BACKGROUND: Transcatheter aortic valve implantation (TAVI) did not receive regulatory approval in Australia until 2013, several years after Europe (2007) and America (2011). Consequently, the uptake of TAVI in Australia initially lagged behind international best practices. This study was undertaken to provide an update on the status of TAVI activity in Australia.
METHODS: A descriptive population-level epidemiological study was performed. Annual activity data for both surgical aortic valve replacement (SAVR) and TAVI were obtained from the Australian Institute of Health and Welfare (AIHW) for the period from 1 July 2012 to 30 June 2022. Dynamic contemporaneous population data were obtained from the Australian Bureau of Statistics (ABS). Trends in absolute activity, population-adjusted activity and age cohort-adjusted activity were examined.
RESULTS: Despite the impact of the COVID-19 pandemic on the Australian healthcare system, TAVI activity has continued to increase. Annual TAVI activity now exceeds annual SAVR activity (3,967 vs 3,870), albeit driven by TAVI in patients aged 85+ years. Population-adjusted TAVI activity now exceeds the reported European average (15.3 vs 14.1 per 100,000 persons). The point of equipoise for the choice between SAVR and TAVI is the 75-79 age cohort (50% vs 50%).
CONCLUSIONS: Australian TAVI activity is now consistent with international best practice.

BACKGROUND: Current European guidelines support transcatheter aortic valve implantation (TAVI) in intermediate-to-low-risk patients ≥75 years-old, but its prognostic relevance is unknown.
METHODS: Intermediate-to-low-risk (The Society of Thoracic Surgeons score <8%) patients enrolled in the HORSE registry were included. We compared the populations aged under 75 with those over 75. The primary endpoint was all-cause mortality.
RESULTS: A total of 2685 patients were included: 280 (8.6%) < 75 and 2405 ≥ 75 years. Through a mean follow-up of 437 ± 381 days, 198 (8.2%) and 23 (8.2%) patients died in the two arms without statistically significant differences (log-rank p = 0.925). At Cox regression analysis, age did not predict the occurrence of all-cause death, neither as a continuous variable (HR 1.01, 95% CI 0.99-1.04, p = 0.294) nor dichotomizing according to the prespecified cutoff of 75 years (HR 0.97, 95% CI 0.63-1.51, p = 0.924). Time-to-event ROC curves showed low accuracy of age to predict all-cause mortality (area under the curve of 0.54 for both 1-year and 2-year outcomes).
CONCLUSIONS: TAVI has comparable benefits across age strata for intermediate-to-low-risk patients. The age cutoff suggested by the current guidelines is not predictive of the risk of adverse events during hospital stays or of all-cause mortality through a mid-term follow-up.

The article summarize the most important changes regarding the management of valvular heart disease, which have been made in the ESC Guidelines 2021. Based on the randomized clinical study data, which were recently published, the most frequent changes were done in terms of the choice of mode of intervention in the aortic and mitral valves as well as in the management of the antithrombotic therapy.

In this EACVI clinical scientific update, we will explore the current use of multi-modality imaging in the diagnosis, risk stratification, and follow-up of patients with aortic stenosis, with a particular focus on recent developments and future directions. Echocardiography is and will likely remain the key method of diagnosis and surveillance of aortic stenosis providing detailed assessments of valve haemodynamics and the cardiac remodelling response. Computed tomography (CT) is already widely used in the planning of transcutaneous aortic valve implantation. We anticipate its increased use as an anatomical adjudicator to clarify disease severity in patients with discordant echocardiographic measurements. CT calcium scoring is currently used for this purpose; however, contrast CT techniques are emerging that allow identification of both calcific and fibrotic valve thickening. Additionally, improved assessments of myocardial decompensation with echocardiography, cardiac magnetic resonance, and CT will become more commonplace in our routine assessment of aortic stenosis. Underpinning all of this will be widespread application of artificial intelligence. In combination, we believe this new era of multi-modality imaging in aortic stenosis will improve the diagnosis, follow-up, and timing of intervention in aortic stenosis as well as potentially accelerate the development of the novel pharmacological treatments required for this disease.

There have been several advances in the diagnosis and management of valvular heart disease (VHD) over the last decade. These have been reflected in the latest European and North American guidelines, although both contain significant similarities and differences. In this review, we highlight the important overlaps and variations between the updated guidelines and their previous versions to help guide the general cardiologist.
There has been extensive revision on the use of percutaneous treatments, the indications for intervention in asymptomatic VHD, and perioperative bridging therapies. The updated guidelines provide new recommendations in many aspects of VHD; however, there remain significant gaps in the role of biomarkers in VHD and the long-term outcomes of novel oral anticoagulants (NOACs) and transcatheter therapies.

Aortic stenosis (AS) is a serious and complex condition, for which optimal management continues to evolve rapidly. An understanding of current clinical practice guidelines is critical to effective patient care and shared decision-making. This state of the art review of the 2021 European Society of Cardiology/European Association for Cardio-Thoracic Surgery Guidelines and 2020 American College of Cardiology/American Heart Association Guidelines compares their recommendations for AS based on the evidence to date. The European and American guidelines were generally congruent with the exception of three key distinctions. First, the European guidelines recommend intervening at a left ventricular ejection fraction of 55%, compared with 60% over serial imaging by the American guidelines for asymptomatic patients. Second, the European guidelines recommend a threshold of ≥65 years for surgical bioprosthesis, whereas the American guidelines employ multiple age categories, providing latitude for patient factors and preferences. Third, the guidelines endorse different age cut-offs for transcatheter vs. surgical aortic valve replacement, despite limited evidence. This review also discusses trends indicating a decreasing proportion of mechanical valve replacements. Finally, the review identifies gaps in the literature for areas including transcatheter aortic valve implantation in asymptomatic patients, the appropriateness of Ross procedures, concomitant coronary revascularization with aortic valve replacement, and bicuspid AS. To summarize, this state of the art review compares the latest European and American guidelines on the management of AS to highlight three areas of divergence: timing of intervention, valve selection, and surgical vs. transcatheter aortic valve replacement criteria.

This 2022 European Atherosclerosis Society lipoprotein(a) [Lp(a)] consensus statement updates evidence for the role of Lp(a) in atherosclerotic cardiovascular disease (ASCVD) and aortic valve stenosis, provides clinical guidance for testing and treating elevated Lp(a) levels, and considers its inclusion in global risk estimation. Epidemiologic and genetic studies involving hundreds of thousands of individuals strongly support a causal and continuous association between Lp(a) concentration and cardiovascular outcomes in different ethnicities; elevated Lp(a) is a risk factor even at very low levels of low-density lipoprotein cholesterol. High Lp(a) is associated with both microcalcification and macrocalcification of the aortic valve. Current findings do not support Lp(a) as a risk factor for venous thrombotic events and impaired fibrinolysis. Very low Lp(a) levels may associate with increased risk of diabetes mellitus meriting further study. Lp(a) has pro-inflammatory and pro-atherosclerotic properties, which may partly relate to the oxidized phospholipids carried by Lp(a). This panel recommends testing Lp(a) concentration at least once in adults; cascade testing has potential value in familial hypercholesterolaemia, or with family or personal history of (very) high Lp(a) or premature ASCVD. Without specific Lp(a)-lowering therapies, early intensive risk factor management is recommended, targeted according to global cardiovascular risk and Lp(a) level. Lipoprotein apheresis is an option for very high Lp(a) with progressive cardiovascular disease despite optimal management of risk factors. In conclusion, this statement reinforces evidence for Lp(a) as a causal risk factor for cardiovascular outcomes. Trials of specific Lp(a)-lowering treatments are critical to confirm clinical benefit for cardiovascular disease and aortic valve stenosis.

Aortic stenosis (AS) is the most common valvular heart disease in Europe and North America requiring a surgical or interventional treatment. Due to demographic changes with an aging population the burden of valvular heart diseases and especially the importance of aortic stenosis (AS) will be growing in future. As the onset of symptoms is associated with a decrease in life expectancy appropriate and early diagnosis are of utmost importance. However, insights of clinical practice underline diagnostic challenges which may lead to a delayed initiation of treatment with an adverse effect on the prognosis. The aim of this review is to display different diagnostic approaches that may be helpful in detecting patients with aortic valve stenosis. This review will focus on both non-invasive and invasive diagnostic approaches that can be implemented in clinical routine. Further-more, we will especially highlight recommendations of the 2021 European guidelines for the management of valvular heart disease.
UNASSIGNED: For this review a selective literature research on the databases PubMed and Google Scholar was conducted. Original articles, reviews and meta-analyses were included when meeting our search criteria. Following terms were used in different combinations: Aortic valve stenosis; Aortic stenosis; diagnosis of aortic stenosis; ESC Guidelines for the management of valvular heart disease.

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