-procedure. There were no significant differences in 30-day mortality or post-procedural paravalvular insufficiency between the groups. In multivariable logistic regression analysis, the COT remained independently associated with lower odds of new post-procedural CD after adjustment for prior right bundle branch block (RBBB), prior first-degree AVB, predilatation, valve size and coronary artery disease (odds ratio [OR] 0.45, 95% confidence interval [CI] 0.24-0.82, p = 0.009). For 30-day PPMI, the cusp-overlap technique demonstrated a borderline association with lower adjusted odds (OR 0.46, 95% CI 0.20-1.02, p = 0.057), while prior RBBB was independently associated with increased PPMI risk (OR 3.54, 95% CI 1.22-10.28, p = 0.020). Conclusions: The COT was associated with shallower implantation depth and lower rates of new post-procedural CD after multivariable adjustment. The association with reduced 30-day PPMI remained directionally consistent but was borderline after adjustment. These findings support the potential value of COT as a procedural strategy to reduce conduction-related complications after TAVR with self-expanding prostheses.

Valve-in-valve transcatheter aortic valve (TAV) replacement (TAVR) is becoming increasingly more common in patients with bioprosthetic valve failure. However, solutions for high-risk patients with prior TAVR deployment remain challenging, and TAV-in-TAV may not be feasible because of the risk for coronary occlusion. We revisit the SURPLUS procedure, surgical resection of prosthetic valve leaflets under direct vision, with hybrid placement of a TAV-in-TAV for a patient who had prior valve-in-valve TAVR complicated by left main coronary artery occlusion warranting emergent left main snorkel placement, now with moderate to severe aortic insufficiency complicated by heart failure.

Despite the technically challenging nature of valve-sparing root replacement, restoration of aortic valve competence can be achieved through a complete understanding of the aortic root anatomy and pathophysiology. In this review, we discuss the physiology of normal aortic root function as well as pathophysiologic mechanisms contributing to aortic valve incompetence. Preoperative planning for valve-sparing root replacement is discussed, including the use of imaging to guide surgical decision-making. Pitfalls and pearls of the critical technical steps for both valve-sparing root replacement and repair of both tricuspid and bicuspid aortic valves are provided. Finally, current evidence guiding best practices in valve-sparing root replacement and aortic valve repair is presented to support decision-making for patient selection.

De novo aortic insufficiency (AI) is a recognized complication in patients supported with continuous-flow durable left ventricular assist devices (LVADs), carrying important clinical consequences including heart failure progression and increased device-related morbidity. We report the case of a HeartMate 3 (Abbott Inc., Chicago, Illinois, USA) patient, previously supported with a micro-axial flow pump (mAFP), who developed severe AI within the first year of LVAD support and ultimately underwent urgent heart transplantation. Intraoperative inspection and histopathological analysis revealed mechanical injury of the aortic valve, likely initiated during mAFP implantation and subsequently exacerbated by LVAD-related turbulent flow. These findings suggest that even subtle valve trauma may evolve into clinically significant AI under continuous-flow support. This case underscores the need for a proactive strategy to minimize the risk of aortic valve micro-lesions during mAFP placement, including meticulous preprocedural assessment of aortic root and valve anatomy and careful intraprocedural technique.