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Challenges and opportunities in improving left ventricular remodelling and clinical outcome following surgical and trans-catheter aortic valve replacement |
Xu Yu Jin1,2(), Mario Petrou3,4, Jiang Ting Hu2, Ed D Nicol4,6, John R Pepper3,4,5 |
1. Surgical Echo-Cardiology Services, Oxford Heart Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 9DU, UK 2. Cardiac Surgical Physiology and Genomics Group, Nuffield Division of Clinical Laboratory Sciences, Radcliffe Department of Medicine, University of Oxford, Oxford OX3 9DU, UK 3. Department of Cardiac Surgery, Royal Brompton Hospital, London SW3 6NP, UK 4. National Heart and Lung Institute, Imperial College London, London SW3 6LY, UK 5. NIHR Imperial Biomedical Research Centre, London W2 1NY, UK 6. Department of Cardiology, Royal Brompton Hospital, London SW3 6NP, UK |
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Abstract Over the last half century, surgical aortic valve replacement (SAVR) has evolved to offer a durable and efficient valve haemodynamically, with low procedural complications that allows favourable remodelling of left ventricular (LV) structure and function. The latter has become more challenging among elderly patients, particularly following trans-catheter aortic valve implantation (TAVI). Precise understanding of myocardial adaptation to pressure and volume overloading and its responses to valve surgery requires comprehensive assessments from aortic valve energy loss, valvular-vascular impedance to myocardial activation, force-velocity relationship, and myocardial strain. LV hypertrophy and myocardial fibrosis remains as the structural and morphological focus in this endeavour. Early intervention in asymptomatic aortic stenosis or regurgitation along with individualised management of hypertension and atrial fibrillation is likely to improve patient outcome. Physiological pacing via the His-Purkinje system for conduction abnormalities, further reduction in para-valvular aortic regurgitation along with therapy of angiotensin receptor blockade will improve patient outcome by facilitating hypertrophy regression, LV coordinate contraction, and global vascular function. TAVI leaflet thromboses require anticoagulation while impaired access to coronary ostia risks future TAVI-in-TAVI or coronary interventions. Until comparable long-term durability and the resolution of TAVI related complications become available, SAVR remains the first choice for lower risk younger patients.
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Keywords
surgical aortic valve replacement
trans-catheter aortic valve implantation
left ventricular hypertrophy and fibrosis
myocardial force-velocity relationship
His-Purkinje pacing
renin-angiotensin system inhibitors
coronary access impairment
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Corresponding Author(s):
Xu Yu Jin
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Just Accepted Date: 12 April 2021
Online First Date: 28 May 2021
Issue Date: 18 June 2021
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