BACKGROUND:Valvular heart disease (VHD) is associated with substantial morbidity, mortality, and health care costs, yet its contemporary prevalence among older adults in the United States is unknown. OBJECTIVES:We performed a decentralized study of older adults (PREVUE-VALVE) to determine the population prevalence of VHD among older Americans. METHODS:Individuals 65-85 years old who previously filled a prescription at CVS or Walgreens pharmacies were randomly selected; contacted via e-mail, direct mail, or text messaging; and invited to participate. Enrolled participants completed study procedures in their homes, including a comprehensive transthoracic echocardiogram. The primary endpoint was the prevalence of moderate or greater (≥ moderate) VHD, weighted to reflect the U.S. POPULATION:The co-primary endpoint was the prevalence of clinically significant VHD, which also included mild-to-moderate regurgitant disease. RESULTS:The study sample (n = 3,000) was representative of older Americans (median age 71 years, 57.1% female, 14.6% non-Hispanic Black, 9.4% Hispanic). The weighted prevalence of ≥ moderate VHD was 8.2% (95% CI: 7.0%-9.5%), which increased to 18.4% (95% CI: 16.7%-20.2%) for clinically significant VHD. Tricuspid regurgitation was the most common lesion, followed by aortic stenosis, mitral regurgitation, aortic regurgitation, and mitral stenosis. Older age, but not sex, was associated with greater prevalence. In age- and sex-adjusted analyses, non-Hispanic Black individuals had a lower prevalence of any VHD compared with non-Hispanic White individuals (adjusted RR: 0.91; 95% CI: 0.83-0.99), driven predominantly by lower rates of aortic stenosis and regurgitation. There were no significant adjusted differences in VHD prevalence between Hispanic and non-Hispanic individuals. Extrapolation of these data to the U.S. population indicates that at least 4.7 million 65-85-year-olds currently have ≥ moderate VHD, and 10.6 million currently have clinically significant VHD-values that are projected to increase to 6.5 and 14.7 million, respectively, by 2060. CONCLUSIONS:In this national in-home echocardiography study, VHD was common among older adults, with important age-related and valve-specific patterns. PREVUE-VALVE establishes the feasibility of large-scale decentralized cardiovascular imaging studies and provides a contemporary foundation for clinical and policy planning related to the burden of VHD. (Age- and Sex-Specific Prevalence of Acquired Valvular Heart Disease (PREVUE-VALVE; NCT05357404).

Background Tricuspid annular plane systolic excursion (TAPSE) to pulmonary artery systolic pressure (PASP) is an established prognostic marker in tricuspid regurgitation (TR). Right ventricular free wall longitudinal strain (RVFWS)/PASP has been proposed as more sensitive prognostic markers than TAPSE/PASP in patients with TR, yet its role in patients undergoing transcatheter tricuspid valve repair (TTVr) remains unclear. The objective of the study was to evaluate and compare the prognostic value of RVFWS/PASP and TAPSE/PASP with two different vendors in symptomatic TTVr cohorts. Methods TTVr-treated patients across three centers (2017-2023) were included. RVFWS was assessed using two vendors (A = GE EchoPAC and B = Tomtec). The primary endpoint was a composite of all-cause mortality or the first heart failure hospitalization at 2-years. Prognostic performance was assessed using Cox regression, C-statistics, and Kaplan-Meier analysis. Results A total of 349 patients were included (137 vendor A and 212 vendor B). Patients in vendor B were older (83 vs. 80; p < 0.001), more symptomatic (New York Heart Association III/IV: 95.8 vs. 81.7%; p < 0.001), had lower 6-minute walk distance (218 vs. 282 m; p < 0.001), and greater right heart dilation, despite similar TR severity. RVFWS was higher in vendor B (23.0 vs. 18.0%, p < 0.001). RVFWS/PASP emerged as an independent predictor of the primary endpoint only in vendor A (hazard ratio per %/mmHg increase: 0.07, 95% CI: 0.01-0.46; p = 0.005), whereas TAPSE/PASP consistently showed independent prognostic association in both cohorts. Discrimination of both indices was not significantly different. Receiver operating characteristics-derived cutoffs identified patient subgroups with markedly different 2-year outcomes in both cohorts. Conclusions Both RVFWS/PASP and TAPSE/PASP provided modest prognostic value after TTVr, with TAPSE/PASP demonstrating consistent independent association across vendors.

Plastics serve multiple functions in an industrialized society, including major applications in all aspects of healthcare such as single use syringes, coatings and implantable devices. Plastics break down into smaller particles called microplastics (MP; diameter smaller than five millimeters) and nanoplastics (NP; diameter smaller than one micrometer), which are resistant to degradation. Recent evidence suggest that the smallest of these particles may accumulate in the human body throughout multiple organ systems. There has been particular interest on the effects of MP and NP accumulation in the cardiovascular system. In this review, we will discuss MP/NP formation, describe the clinical evidence supporting cardiovascular effects of these particles, with also a discussion on the possible molecular mechanisms behind these interactions. Finally, we will discuss the major knowledge gaps and current controversies involving MP and NP research as they relate to cardiovascular disease. Current evidence linking MP/NPs to cardiovascular disease remains largely correlative, with limited mechanistic validation.

Background Artificial intelligence (AI) diagnostic models are typically developed in hospital-based populations enriched for disease prevalence and severity, where distinctions between health and disease are pronounced. When deployed in community-dwelling populations with lower prevalence and milder phenotypes, these distinctions may become less well-defined, raising questions about transportability and the impact of disease spectrum on model performance. Objectives The purpose of this study was to evaluate how differences in disease spectrum influence the transportability of AI-based diagnostic models into community-dwelling populations, using artificial intelligence electrocardiogram analysis (AI-ECG) for structural heart disease (SHD) as a test case. Methods EchoNext is an AI-ECG model trained in a multicenter, hospital-based cohort to detect SHD. We evaluated its performance in PREVUE-VALVE (Age and Sex-Specific PREValence of AcqUirEd VALVular Heart DiseasE Study), a community-based study of individuals aged 65 to 85 years undergoing in-home ECG and transthoracic echocardiography. Performance was assessed using area under the receiver operating characteristic curve (AUC) and predictive value and compared with derivation and external hospital-based cohorts, using propensity matching to account for differences in disease prevalence and case mix. Subgroup analyses were performed in clinically relevant populations. Results Among 3,000 PREVUE-VALVE participants, 2,402 met criteria for analysis. Compared with hospital-based cohorts, PREVUE-VALVE had lower SHD prevalence (8% vs 43%), less severe disease, and a shift in phenotype, including more moderate tricuspid regurgitation and less systolic heart failure. Consistent with these differences, model discrimination was lower in PREVUE-VALVE than in the hospital-based cohort (AUC: 71% [95% CI: 66%-76%] vs 83% [95% CI: 82%-83%]). Propensity matching attenuated but did not eliminate this difference, while performance was similar across external hospital-based cohorts, supporting disease spectrum and clinical context as key drivers. Performance was modestly better in PREVUE-VALVE subgroups with higher SHD prevalence and greater disease severity, such as individuals with an abnormal ECG (AUC: 79% [95% CI: 75%-83%]) or impaired health status (AUC: 76% [95% CI: 70%-82%]). Conclusions In a community-dwelling population with lower disease prevalence and milder phenotypes, AI-ECG performance was attenuated relative to hospital-based cohorts, driven by differences in disease spectrum. These findings underscore the impact of both disease prevalence and case mix on AI performance and highlight the importance of model evaluation within intended use populations. (Age and Sex-Specific PREValence if AcqUirEd VALVular Heart DiseasE; NCT05357404)

BACKGROUND:Transcatheter aortic valve replacement (TAVR) results in early improvements in health status outcomes relative to surgical aortic valve replacement (SAVR) in low-surgical risk patients with symptomatic severe aortic stenosis. However, long-term data comparing the detailed health status outcomes of these 2 treatments are lacking. OBJECTIVE:The purpose of this study was to compare long-term health status outcomes between TAVR and SAVR in low-risk patients and explore heterogeneity of treatment effect. METHODS:The PARTNER 3 (Placement of Aortic Transcatheter Valves) trial randomized patients with severe aortic stenosis and low surgical risk 1:1 to TAVR with a balloon-expandable valve vs SAVR. Health status was evaluated with the Kansas City Cardiomyopathy Questionnaire (KCCQ) and Short Form-36 Heath Survey at baseline and 1 month, 6 months, and annually from years 1 to 7. Between treatment group differences in health status scores over time were examined with mixed effects models for repeated measures adjusted for baseline. RESULTS:The analytic cohort included 943 patients enrolled in the PARTNER 3 trial who had baseline KCCQ assessments and underwent their assigned procedure (494 TAVR, 449 SAVR; mean age: 73.5 ± 5.9 years; 69.2% men; mean Society of Thoracic Surgeons-Predicted Risk of Mortality: 1.9% ± 0.6%; mean KCCQ-overall summary [KCCQ-OS] score: 70.9 ± 20.5). TAVR and SAVR both resulted in significant improvements in KCCQ and Short Form-36 Heath Survey summary scores relative to baseline through 7-year follow-up. KCCQ-OS scores were substantially higher at 1 month after TAVR vs SAVR (mean treatment difference: +16.2 points; 95% CI: 14.3-18.1) and remained modestly higher through 2 years of follow-up (mean difference at 2 years: +1.9 points; 95% CI: 0.2-3.7), but there were no significant between-group differences in years 3-7. At 7 years, ∼60% of patients in both treatment groups had an excellent outcome (alive, KCCQ-OS ≥75; no KCCQ-OS decline ≥10 from baseline). CONCLUSIONS:Patients with severe aortic stenosis at low surgical risk had substantial improvement in patient-reported health status with either TAVR or SAVR that was sustained through 7 years. Patients had earlier recovery with TAVR, but health status outcomes after 2 years were similar between treatment groups. (PARTNER 3 Trial: Safety and Effectiveness of the SAPIEN 3 Transcatheter Heart Valve in Low Risk Patients With Aortic Stenosis; NCT02675114).

The first Tricuspid Valve Academic Research Consortium publication standardized definitions of disease etiology and severity, as well as standardized endpoints for trials to address the knowledge gaps related to identification and management of patients with tricuspid regurgitation. Based on randomized trials comparing transcatheter tricuspid valve intervention with optimal medical therapy, transcatheter edge-to-edge repair and tricuspid valve replacement were approved by the U.S. Food and Drug Administration and received CE Mark. These technologies represent a major step forward for patients with severe symptomatic tricuspid regurgitation and transcatheter tricuspid valve intervention. This second chapter of the Tricuspid Valve Academic Research Consortium focuses on defining specific trial design and endpoint options for comparisons of emerging technologies, tricuspid valve surgery, and medical therapy.

The presence of tricuspid regurgitation (TR) in patients with heart failure is associated with poor outcomes. Similarly, TR in patients with durable left ventricular assist device (LVAD) support is associated with increased morbidity and mortality. The role of tricuspid valve (TV) intervention to correct TR at the time of LVAD implantation remains uncertain because multiple studies thus far have shown conflicting results on clinical outcomes. This review discusses the mechanism of TR in LVAD recipients, the hemodynamic effects of TR after LVAD implantation, and the significance of corrected and uncorrected TR in the context of LVAD support. It also examines predictors of TR following LVAD implantation and highlights the discrepancies and gaps in the existing published reports. Finally, the review evaluates the potential role of novel transcatheter tricuspid therapies in these patients.

Background:The mortality rate of cardiogenic shock complicating acute myocardial infarction (AMI-CS) remains high and underscores an unmet clinical need for more effective therapeutic strategies in this space. Reducing myocardial O2 consumption (MVO2) improves myocardial O2 supply-demand balance, even in the presence of ongoing ischemia, and limits infarct size. Methods:Using a comprehensive cardiovascular simulation, we aimed to examine the impact of mechanical unloading with a percutaneous left ventricular assist device (pVAD) combined with heart rate and contractility reduction, also referred to as pharmacologic chronotropic and inotropic unloading (mechano-ino-chronotropic unloading [MIC]), on MVO2 and hemodynamic parameters in a model of AMI-CS. Results:We found that MIC unloading is more effective at reducing MVO2 than mechanical unloading alone, without adverse hemodynamic effects when adequate mechanical unloading is utilized. Furthermore, we show that the degree of mechanical unloading achieved by pVAD is enhanced at lower heart rates due to longer periods of outflow from the left ventricle during diastole; that is, pVAD and lower heart rate are synergistic with regards to unloading. Conclusions:Overall, these findings suggest that MIC unloading may be more effective than mechanical unloading in reducing infarct size in AMI-CS, potentially leading to greater short-term and long-term left ventricular recovery. Future clinical investigations of this therapeutic approach are encouraged.

We describe a series of 3 patients presenting with acute hemodynamic instability (AHI) after transcatheter tricuspid valve replacement (TTVR). The first case illustrates abrupt right ventricular-pulmonary artery uncoupling due to the marked increase in afterload that stereotypically occurs after acute reduction of tricuspid regurgitation. The second case illustrates AHI after myocardial ischemia triggered by TTVR in a patient with infiltrative cardiomyopathy. The third case highlights AHI as a consequence of marked vasoplegia precipitated by a robust, unregulated inflammatory response after TTVR. Although AHI after TTVR is infrequent, the condition is highly morbid, and prompt recognition of the underlying cause is essential to stabilize the patient and facilitate recovery. We also illustrate the potential for using a cardiac simulator to predict the hemodynamic consequences of TTVR. Development of novel predictive tools and familiarity with the clinical patterns of AHI after TTVR will become increasingly important as TTVR becomes more common.

Left ventricular (LV) longitudinal function is mechanically coupled to the elasticity of the ascending aorta (AA). The pathophysiologic link between a stiff AA and reduced longitudinal strain and the subsequent deterioration in longitudinal LV systolic function is likely relevant in heart failure with preserved ejection fraction (HFpEF). The proposed therapeutic effect of freeing the LV apex and allowing for LV inverse longitudinal shortening was studied in silico utilizing the Living Left Heart Human Model (Dassault Systémes Simulia Corporation). LV function was evaluated in a model with (A) an elastic AA, (B) a stiff AA, and (C) a stiff AA with a free LV apex. The cardiac model simulation demonstrated that freeing the apex caused inverse LV longitudinal shortening that could abolish the deleterious mechanical effect of a stiff AA on LV function. A stiff AA and impairment of the LV longitudinal strain are common in patients with HFpEF. The hypothesis-generating model strongly suggests that freeing the apex and inverse longitudinal shortening may improve LV function in HFpEF patients with a stiff AA.