[31] Baron SJ, Wang K,

House JA, Magnuson EA, Reynolds MR, Makkar R, Herrmann HC, Kodali S, Thourani VH, Kapadia S, Svensson L. Cost-effectiveness of transcatheter versus surgical aortic valve replacement in patients with severe aortic stenosis at intermediate risk: results from the PARTNER 2 trial. Circulation. 2019 Feb 12;139(7):877-88.

[32] El-Haddad H, Resar J. Stenting the Snorkel: PCI of a Restenosed Left Main Stent Placed for Coronary Obstruction after Valve in Valve TAVR. Journal of Structural Heart Disease. 2019 Apr;5(2):48-51.

[33] Voudris KV, Petropulos P, Karyofillis P, Charitakis K. Timing and Outcomes of PCI in the TAVR Era. Current treatment options in cardiovascular medicine. 2018 Mar 1;20(3):22.

[34] Faroux L, Campelo-Parada F, Munoz-Garcia E, Nombela-Franco L, Fischer Q, Donaint P, Serra V, Veiga G, Gutiérrez E, Vilalta V, Alperi A. Procedural Characteristics and Late Outcomes of Percutaneous Coronary Intervention in the Workup Pre-TAVR. JACC: Cardiovascular Interventions. 2020 Oct 14.

[35] Tarus A, Tinica G, Bacusca A, Artene B, Popa IV, Burlacu A. Coronary revascularization during treatment of severe aortic stenosis: A meta-analysis of the complete percutaneous approach (PCI plus TAVR) versus the complete surgical approach (CABG plus SAVR). Journal of Cardiac Surgery. 2020 Aug;35(8):2009-16.

**15**

*Introductory Chapter: The Evolution of Complex Valve Pathology - The Surgeon's Perspective*

*DOI: http://dx.doi.org/10.5772/intechopen.95049*

Baiocchi M, Lingala B, Patrick WL, Fischbein MP, Woo YJ. Mechanical or biologic prostheses for aortic-valve and mitral-valve replacement. New England Journal of Medicine. 2017 Nov

[37] Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Fleisher LA, Jneid H, Mack MJ, McLeod CJ, O'Gara PT, Rigolin VH. 2017 AHA/ ACC focused update of the 2014 AHA/ ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association

Task Force on Clinical Practice Guidelines. Journal of the American College of Cardiology. 2017 Jul

[38] James TM, Stamou SC, Rothenberg M, Nores MA.

Transcatheter aortic valve in valve implantation with bioprosthetic valve fracture. Catheterization and Cardiovascular Interventions. 2019 May

[39] Coylewright M, Forrest JK, McCabe JM, Nazif TM. TAVR in lowrisk patients: FDA approval, the new NCD, and shared decision-making. Journal of the American College of Cardiology. 2020 Mar 17;75(10):1208-11.

[36] Goldstone AB, Chiu P,

9;377(19):1847-57.

3;70(2):252-89.

1;93(6):1170-2.

*Introductory Chapter: The Evolution of Complex Valve Pathology - The Surgeon's Perspective DOI: http://dx.doi.org/10.5772/intechopen.95049*

[36] Goldstone AB, Chiu P, Baiocchi M, Lingala B, Patrick WL, Fischbein MP, Woo YJ. Mechanical or biologic prostheses for aortic-valve and mitral-valve replacement. New England Journal of Medicine. 2017 Nov 9;377(19):1847-57.

*Advances in Complex Valvular Disease*

[24] Alkhouli M, Alqahtani F, Harris AH, Hohmann SF, Rihal CS. Early Experience With Cerebral Embolic Protection During Transcatheter Aortic Valve Replacement in the United States. JAMA internal medicine. 2020 May

[25] Subramani S, Arora L, Krishnan S, Hanada S, Sharma A, Ramakrishna H. Analysis of Conduction Abnormalities and Permanent Pacemaker Implantation [30] Armoiry X, Obadia JF, Iung B, Polazzi S, Duclos A. Clinical outcomes and direct costs after transcatheter aortic valve implantation in French centres: a longitudinal study of 1332 patients using a national database. Interactive cardiovascular and thoracic surgery. 2016 Dec 1;23(6):883-8.

House JA, Magnuson EA, Reynolds MR, Makkar R, Herrmann HC, Kodali S, Thourani VH, Kapadia S, Svensson L. Cost-effectiveness of transcatheter versus surgical aortic valve replacement in patients with severe aortic stenosis at intermediate risk: results from the PARTNER 2 trial. Circulation. 2019 Feb

[32] El-Haddad H, Resar J. Stenting the Snorkel: PCI of a Restenosed Left Main Stent Placed for Coronary Obstruction after Valve in Valve TAVR. Journal of Structural Heart Disease. 2019

[31] Baron SJ, Wang K,

12;139(7):877-88.

Apr;5(2):48-51.

1;20(3):22.

2020 Oct 14.

Aug;35(8):2009-16.

[33] Voudris KV, Petropulos P, Karyofillis P, Charitakis K. Timing and Outcomes of PCI in the TAVR Era. Current treatment options in cardiovascular medicine. 2018 Mar

[34] Faroux L, Campelo-Parada F, Munoz-Garcia E, Nombela-Franco L,

[35] Tarus A, Tinica G, Bacusca A, Artene B, Popa IV, Burlacu A. Coronary revascularization during treatment of severe aortic stenosis: A meta-analysis of the complete percutaneous approach (PCI plus TAVR) versus the complete surgical approach (CABG plus SAVR). Journal of Cardiac Surgery. 2020

Veiga G, Gutiérrez E, Vilalta V, Alperi A. Procedural Characteristics and Late Outcomes of Percutaneous Coronary Intervention in the Workup Pre-TAVR. JACC: Cardiovascular Interventions.

Fischer Q, Donaint P, Serra V,

After Transcatheter Aortic Valve Replacement. Journal of Cardiothoracic and Vascular Anesthesia. 2020 Apr

[26] Fujita B, Schmidt T, Bleiziffer S, Bauer T, Beckmann A, Bekeredjian R, Möllmann H, Walther T, Landwehr S, Hamm C, Beyersdorf F. Impact of new pacemaker implantation following surgical and transcatheter aortic valve replacement on 1-year outcome. European Journal of Cardio-Thoracic Surgery. 2020 Jan 1;57(1):151-9.

[27] Mazzella AJ, Hendrickson MJ, Arora S, Sanders M, Li Q, Vavalle JP, Gehi AK. Shifting Trends in Timing of Pacemaker Implantation After Transcatheter Aortic Valve Replacement. Cardiovascular Interventions. 2020 Nov 9.

[28] Pollari F, Dell'Aquila AM, Söhn C, Marianowicz J, Wiehofsky P, Schwab J, Pauschinger M, Hitzl W, Fischlein T, Pfeiffer S. Risk factors for paravalvular leak after transcatheter aortic valve replacement. The Journal of thoracic and cardiovascular surgery. 2019 Apr

[29] Leon MB, Smith CR, Mack MJ, Makkar RR, Svensson LG, Kodali SK, Thourani VH, Tuzcu EM, Miller DC, Herrmann HC, Doshi D. Transcatheter or surgical aortic-valve replacement in intermediate-risk patients. New England Journal of Medicine. 2016 Apr

1;180(5):783-4.

1;34(4):1082-93.

**14**

1;157(4):1406-15.

28;374(17):1609-20.

[37] Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Fleisher LA, Jneid H, Mack MJ, McLeod CJ, O'Gara PT, Rigolin VH. 2017 AHA/ ACC focused update of the 2014 AHA/ ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Journal of the American College of Cardiology. 2017 Jul 3;70(2):252-89.

[38] James TM, Stamou SC, Rothenberg M, Nores MA. Transcatheter aortic valve in valve implantation with bioprosthetic valve fracture. Catheterization and Cardiovascular Interventions. 2019 May 1;93(6):1170-2.

[39] Coylewright M, Forrest JK, McCabe JM, Nazif TM. TAVR in lowrisk patients: FDA approval, the new NCD, and shared decision-making. Journal of the American College of Cardiology. 2020 Mar 17;75(10):1208-11.

**17**

**Chapter 2**

**Abstract**

high-risk patients.

**1. Introduction**

TAVI, aortic valve repair

older than 75 years [1].

North America [5–7].

aortic dilation causing aortic regurgitation [2].

disease (5-HT2B receptor agonists) are on the rise [8–10].

the Art

*Adam El Gamel*

Aortic Valve Disease: State of

Aortic valve replacement is the most commonly performed valve operation. It has been shown to be an effective therapy in all age groups, including the very elderly (age > 90 years). The most common etiologies for aortic stenosis are calcific degeneration, rheumatic disease, and congenital bicuspid valves. The most common causes of pure aortic regurgitation include annuloaortic ectasia and associated dilation of the aortic root, endocarditis, aortic dissection, and rheumatic disease. The indications for surgery depend on the pathophysiology and symptoms. The choice of the prosthesis can be difficult and depends on multiple clinical and lifestyle considerations. Early and late outcomes are generally quite good, even in

**Keywords:** aortic valve, aortic stenosis, aortic incompetence, valve replacement,

Valve disease still a significant health problem in the developed countries, In United states nearly 2.5% of the population has moderate or severe valve disease, with increased the prevalence for people older than 64 years and is 13% in those

The commonest valve diseases in the elderly are calcific aortic valve disease and

While rheumatic heart disease is the most prevalent pathology of valve disease globally, especially in the adolescent and young adults with a projected prevalence of 16–20 million, rheumatic fever is the most frequent trigger of valve disease in the young, particularly in Africa, India, the Middle East, South America, and parts of Australia and New Zealand, China, and Russia [3]. In western countries, the incidence of rheumatic disease declined in the latter half of the twentieth century, with the occurrence of transitory local episodes. In Africa, endomyocardial fibrosis is a common, poorly investigated pathology that leads to valve disease in all ages [4]. On the other hand, in the developed countries valve diseases of elderly predominate, particularly calcific aortic stenosis and functional mitral regurgitation, with a prevalence of 13% in those older than 75 years reported in

Other pathological conditions like infective endocarditis and drug-induced valve
