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Conventional aortic root and valve-sparing root replacement surgery are two current surgical treatments for aortic dilatation syndromes. This review article aims to review the current literature surrounding these two established techniques.This review article will address the current indications for valve-sparing root replacement surgery, technical considerations in surgical planning and a comparison of clinical outcomes between these two surgical techniques.Valve-sparing root replacement surgery is a safe and established treatment for aortic syndromes. Valve-sparing surgery procedure avoids the inherent risk of prosthetic valve dysfunction and prosthesis infection by preserving the native aortic valve compared to conventional aortic root surgery. This has been demonstrated in various observational studies and should be considered in clinically and anatomically appropriate patients. Other technical considerations, such as reimplantation versus remodelling technique and aortic cusp repair in select patients, may impact in short-term procedural and long-term clinical success with valve-sparing surgery.

Guidelines endorse a heart team (HT) approach to standardize the decision-making process for patients with complex coronary artery disease (CAD). With percutaneous treatment options for complex CAD increasing, we hypothesized that practice had changed over the past decade-and that more individuals, previously deemed too high risk for intervention, would now be referred for either surgical or percutaneous revascularization.This observational study was conducted at St Thomas' Hospital (London, United Kingdom). All patients discussed at HT meetings were recorded and treatment recommendations audited. A subset of historic cases was selected for blinded, repeat discussion.From April 2018 to 2019, a total of 52 HT meetings discussing 375 cases were held. Patients tended to be male, with a majority demonstrating multivessel CAD in the context of preserved left ventricular function. SYNTAX scores were balanced across the tertiles. Thirty-five percent of patients had at least 1 chronic total occlusion (mean J-CTO, 3 [interquartile range, 2-3]), affecting the right coronary artery in 60%. Fifteen historic patients with isolated CTOs were re-presented an average of 8 years later; only 3 patients received the same outcome, with 80% now receiving a recommendation for revascularization over medical therapy.A dedicated program supporting complex coronary intervention is associated with a change in treatment recommendations issued by the local HT. In line with international guidelines, this might indicate that any complex or multivessel CAD should be discussed at HT meetings with, ideally, the presence of CTO operators.

Subclinical leaflet thrombosis (LT) may occur following surgical and transcatheter aortic valve replacement. Computed tomography (CT) has become an established imaging modality to diagnose subclinical LT following bioprosthetic aortic valve replacement. Even so, there is a limited (but growing) experience in utilising CT imaging for this indication. This review emphasises a systematic approach to acquiring and analysing CT imaging for subclinical LT, highlighting evidence surrounding clinical sequelae of subclinical LT and anti-thrombotic implications following diagnosis.

AimsDurability of transcatheter aortic valve implantation (TAVI) is key to its expansion. We sought to identify incidence of valve thrombosis and predictors of valve thrombosis in our single centre with associated coagulation testing pre-TAVI and post-TAVI.Methods and resultsThis single-centre observational study comprised patients undergoing transfemoral TAVI discussed in the Heart Team meeting . Patients were followed up with echocardiography at 120 days to identify incidence of elevated transvalvular gradient and multivariable analysis was performed to identify factors associated with an increased odds of developing valve thrombosis. In addition, 11 patients underwent baseline, day 1 and day 120 post-TAVI coagulation testing. Between August 2017 and August 2019, 437 consecutive patients underwent transfemoral TAVI. Of these patients, 207/437 (47.4%) had 3-month follow-up echo data available and were analysed. Of these patients, 26/207 (12.6%) had elevated transvalvular gradients. These patients tended to be younger (80±14 vs 83±6 years; p=0.047) with a lower ejection fraction (49±13 vs 54%±11%; p=0.021), with a greater proportion of the population experiencing atrial fibrillation (14/21, 54% vs 68/181, 38%; p=0.067). Following multivariable analysis, there remained a trend towards higher eccentricity index associated with elevated gradients. Baseline (pre-TAVI) elevation of thrombin antithrombin levels (56±63; reference range 1.0–4.1 ng/L) and PF 1+2 (791±632; reference range 69–229 ng/mL) normalised at 120 days post-TAVIConclusionThis study demonstrated that in the cohort of patients undergoing transfemoral TAVI in our centre: younger age, poor ejection fraction, atrial fibrillation and increased baseline eccentricity of the aortic valve annulus were present to a greater extent in patients exhibiting elevated transvalvular gradients at 3-month follow-up. Further work is required to delineate the extent of coagulation derangement and confirm predictors of thrombosis.

Learning objectives Endocarditis is defined as inflammation of the endocardium, the lining of the cardiac chambers and valves, and characterised by vegetations, most commonly caused by infection with bacteria or fungi. Non-infective endocarditis, also known as non-bacterial thrombotic endocarditis (NBTE) or aseptic endocarditis, refers to a rare condition characterised by formation of sterile vegetations. Without treatment, these can lead to valve dysfunction, heart failure, systemic embolism and death. Herein, we review the pathophysiology, clinical features, diagnosis and treatment of NBTE. The first description of sterile vegetations on the heart valves was provided by Zeigler in 1888.1 Libman and Sacks then published a case series of four patients in 1924 which associated these atypical lesions with systemic lupus erythematosus (SLE).2 These vegetations are not associated with an inflammatory response or bacteraemia and commonly occur as a result of fibrin deposition and platelet aggregation. Sterile vegetations can develop in a number of conditions, including autoimmune disease, malignancy and hypercoagulable states. Although Libman–Sacks endocarditis refers specifically to NBTE seen in patients with the autoimmune disorders SLE and antiphospholipid syndrome (APLS), other interchangeable terminology for NBTE includes verrucous endocarditis and marantic endocarditis. A vegetation is defined as an oscillating intra-cardiac mass on a valve (or its supporting structure) or implanted material. The rapid evolution of echocardiographic imaging techniques has resulted in higher rates of vegetation detection in more recent studies using these developed imaging modalities.3 4 NBTE is a rare condition and most commonly diagnosed at post-mortem. The exact incidence is unknown but rates of up to 3.7% have …

A recent British Junior Cardiologists Association survey demonstrated gender disparity in procedure-based subspecialties within cardiology in the UK.1 Women form between 4.5% and 7.5% of the interventional cardiology (IC) workforce worldwide2 3 and even fewer in electrophysiology (EP): only 6% of female UK cardiology trainees choose EP.1 Interestingly, female trainees were more likely than males to change their preferred subspecialty during early training, away from intervention and EP, in favour of imaging, heart failure and adult congenital heart disease.4 Common elements identified in feedback from potential female cardiology trainees are the shortage of visible female role models and mentors, and concerns about work-life balance.4 5 In this article, four female cardiologists, who are leaders in their chosen procedure-based specialties, discuss their journeys and give advice to all trainees who may be considering an interventional subspecialty. They were each interviewed by trainees from their chosen subspecialty. Dr Rasha Al-Lamee is one of the few female academic interventional cardiologists (IC), and works at Imperial College, London. She completed most of her cardiology training in London, finishing with an interventional fellowship in Milan, Italy, and then a PhD at Imperial College. Rasha combines being a mother, with a fulltime interventional cardiology practice, in addition to a fulfilling academic career. Dr Shazia Hussain is an IC at Glenfield Hospital in Leicester. In addition to cardiology training at Papworth Hospital, she completed a PhD from King’s College London and was awarded the competitive British Cardiovascular Intervention Society Interventional Fellowship in Toronto. Dr Margaret McEntegart is an IC at the Golden Jubilee National Hospital in Glasgow and Honorary Associate Professor of Cardiology at the University of Glasgow. She completed much of her training in Scotland, finishing with an Interventional Fellowship at Columbia University Medical Centre, New York. Margaret is a globally …