Aortic stenosis (AS) is the most common valvular heart disorder in the elderly population. As a result of the shared pathophysiological processes, AS frequently coexists with coronary artery disease (CAD). These patients have traditionally been managed through surgical aortic valve replacement (SAVR) and coronary artery bypass grafting. However, increasing body of evidence supports transcatheter aortic valve implantation (TAVI) as an alternative treatment for severe AS across the spectrum of operative risk. This has created the potential for treating AS and concurrent CAD completely percutaneously. In this review we consider the evidence guiding the optimal management of patients with severe AS and CAD. While invasive coronary angiography plays a central role in detecting CAD in patients with AS undergoing surgery or TAVI, the benefits of complementary functional assessment of coronary stenosis in the context of AS have not been fully established. Although the indications for revascularisation of significant proximal CAD in SAVR patients have not recently changed, routine revascularisation of all significant CAD before TAVI in patients with minimal angina is not supported by the latest evidence. Several ongoing trials will provide new insights into physiology-guided revascularisation in TAVI recipients. The role of the heart team remains essential in this complex patient group, and if revascularisation is being considered careful evaluation of clinical, anatomical and procedural factors is essential for individualised decision-making.

Background: Vascular complications after percutaneous transfemoral transcatheter aortic valve implantation (TAVI) are associated with adverse clinical outcomes and remain a significant challenge.Aims: The purpose of this review is to synthesize the existing evidence regarding the iliofemoral artery features predictive of vascular complications after TAVI on pre‐procedural contrast‐enhanced multidetector computed tomography (MDCT).Methods: A systematic search was performed in Embase and Medline (Pubmed) databases. Studies of patients undergoing transfemoral TAVI with MDCT were included. Studies with only valve‐in‐valve TAVI, planned surgical intervention and those using fluoroscopic assessment were excluded. Data on study cohort, procedural characteristics and significant predictors of vascular complications were extracted.Results: We identified 23 original studies involving 8697 patients who underwent TAVI between 2006 and 2020. Of all patients, 8514 (97.9%) underwent percutaneous transfemoral‐TAVI, of which 8068 (94.8%) had contrast‐enhanced MDCT. The incidence of major vascular complications was 6.7 ± 4.1% and minor vascular complications 26.1 ± 7.8%. Significant independent predictors of major and minor complications related to vessel dimensions were common femoral artery depth (>54 mm), sheath‐to‐iliofemoral artery diameter ratio (>0.91–1.19), sheath‐to‐femoral artery diameter ratio (>1.03–1.45) and sheath‐to‐femoral artery area ratio (>1.35). Substantial iliofemoral vessel tortuosity predicted 2–5‐fold higher vascular risk. Significant iliofemoral calcification predicted 2–5‐fold higher risk. The iliac morphology score was the only hybrid scoring system with predictive value.Conclusions: Independent iliofemoral predictors of access‐site complications in TAVI were related to vessel size, depth, calcification and tortuosity. These should be considered when planning transfemoral TAVI and in the design of future risk prediction models.

Right ventricle-pulmonary artery (RV-PA) coupling is prognostically important in valvular heart disease. The authors performed a systematic review and meta-analysis to quantify the association of RV-PA coupling with clinical endpoints after intervention for aortic stenosis (AS), mitral regurgitation (MR), and tricuspid regurgitation (TR). The primary outcome was all-cause mortality, and the secondary outcome was a composite of major adverse cardiovascular events (MACE). A random-effects model was used to compute pooled effect estimates, and summary receiver-operating characteristic curves identified optimal RV-PA thresholds. In total, 30 interventional studies (N = 12,992) met eligibility criteria, including 14 AS (n = 6,100), 12 MR (n = 5,032), and 4 TR (n = 1,860) studies. Tricuspid annular plane systolic excursion (TAPSE) to pulmonary artery systolic pressure (PASP) was the most studied RV-PA coupling index. Reduced TAPSE/PASP was independently associated with all-cause mortality (AS adjusted HR: 1.69 [95% CI: 1.30-2.20]; MR adjusted HR: 1.94 [95% CI: 1.40-2.69]; P < 0.001) and the composite MACE (AS adjusted HR: 1.60 [95% CI: 1.29-2.00]; MR adjusted HR: 2.01 [95% CI: 1.54-2.62]; P < 0.001). There were significant nonlinear associations between TAPSE/PASP and adverse outcomes in AS and MR (P < 0.001). There were insufficient data to estimate a pooled effect-size in TR. Optimal TAPSE/PASP thresholds to predict all-cause mortality were ≤0.51 mm/mm Hg for AS interventions, ≤0.33 mm/mm Hg for MR interventions and ≤0.44 mm/mm Hg for TR interventions. TAPSE/PASP is an independent predictor of outcomes after interventions for AS and MR. The disease-specific TAPSE/PASP cutoffs could be integrated into risk-stratification models to better predict mortality before valve interventions and improve patient selection.

OBJECTIVES: Right ventricular-to-pulmonary artery coupling has been associated with outcomes in mitral regurgitation treated by transcatheter approaches. We evaluated right ventricular-to-pulmonary artery coupling as a predictor of survival and postoperative length of hospital stay (LOS) in patients with mitral regurgitation undergoing mitral valve surgery. METHODS: In this retrospective analysis (median follow-up: 5.8 years), right ventricular-to-pulmonary artery coupling was quantified as the ratio of tricuspid annular plane systolic excursion to pulmonary artery systolic pressure (TAPSE/PASP) using transthoracic echocardiography. Receiver operating characteristic curve analysis was used to determine the optimum cut-point of TAPSE/PASP to predict all-cause mortality, and the study population was dichotomized according to this value. The primary end point was all-cause mortality. A secondary end point of LOS was also assessed. RESULTS: Out of 142 patients (median age: 67, female: 49%), 35 showed impaired coupling at baseline (TAPSE/PASP ≤0.35). Patients with TAPSE/PASP ≤0.35 had higher absolute mortality (37% vs 8%, P < 0.001) and longer LOS (7 days vs 9 days, P = 0.04). Kaplan–Meier analysis revealed lower survival in patients with TAPSE/PASP ≤0.35 (log-rank: P < 0.0001). In multivariable Cox regression, TAPSE/PASP ≤0.35 was the most significant predictor of all-cause mortality (hazard ratio: 3.69, 95% confidence interval 1.31–10.1, P = 0.011), alongside chronic obstructive pulmonary disease and estimated glomerular filtration rate. TAPSE/PASP ≤0.35 was associated with significantly increased LOS (β: 4.6, 95% confidence interval 0.66–8.5, P = 0.022) alongside left ventricular ejection fraction, mitral valve replacement and urgent operation. CONCLUSIONS: In mitral regurgitation patients undergoing mitral valve surgery, TAPSE/PASP ≤0.35 is associated with increased mortality and LOS. Further validation is indicated in larger, prospective cohorts.

Aortic stenosis (AS) was historically considered a disease of the left side of the heart, with the main pathophysiological impact being predominantly on the left ventricle (LV). However, progressive pressure overload in AS can initiate a cascade of extra-valvular myocardial remodeling that could also precipitate maladaptive alterations in the structure and function of the right ventricle (RV). The haemodynamic and clinical importance of these changes in patients with AS have been largely underappreciated in the past. Contemporary data indicates that RV dilatation or impairment identifies the AS patients who are at increased risk of adverse clinical outcomes after aortic valve replacement (AVR). It is now increasingly recognised that effective quantitative assessment of the RV plays a key role in delineating the late clinical stage of AS, which could improve patient risk stratification. Despite the increasing emphasis on the pathological significance of RV changes in AS, it remains to be established if earlier detection of these changes can improve the timing for intervention. This review will summarise the features of normal RV physiology and the mechanisms responsible for RV impairment in AS. In addition, we will discuss the multimodality approach to the comprehensive assessment of RV size, function and mechanics in AS patients. Finally, we will review the emerging evidence reinforcing the negative impact of RV dysfunction on clinical outcomes in AS patients treated with AVR.

Calcium scoring from noncontrast computed tomography (CT) is used clinically to adjudicate aortic stenosis severity in patients with discordant echocardiography. The aim of this study was to investigate whether quantification of aortic valve calcium volume from computed tomography angiography (CTA) can provide robust diagnostic discrimination of disease severity and inform risk stratification of patients with aortic stenosis. Patients with mild to severe aortic stenosis who underwent concurrent CTA and echocardiography were included in a retrospective international multicenter observational cohort study. Accuracy of aortic valve calcium volume to diagnose severe aortic stenosis in patients with concordant disease on echocardiography was assessed. Association of aortic valve calcium volume with the incidence of aortic valve replacement or all-cause death was investigated. The study included 1,521 patients (mean age: 74 ± 10 years; 44% female; median peak aortic jet velocity: 3.8 m/s [Q1-Q3: 3.1-4.5 m/s]). Indexed aortic valve calcium volume correlated with peak aortic jet velocity (ρ = 0.723; P < 0.001) and noncontrast CT calcium score (ρ = 0.896; P < 0.001). In the derivation cohort (n = 689), sex-specific thresholds for indexed calcium volume (men: 122 mm³/cm²; women: 61 mm³/cm²) provided excellent diagnostic discrimination for severe aortic stenosis (C-statistic: 0.900 for men; 0.926 for women). Similar diagnostic discrimination was observed in the validation cohort (n = 459; C-statistic: 0.933 for men; 0.944 for women). Clinical outcomes were available in 711 patients (25% with discordant echocardiography), with 249 reaching the primary endpoint after 26 months (Q1-Q3: 12-53 months). Indexed calcium volume thresholds were independently associated with aortic valve replacement or all-cause mortality in both the cohort as a whole (HR: 2.01 [95% CI: 1.30-3.10]; P < 0.01) and those with discordant echocardiography (HR: 1.58 [95% CI: 1.01-2.44]). In patients with aortic stenosis, indexed aortic valve calcium volume from CTA provides accurate discrimination of disease severity and additive prognostic information. This technique can be easily applied to patients undergoing CTA for transcatheter aortic valve replacement or coronary artery evaluation without the need for a separate noncontrast CT scan.