Background Differences in the impact of contrast medium on the development of contrast‐induced acute kidney injury (CI‐AKI) in patients undergoing transcatheter aortic valve implantation (TAVI) or a coronary angiography/percutaneous coronary intervention (CA/PCI) have not been previously investigated. Methods and Results Patients treated with TAVI or elective CA/PCI were retrospectively analyzed in terms of baseline and procedural characteristics, including preprocedural and postprocedural kidney function. CI‐AKI was defined as a relative increase in serum creatinine concentration of at least 0.3 mg/dL within 72 hours of contrast‐medium administration compared with baseline. The incidence of CI‐AKI in the TAVI versus CA/PCI group was compared. After the exclusion of patients in dialysis and emergency procedures, 977 patients were analyzed; there were 489 patients who had undergone TAVI (50.1%) and 488 patients who had undergone CA/PCI (49.9%). Patients treated by TAVI were older, presenting a higher rate of anemia and chronic kidney disease ( P <0.001 for all comparisons). Consistently, they also had a significantly lower glomerular filtration rate and higher serum creatinine concentration ( P <0.001 for all). However, the occurrence of CI‐AKI was significantly lower in these patients compared with patients treated by a CA/PCI (6.7% versus 14.5%, P <0.001). At multivariate analysis, the TAVI procedure had an independent protective effect on CI‐AKI incidence among total population (odds ratio, 0.334; 95% CI, 0.193–0.579; P <0.001). This observation was confirmed after propensity score matching among 360 patients (180 by TAVI and 180 by CA/PCI; P =0.002). Conclusions CI‐AKI occurred less frequently in patients undergoing TAVI than in patients undergoing a CA/PCI, despite a worse‐risk profile. The impact of contrast administration on kidney function in patients who had undergone TAVI may be better tolerated because of the hemodynamic changes following aortic valve replacement.

The need for multiple transducer positions, especially from right parasternal windows, is consistently mentioned in the recommendations for the accurate measurement of peak velocities across a stenotic aortic valve, but yet poorly adopted. We performed a subanalysis of the largest prospective series on the right parasternal acoustic windows in patients with aortic stenosis (330 consecutive) to calculate the degree of misalignment and estimate the potential outcome implication of this often-forgotten approach. The right parasternal view was highly feasible with an average estimated misalignment from the apical view of 14 ± 16 degree; in 10 cases, an estimated misalignment >40 degree. Right parasternal assessment (vs. apical alone) provided a significant reclassification from moderate to severe or even very-severe aortic valve stenosis. Considering a wellestablished survival benefit provided by either percutaneous or surgical valve replacement in patients with severe aortic stenosis the reclassification would result in approximately 1 life-year saved for every 30–35 patients in whom parasternal view were effectively utilized.

Aortic stenosis (AS) may present frequently combined with other valvular diseases or mixed with aortic regurgitation, with peculiar physio-pathological and clinical implications. The hemodynamic interactions between AS in mixed or combined valve disease depend on the specific combination of valve lesions and may result in diagnostic pitfalls at echocardiography; other imaging modalities may be helpful. Indeed, diagnosis is challenging because several echocardiographic methods commonly used to assess stenosis or regurgitation have been validated only in patients with the single-valve disease. Moreover, in the developed world, patients with multiple valve diseases tend to be older and more fragile over time; also, when more than one valvular lesion needs to address the surgical risk rises together with the long-term risk of morbidity and mortality associated with multiple valve prostheses, and the likelihood and risk of reoperation. Therefore, when AS presents mixed or combined valve disease, the heart valve team must integrate various parameters into the diagnosis and management strategy, including suitability for single or multiple transcatheter valve procedures. This review aims to summarize the most critical pathophysiological mechanisms underlying AS when associated with mitral regurgitation, mitral stenosis, aortic regurgitation, and tricuspid regurgitation. We will focus on echocardiography, clinical implications, and the most important treatment strategies.

The combination of aortic stenosis (AS) and mitral regurgitation (MR) is common in patients with degenerative valvular disease. It is characterized by having complex pathophysiology, leading to potential diagnostic pitfalls. Evidence is scarce in the literature to direct the diagnostic framework and treatment of patients with this particular combination of multiple valvular diseases. In this complex scenario, the appropriate use of advanced echocardiography and multimodality imaging methods plays a central role. Transcatheter mitral valve replacement or repair and transcatheter aortic valve replacement widen the surgical options for valve diseases. Therefore, there is an increasing need to reconsider the function, timing, and mode intervention for patients with a combination of AS with MR towards more personalized treatment.

No abstract