Perspectives in Aortic Valve Disease: Clinical and Morphological Characteristics, Diagnosis and Treatments

Contents
Foreword
Preface
Chapter 1
Surgical Anatomy and Pathology of  Aortic Valve: Morphogenesis, Normal  and Pathological Anatomy
	Abstract
	Introduction
	Aortic Valve Morphogenesis
		Structural Components
	The Aortic Root
		Anatomical Landmarks and Uniform Terminology
		Definition of the Aortic Root
			The Sinotubular Junction
			The Valsalva Sinuses
			The Aortic Valve Structure (Semilunar Leaflets and Commissures)
			The Interleaflet Triangles
			The Ventriculo-Aortic Junction
		Functional Anatomy
		Aortic Stenosis
		Aortic Regurgitation
			Morphofunctional Classification of Aortic Regurgitation
	The Bicuspid Valve
		Morphology of BAV
		Genetics of BAV
		Aortic Stenosis in BAV
		Aortic Regurgitation in BAV
		Aortopathy and Aortic Dissection in BAV
	References
Chapter 2
Epidemiology and Clinical Approach
to Aortic Valve Disease
	Abstract
	Abbreviations
	Introduction
	Epidemiology and Etiologies
	Clinical Approach to Aortic Valve Disease
		Aortic Stenosis
			Symptoms
			Signs
			Diagnosis and Evaluation
			Clinical Features of Advanced AS
		Aortic Regurgitation
			Acute Aortic Regurgitation
				Symptoms and Signs
				Diagnosis and Evaluation
			Chronic Aortic Regurgitation
				Symptoms
				Signs
				Diagnosis and Evaluation
				Staging and Serial Monitoring
	Conclusion
	References
Chapter 3
Non-Invasive Imaging of Aortic  Valve – Ultrasounds: Trans-Thoracic,  Trans-Esophageal  and Stress Echocardiography
	Abstract
	Introduction
	Trans-Thoracic Echocardiography
		Anatomic Assessment of the Aortic Valve in Physiology and Pathology
		Doppler-Based Assessment of Aortic Stenosis
		Doppler-Based Assessment of Aortic Regurgitation
	Trans-Esophageal Echocardiography
		Aortic Stenosis
		Aortic Regurgitation
		Thoracic Aorta and Aortic Arch
		3D-Transesophageal Assessment
		TEE as a Key Tool before and after Percutaneous and Surgical Procedures
	Stress Echocardiography
		Stress Echocardiography in Aortic Stenosis
		Low-Flow Low-Gradient Aortic Stenosis
		Stress Echocardiography in Aortic Regurgitation
	Conclusion
	References
Chapter 4
Advanced Imaging and Functional Tools for Aortic Valve Assessment: Cardiovascular Magnetic Resonance and Cardiac Computed Tomography Angiography
	Abstract
	Aortic Valve Morphology
		Normal Anatomy
		Aortic Valve Variants
	Aortic Valve Stenosis
	Aortic Valve Regurgitation
	Combined Aortic Valve Disease
	Aortic Valve Masses And Pseudomasses
	Ventricular Remodelling and Dysfunction
	Myocardial Tissue Characterization
	Aortic Remodelling and Dilation
	Planning Surgical Interventions
	Planning Percutaneous Interventions
	Post-Procedural Imaging
		Aortic Valve Complications
		Aortic Complications
		Ventricular Remodelling
	Technical Limitations
	Conclusion
	References
Chapter 5
Degenerative Aortic Valve Disease
	Abstract
	Abbreviations
	Introduction
	Pathophysiology
		Degenerative Aortic Valve Disease and Atherosclerosis
		Calcification
		Genetic Factors
	Role of Imaging
	Pharmacological Strategies
		Lipid-Lowering Drugs
		Drugs Acting on the Renin-Angiotensin-Aldosterone System
		Modulators of Valve Calcification
		Other Pharmacological Strategies
	Interventional Therapies
		Tissue Engineering
	Conclusion
	References
Chapter 6
Aortic Valve Endocarditis:  Epidemiology, Treatment and Outcomes
	Abstract
	Introduction
	Classification
	Epidemiology
	Physiopathology
	Microbiology
	Symptoms
	Diagnosis
	Treatment
	Surgery
		Indication
		Techniques
		Results
	Prosthetic Valve Endocarditis
	Our Experience at the Lancisi Cardiovascular Center
	Conclusion
	References
Chapter 7
Neoplastic Disorders Involving  the Aortic Valve
	Abstract
	Abbreviations
	Introduction
	Benign Tumors of the Aortic Valve
		Papillary Fibroelastoma
			Clinical Features
			Imaging
			Macroscopic Features
			Microscopic Features
		Myxoma
			Clinical Features
			Imaging
			Macroscopic Features
			Microscopic Features
		Fibroma
			Clinical Features
			Imaging
			Macroscopic Features
			Microscopic Features
		Hemangioma
			Imaging
			Macroscopic Features
			Microscopic Features
		Inflammatory Myofibroblastic Tumor
	Primary Malignant Tumors of the Aortic Valve
		Sarcoma
		Non-Hodgkin Lymphoma
	Cardiac Metastases
	Non-Neoplastic Lesions (Pseudotumors)  of the Aortic Valve
		Endocarditis
		Rheumatoid Nodules
	Conclusion
	References
Chapter 8
Aortic Root Involvement in Congenital Heart Defects: Special Surgical Topics
	Abstract
	Truncus Arteriosus and Truncal Valve Regurgitation
		Introduction
			Anatomy and Classification
			Truncal Valve
		Methods
			Surgical Repair of Truncal Valve Regurgitation
		Discussion
			Outcomes of Truncal Valve Surgery and Current Perspestives
	Ventricular Septal Defect and Aortic  Valve Regurgitation
		Introduction
			Description
			Epidemiology
		Methods
			Etiology, Pathophysiology and Clinical Description
				Anatomical Factor
				Hemodynamic Factor
		Diagnosis
		Surgical Management
		Discussion
			Outcome and Perspectives
	Aortico-Left Ventricular Tunnel (ALVT)
		Introduction
			Description and Anatomical Considerations
			Etiology
			Pathophysiology and Clinical Description
			Diagnosis
		Methods
			Principles of Surgical Management
		The Two-Patch Technique
			Associated Anomalies
		Discussion
			Outcome and Current Perspectives
	References
Chapter 9
Adult Bicuspid Aortic Valve
	Abstract
	Introduction
	Phenotypes of Bicuspid Aortic Valve
		Embryogenesis and Hemodynamic Effects of Different Morphotypes
		Different Inherent Risks?
	Bicuspid Aortic Valve Stenosis
		BAV is a Relevant Cause of Aortic Valve Stenosis
		Invasive Treatment of BAV Stenosis
	Bicuspid Aortic Valve Regurgitation
		The Regurgitant BAV
		Principles of BAV Repair
	Endocarditis of the BAV
		Indications for Prophylaxis, Risks and Treatments
	BAV Aortopathy
		Pathogenetic Hypotheses
		Indications to Treatment: Wavering Guidelines
		The Risk of Aortic Dissection
	References
Chapter 10
Management of Aortic Valve Disease  in LVADs
	Abstract
	Introduction
	De Novo Aortic Regurgitation
		Hemodynamic Effect
	Treatment Strategies for De Novo Ai
	Assessment and Indication for Treatment of Aortic Regurgitation at the Time of LVAD Implantation
	Strategies for AV Repair at Time of LVAD Implantation
	Conclusion
	References
Chapter 11
Multidisciplinary Approach  to the Treatment of Aortic Valve  Disease: The Role of the Heart Team
	Abstract
	Introduction
	Developments in Aortic Valve Surgery
	Advantages of a Multidisciplinary Approach  in Aortic Valve Disease
	The Heart Team in Valvular Heart Disease
	Conclusion
	References
Chapter 12
Pharmacological Treatment of  Aortic Valve Disease
	Abstract
	Introduction
	Novel Pharmacological Targets for Calcific  Aortic Valve Disease
		Lipid-Lowering Approaches
			Failure of Statins
			Lipoprotein(a) Reduction
			PCSK9 Inhibition
		Aortic Valve Adverse Remodeling Therapeutic Targets
			Purinergic Receptor 2Y2 Activation
			Phosphate Inorganic Transporter 1 Inhibition
			Peroxisome Proliferator-Activated Receptor-Gamma Activation
			Dipeptidyl Peptidase 4 Inhibition
			5-Hydroxytryptamine Receptor 2B Inhibition
			Cadherin 11 Inhibition
			Cathepsin S Inhibition
		Multi-Omic Approach
		Conclusion
	Rational for Medical Treatment in Aortic  Aortic Regurgitation
		Vasodilators
			Acute AR
			Chronic AR
		Short-Term Effects of Vasodilators
		Long-Term Effects of Vasodilators
		Limitations
	↑-Adrenoceptor Antagonists
		Other Treatment in AR and Systemic Prevention of Endocarditis
	Evidence-Based Management of AR:  Place of Medical Therapy
	Future Prospects
	Conclusion
	References
Chapter 13
Surgical Treatment of Aortic Valve Disease: Indications, Risk Stratification  and Outcomes
	Abstract
	Introduction
	Indications
	Risk Stratification
	Outcomes
		Early or Peri-Operative Mortatlity
		Early Complications
			Neurologic Complications
			Heart Block and Permanent Pacemaker Implantation
		Long-Term Survival
		Late Complications
			Thromboembolism, Anticoagulation, and Bleeding Complications
			Prosthetic Valve Endocarditis
			Structural Valve Deterioration and Freedom from Reoperation
			Symptomatic Relief
		Left Ventricular Remodeling
		Prosthesis-Patient Mismatch
	References
Chapter 14
Surgical Approach: Conventional  and Minimally Invasive Treatments
	Abstract
	Introduction
	Conventional Treatment
		Cardiopulmonary Bypass and Myocardial Protection
		Exposure of the Aortic Valve
		Valve Excision, Debridement, and Sizing
		Valve Implantation
			Stented Prosthesis
			Homograft Prosthesis
			Stentless Prosthesis
			Sutureless and Rapid Deployment Prostheses
			Ross Procedure
		Aortotomy Closure and De-airing
	Minimally Invasive Treatment
		Principles and Advantages
		Preoperative Assessment and Preparation
		Anesthesia
			Ministernotomy: Surgical Technique
			Right Anterior Minitoracothomy: Surgical Technique
	Outcomes in Minimally Invasive Aortic Surgery
	References
Chapter 15
Totally Endoscopic Aortic Valve Replacement (EAVR)
	Abstract
	Introduction
	Minimally Invasive Concept
		MICS and Endoscopic MICS
	General Considerations
	Patient Selection and Preoperative
	Assessment for Eavr
	Operating Theatre Setup and Patient Positioning
	Surgical Access
	Cardiopulmonary Bypass
	Aortic Cross Clamping, Cardioplegia
	and Ventricular Venting
	Aortic Valve Access in Endoscopic Surgery
	Surgical Technique
		Aortotomy
		Aortic Valve Replacement (AVR)
		Aortorrhaphy
		Deairing
		Electrodes
		Drainages
	Conclusion
	References
Chapter 16
REDO Surgery for Aortic Valve: Demographics and Operative Options
	Abstract
	Introduction
	Surgical Approach
		Resternotomy
		Minimally Invasive Approach
		Valve in Valve for Failed Aortic Bioprosthesis
	Conclusion
	References
Chapter 17
Aortic Prosthesis: Mechanical  and Sutured Biological Valves
	Abstract
	Introduction
	Biological Models
	Hemodynamic Performance and Durability
	References
Chapter 18
New Generation of Aortic Bioprosthesis: Sutureless and Rapid Deployment Valves
	Abstract
	Introduction
	Methods
		Sutureless Perceval S Bioprosthesis
			Perceval Platform Technology
		Implantation Technique
		Sizing
		Role of Oversizing
		Results
	Rapid Deployment Intuity Elite Valve
		INTUITY Platform Technology
		Implantation Technique
		Sizing
		Results
	References
Chapter 19
Aortic Valve Repair
	Abstract
	Introduction
	Anatomy of the Aortic Valve
	Functional Classification of Aortic Regurgitation
	General Principles of AV Repair
	Aortic Valve Repair in Tricuspid AV
		Valve-Sparing Aortic Root Replacement with the Reimplantation Technique
		Cusp Prolapse Repair in Tricuspid AV
		Central Leaflet Plication and Triangular Resection
		Free Margin Resuspension
		Cusp Fenestration Repair
		Cusp Perforation
	Aortic Valve Repair in Bicuspid AV
		Anatomical Considerations
		Surgical Techniques for BAV Repair
			Cusp Repair in BAV
			Annuloplasty and Aorta Management
	Results of Aortic Valve Repair
		Outcomes of Valve-Sparing Root Replacement with the  Reimplantation Technique
		Outcomes of Isolated Aortic Valve Repair
	References
Chapter 20
Aortic Valve Sparing:  Remodeling and Reimplantation
	Abstract
	Introduction
	The Rational
		Surgical Anatomy and Physiology of the Aortic Root
		The Role of Imaging
		The History of Remodeling
		The History of Reimplantation
		The Similarity of the Two Procedures after All Modifications… from Remodeling to Reimplantation (the “Ring”)
		The Similarity of the Two Procedures after All Modifications…  from Reimplantation to Remodeling (the “Space”)
		Indications and Choice of the Strategy (Remodeling vs. Reimplantation)
		Additional Leaflets Repair (Further Scientific Contribution)
	Conclusion
	References
Chapter 21
Transcatheter Therapy:  Devices and Techniques
	Abstract
	Introduction
	TAVI Devices
		Valves Prostheses
			Sapien (Edwards Lifesciences, Irvine, CA, USA)
			Medtronic CoreValve (Medtronic Inc, MN, USA)
			Portico (St. Jude Medical, CA, USA)
			Acurate Neo (Boston Scientific Corporation, MA, USA)
			Lotus (Boston Scientific Corporation, MA, USA)
			Allegra (New Valve Technology, Switzerland)
			Myval (Meril Lifesciences, Pvt. Ltd., India)
	Techniques
		Transfemoral Approach
			Access Site Management
			Temporary Pacemaker Implantation
			Valve Implantation
	Alternative Approaches
		Subclavian/Transaxillary
		Transaortic
		Transcarotid
		Transapical
		Transcaval
	Additional Techniques in Complex Clinical Scenarios
		Low Coronaries: When and How to Protect Them
		TAVI in the Setting of Acutely Decompansated Aortic Stenosis
		The Role of Emergent BAV
		The Role of Emergent TAVI
	Conflict of Interest
	References
About the Editor
Index
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