51
|
Tanino T, Yufu K, Shuto T, Sato H, Takano M, Ishii Y, Kira S, Saito S, Kondo H, Fukui A, Fukuda T, Akioka H, Teshima Y, Wada T, Miyamoto S, Takahashi N. Proposal criteria of paradoxical low-flow low-gradient aortic stenosis for predicting prognosis in patients undergoing transcatheter aortic valve implantation. Heart Vessels 2021; 37:1044-1054. [PMID: 34822000 DOI: 10.1007/s00380-021-01992-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Accepted: 11/12/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Paradoxical low-flow, low-gradient (PLF-LG) aortic stenosis (AS) is associated with poor prognosis in patients undergoing transcatheter aortic valve implantation (TAVI). This study aimed to verify the conventional criteria of PLF-LG AS (left ventricular ejection fraction [LVEF] > 50%, mean aortic valve pressure gradient [AVPG] < 40 mm Hg and stroke volume index [SVI] < 35 ml/m2 by measuring Doppler method) compatible for predicting prognosis in patients undergoing TAVI. MATERIALS AND METHODS A total of 128 consecutive patients who underwent TAVI for AS with LVEF > 50% were enrolled. The primary endpoint was the hospital readmission due to heart failure (HRHF) and the secondary endpoint was all-cause mortality after hospital discharge. The patients were classified by both the conventional criteria of PLF-LG AS and the proposal criteria of PLF-LG AS if mean aortic valve pressure gradient (AVPG) < 40 mmHg and SVI by measuring Simpson's method < cut off value based on the ROC curve for predicting HRHF. RESULTS According to the conventional criteria, only 6 patients were diagnosed with PLF-LG AS. However, according to the proposal criteria, 16 patients were diagnosed with PLF-LG AS. Fourteen patients developed HRHF during the follow-up period after TAVI. Based on the ROC curves, SVI by measuring Simpson's method (cut off value = 25 ml/m2) had higher sensitivity and specificity for predicting HRHF (AUC = 0.74, p = 0.0013) than SVI by measuring Doppler method (AUC = 0.63, p = 0.045). The multivariate analysis revealed that PLF-LG AS defined by the proposal criteria (HR: 5.25; 95% CI: 1.60-17.16; p = 0.0073) but not by the conventional criteria was independently associated with HRHF. PLF-LG AS defined by the conventional criteria and the proposal criteria were not associated with all-cause mortality in the univariate analysis. CONCLUSIONS Our results demonstrated that new criteria of PLF-LG AS defined as SVI < 25 ml/m2 measured by Simpson's method could predict HRHF in patients with severe AS who underwent TAVI.
Collapse
Affiliation(s)
- Tomomi Tanino
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University, Yufu, Oita, 879-5593, Japan
| | - Kunio Yufu
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University, Yufu, Oita, 879-5593, Japan.
| | - Takashi Shuto
- Department of Cardiovascular Surgery, Faculty of Medicine, Oita University, Yufu, Japan
| | - Hiroki Sato
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University, Yufu, Oita, 879-5593, Japan
| | - Masayuki Takano
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University, Yufu, Oita, 879-5593, Japan
| | - Yumi Ishii
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University, Yufu, Oita, 879-5593, Japan
| | - Shintaro Kira
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University, Yufu, Oita, 879-5593, Japan
| | - Shotaro Saito
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University, Yufu, Oita, 879-5593, Japan
| | - Hidekazu Kondo
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University, Yufu, Oita, 879-5593, Japan
| | - Akira Fukui
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University, Yufu, Oita, 879-5593, Japan
| | - Tomoko Fukuda
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University, Yufu, Oita, 879-5593, Japan
| | - Hidefumi Akioka
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University, Yufu, Oita, 879-5593, Japan
| | - Yasushi Teshima
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University, Yufu, Oita, 879-5593, Japan
| | - Tomoyuki Wada
- Department of Cardiovascular Surgery, Faculty of Medicine, Oita University, Yufu, Japan
| | - Shinji Miyamoto
- Department of Cardiovascular Surgery, Faculty of Medicine, Oita University, Yufu, Japan
| | - Naohiko Takahashi
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University, Yufu, Oita, 879-5593, Japan
| |
Collapse
|
52
|
Abstract
Aortic stenosis (AS) is defined as severe in the presence of: mean gradient ≥40 mmHg, peak aortic velocity ≥4 m/s, and aortic valve area (AVA) ≤1 cm2 (or an indexed AVA ≤0.6 cm2/m2). However, up to 40% of patients have a discrepancy between gradient and AVA, i.e. AVA ≤1 cm2 (indicating severe AS) and a moderate gradient: >20 and <40 mmHg (typical of moderate stenosis). This condition is called ‘low-gradient AS’ and includes very heterogeneous clinical entities, with different pathophysiological mechanisms. The diagnostic tools needed to discriminate the different low-gradient AS phenotypes include colour-Doppler echocardiography, dobutamine stress echocardiography, computed tomography scan for the definition of the calcium score, and recently magnetic resonance imaging. The prognostic impact of low-gradient AS is heterogeneous. Classical low-flow low-gradient AS [reduced left ventricular ejection fraction (LVEF)] has the worst prognosis, followed by paradoxical low-flow low-gradient AS (preserved LVEF). Conversely, normal-flow low-gradient AS is associated with a better prognosis. The indications of the guidelines recommend surgical or percutaneous treatment, depending on the risk and comorbidities of the individual patient, both for patients with classic low-flow low-gradient AS and for those with paradoxical low-flow low-gradient AS.
Collapse
Affiliation(s)
- Vittoria Rizzello
- Dipartimento Cardiovascolare, Unità di Cardiologia d’Urgenza e UTIC, Azienda Ospedaliera San Giovanni Addolorata, Roma, Italy
- Corresponding author.
| |
Collapse
|
53
|
Should We Quantify Valvular Calcifications on Cardiac CT in Patients with Infective Endocarditis? J Clin Med 2021; 10:jcm10194458. [PMID: 34640477 PMCID: PMC8509527 DOI: 10.3390/jcm10194458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 09/21/2021] [Accepted: 09/27/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Evaluate the impact of valvular calcifications measured on cardiac computed tomography (CCT) in patients with infective endocarditis (IE). METHODS Seventy patients with native IE (36 aortic IE, 31 mitral IE, 3 bivalvular IE) were included and explored with CCT between January 2016 and April 2018. Mitral and aortic valvular calcium score (VCS) were measured on unenhanced calcium scoring images, and correlated with clinical, surgical data, and 1-year death rate. RESULTS VCS of patients with mitral IE and no peripheral embolism was higher than those with peripheral embolism (868 (25-1725) vs. 6 (0-95), p < 0.05). Patients with high calcified mitral IE (mitral VCS > 100; n = 15) had a lower rate of surgery (40.0% vs.78.9%; p = 0.03) and a higher 1-year-death risk (53.3% vs. 10.5%, p = 0.04; OR = 8.5 (2.75-16.40) than patients with low mitral VCS (n = 19). Patients with aortic IE and high aortic calcifications (aortic VCS > 100; n = 18) present more frequently atypical bacteria on blood cultures (33.3% vs. 4.8%; p = 0.03) than patients with low aortic VCS (n = 21). CONCLUSION The amount of valvular calcifications on CT was associated with embolism risk, rate of surgery and 1-year risk of death in patients with mitral IE, and germ's type in aortic IE raising the question of their systematic quantification in native IE.
Collapse
|
54
|
Onishi H, Izumo M, Mitomo S, Naganuma T, Nishikawa H, Suzuki T, Sato Y, Watanabe M, Kuwata S, Kamijima R, Akashi YJ, Nakamura S. Resting echocardiographic predictors for true-severe aortic stenosis in patients with low-gradient severe aortic stenosis: A dobutamine stress echocardiography study. Echocardiography 2021; 38:1731-1740. [PMID: 34555213 DOI: 10.1111/echo.15201] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 07/31/2021] [Accepted: 08/25/2021] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE Dobutamine stress echocardiography (DSE) is not always feasible in patients with low-gradient severe aortic stenosis (LG-SAS), and there are limited data available on the resting echocardiographic predictors for true-severe aortic stenosis (TSAS). This study investigated resting echocardiographic predictors for TSAS. METHODS Clinical data of 106 LG-SAS patients who underwent DSE were retrospectively analyzed. LG-SAS was defined as an aortic valve area index (AVAi) < .6 cm2 /m2 , and a mean AV pressure gradient < 40 mm Hg. The velocity ratio (VR) was calculated as the peak left ventricular outflow tract velocity/peak AV velocity. TSAS was defined as a projected AVAi < .6 cm2 /m2 . RESULTS The mean age was 79.3 ± 7.3 years, and 45 (42.5%) were men. The resting AV data were as follows: AVAi, .50 ± .07 cm2 /m2 ; mean AV pressure gradient, 23.0 ± 7.4 mm Hg; and VR, .25 ± .05. The projected AVAi was .58 ± .09 cm2 /m2 , and TSAS was documented in 65 (61.3%) patients. In multivariate analysis, the independent predictors of TSAS were AVAi (p = 0.012) and VR (p = 0.004) with respective best cut-off values of .52 cm2 /m2 and .25 on receiver-operating characteristic curve analysis. According to incremental numbers of the predictors, correct classification percentages of TSAS significantly increased with the Cochran-Armitage trend test (16.2% in no predictors, 65.2% in one predictor, and 95.7 % in two predictors; p < 0.001). CONCLUSIONS Resting AVAi and VR were independent predictors of TSAS in LG-SAS patients. The true severity might be predictable using the combination of resting parameters.
Collapse
Affiliation(s)
- Hirokazu Onishi
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, Kanagawa, Japan.,Department of Cardiology, New Tokyo Hospital, Chiba, Japan
| | - Masaki Izumo
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Satoru Mitomo
- Department of Cardiology, New Tokyo Hospital, Chiba, Japan
| | - Toru Naganuma
- Department of Cardiology, New Tokyo Hospital, Chiba, Japan.,Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Haruka Nishikawa
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Tomomi Suzuki
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Yukio Sato
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Mika Watanabe
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Shingo Kuwata
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Ryo Kamijima
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Yoshihiro J Akashi
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Sunao Nakamura
- Department of Cardiology, New Tokyo Hospital, Chiba, Japan
| |
Collapse
|
55
|
Reply: Calcium Score to Specify Assessment of Low-Flow Aortic Stenosis Severity. J Am Coll Cardiol 2021; 78:e73. [PMID: 34503690 DOI: 10.1016/j.jacc.2021.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 07/10/2021] [Indexed: 11/24/2022]
|
56
|
Galli E, Le Ven F, Coisne A, Sportouch C, Le Tourneau T, Bernard A, Bière L, Habib G, Lancellotti P, Lederlin M, Tribouilloy C, Oger E, Donal E. Rational and design of the ROTAS study: a randomized study for the optimal treatment of symptomatic patients with low-gradient severe aortic valve stenosis and preserved left ventricular ejection fraction. Eur Heart J Cardiovasc Imaging 2021; 22:229-235. [PMID: 32187352 DOI: 10.1093/ehjci/jeaa036] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Revised: 02/09/2020] [Accepted: 02/17/2020] [Indexed: 01/04/2023] Open
Abstract
AIMS Fifteen to thirty percentage of patients with severe aortic stenosis (AS) have preserved left ventricular ejection fraction (LVEF) and a discordant AS pattern at Doppler echocardiography, which is characterized by a small (<1 cm2) aortic area and low mean aortic gradient (<40 mmHg). The 'Randomized study for the Optimal Treatment of symptomatic patients with low-gradient severe Aortic Stenosis and preserved left ventricular ejection fraction' (ROTAS trial) aims at demonstrating the superiority of aortic valve replacement vs. a 'watchful waiting strategy' in symptomatic patients with low-gradient (LS), severe AS, and preserved LVEF, stratified according to indexed stroke volume, in terms of all-cause mortality or cardiovascular-related hospitalization during follow-up (FU). METHODS AND RESULTS The ROTAS trial will be a multicentre randomized non-blinded study involving 16 reference centres. AS severity will be confirmed by a multimodality approach (rest and stress echocardiography, calcium scoring, and cardiac magnetic resonance imaging for optimally characterize the population), which could provide important inputs to improve the pathophysiological understanding of this complex disease. Well-characterized patients will be randomized according to the management strategy. The primary endpoint will be the occurrence of all-cause mortality or cardiac related-hospitalizations during 2-year FU. One hundred and eighty subjects per group will be included. CONCLUSION The management of patients with LS severe AS and preserved LVEF is largely debated. ROTAS trial will allow a comprehensive evaluation of this particular pattern of AS and will establish which is the most appropriate management of these patients.
Collapse
Affiliation(s)
- Elena Galli
- University of Rennes, CHU Rennes, Inserm, LTSI - UMR 1099, F-35000 Rennes, France
| | - Florent Le Ven
- Service de cardiologie, hôpital Cavale Blanche, CHRU Brest, 29200 Brest, France
| | - Augustin Coisne
- Department of Clinical Physiology and Echocardiography, CHU Lille, Heart Valve Center, Univ. Lille, U1011 - EGID, Institut Pasteur de Lille, F-59000 Lille, France
| | | | - Thierry Le Tourneau
- Department of Cardiology, Thorax Institute, Centre Hospitalier Universitaire de Nantes, Site Hotel-Dieu-Hme 1, Place Alexis Ricordeau, Nantes, France
| | - Anne Bernard
- Cardiology Department, Trousseau Hospital, University of Tours, Tours, France
| | - Loic Bière
- Institut MITOVASC, UMR INSERM U1083 and CNRS 6015, Service de Cardiologie, CHU Angers, Université Angers, Angers, France
| | - Gilbert Habib
- Aix Marseille Université, IRD, APHM, MEPHI, IHU-Méditerranée Infection, France
| | - Patrizio Lancellotti
- Department of Cardiology, Heart Valve Clinic, University of Liège Hospital, GIGA Cardiovascular Sciences, CHU Sart Tilman, Belgium
| | | | - Christophe Tribouilloy
- Department of Cardiology, Amiens University Hospital, 1 Rue du Professeur Christian Cabrol, Amiens, France
| | - Emmanuel Oger
- Pharmacologie Clinique et CIC-IP 1414, CHU Rennes et Université Rennes-1, Rennes, France
| | - Erwan Donal
- University of Rennes, CHU Rennes, Inserm, LTSI - UMR 1099, F-35000 Rennes, France
| |
Collapse
|
57
|
Hohri Y, Itatani K, Matsuo A, Komori Y, Okamoto T, Goto T, Kobayashi T, Hiramatsu T, Miyazaki S, Nishino T, Yaku H. Estimating the Haemodynamic Streamline Vena Contracta as the Effective Orifice Area Measured from Reconstructed Multislice Phase-contrast MR Images for Patients with Moderately Accelerated Aortic Stenosis. Magn Reson Med Sci 2021; 21:569-582. [PMID: 34334586 DOI: 10.2463/mrms.mp.2021-0001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE In aortic stenosis (AS), the discrepancy between moderately accelerated flow and effective orifice area (EOA) continues to pose a challenge. We developed a method of measuring the vena contracta area as hemodynamic EOA using cardiac MRI focusing on AS patients with a moderately accelerated flow to solve the problem that AS severity can currently be determined only by echocardiography. METHODS We investigated 40 patients with a peak transvalvular velocity > 3.0 m/s on transthoracic echocardiography (TTE). The patients were divided into highly accelerated and moderately accelerated AS groups according to whether or not the peak transvalvular velocity was ≥ 4.0 m/s. From the multislice 2D cine phase-contrast MRI data, the cross-sectional area of the vena contracta of the reconstructed streamline in the Valsalva sinus was defined as MRI-EOAs. Patient symptoms and echocardiography data, including EOA (defined as TTE-EOA), were derived from the continuity equation using TTE. RESULTS All participants in the highly accelerated AS group (n = 19) showed a peak velocity ≥ 4.0 m/s in MRI. Eleven patients in the moderately accelerated AS group (n = 21) had a TTE-EOA < 1.00 cm2. In the moderately accelerated AS group, MRI-EOAs demonstrated a strong correlation with TTE-EOAs (r = 0.76, P < 0.01). Meanwhile, in the highly accelerated AS group, MRI-EOAs demonstrated positivity but a moderate correlation with TTE-EOAs (r = 0.63, P = 0.004). MRI-EOAs were overestimated compared to TTE-EOAs. In terms of the moderately accelerated AS group, the best cut-off value for MRI-EOAs was < 1.23 cm2, compatible with TTE-EOAs < 1.00 cm2, with an excellent prediction of the New York Heart Association classification ≥ III (sensitivity 87.5%, specificity 76.9%). CONCLUSION MRI-EOAs may be an alternative to conventional echocardiography for patients with moderately accelerated AS, especially those with discordant echocardiographic parameters.
Collapse
Affiliation(s)
- Yu Hohri
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine
| | | | - Akiko Matsuo
- Department of Cardiology, Japanese Red Cross Kyoto Daini Hospital
| | | | - Takeshi Okamoto
- Department of Radiology, Japanese Red Cross Kyoto Daini Hospital
| | - Tomoyuki Goto
- Department of Cardiovascular Surgery, Japanese Red Cross Kyoto Daini Hospital
| | - Takuma Kobayashi
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine
| | - Takeshi Hiramatsu
- Department of Cardiovascular Surgery, Tokyo Women's Medical University Yachiyo Medical Center
| | | | | | - Hitoshi Yaku
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine
| |
Collapse
|
58
|
Okuno T, Corpataux N, Spano G, Gräni C, Heg D, Brugger N, Lanz J, Praz F, Stortecky S, Siontis GCM, Windecker S, Pilgrim T. True-severe stenosis in paradoxical low-flow low-gradient aortic stenosis: outcomes after transcatheter aortic valve replacement. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2021; 7:366-377. [PMID: 33576388 DOI: 10.1093/ehjqcco/qcab010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 01/27/2021] [Accepted: 02/02/2021] [Indexed: 06/12/2023]
Abstract
AIMS The ESC/EACTS guidelines propose criteria that determine the likelihood of true-severe aortic stenosis (AS). We aimed to investigate the impact of the guideline-based criteria of the likelihood of true-severe AS in patients with low-flow low-gradient (LFLG) AS with preserved ejection fraction (pEF) on outcomes following transcatheter aortic valve replacement (TAVR). METHODS AND RESULTS In a prospective TAVR registry, LFLG-AS patients with pEF were retrospectively categorized into high (criteria ≥6) and intermediate (criteria <6) likelihood of true-severe AS. Haemodynamic, functional, and clinical outcomes were compared with high-gradient AS patients with pEF. Among 632 eligible patients, 202 fulfilled diagnostic criteria for LFLG-AS. Significant haemodynamic improvement after TAVR was observed in LFLG-AS patients, irrespective of the likelihood. Although >70% of LFLG-AS patients had functional improvement, impaired functional status [New York Heart Association (NYHA III/IV)] persisted more frequently at 1 year in LFLG-AS than in high-gradient AS patients (7.8%), irrespective of the likelihood (high: 17.4%, P = 0.006; intermediate: 21.1%, P < 0.001). All-cause death at 1 year occurred in 6.6% of high-gradient AS patients, 10.9% of LFLG-AS patients with high likelihood [hazard ratio (HR)adj 1.43, 95% confidence interval (CI) 0.68-3.02], and in 7.2% of those with intermediate likelihood (HRadj 0.92, 95% CI 0.39-2.18). Among the criteria, only the absence of aortic valve area ≤0.8 cm2 emerged as an independent predictor of treatment futility, a combined endpoint of all-cause death or NYHA III/IV at 1 year (OR 2.70, 95% CI 1.14-6.25). CONCLUSION Patients with LFLG-AS with pEF had comparable survival but worse functional status at 1 year than high-gradient AS with pEF, irrespective of the likelihood of true-severe AS. CLINICAL TRIAL REGISTRATION https://www.clinicaltrials.gov. NCT01368250.
Collapse
Affiliation(s)
- Taishi Okuno
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, CH-3010 Bern, Switzerland
| | - Noé Corpataux
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, CH-3010 Bern, Switzerland
| | - Giancarlo Spano
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, CH-3010 Bern, Switzerland
| | - Christoph Gräni
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, CH-3010 Bern, Switzerland
| | - Dik Heg
- CTU, University of Bern, Bern, Switzerland
| | - Nicolas Brugger
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, CH-3010 Bern, Switzerland
| | - Jonas Lanz
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, CH-3010 Bern, Switzerland
| | - Fabien Praz
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, CH-3010 Bern, Switzerland
| | - Stefan Stortecky
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, CH-3010 Bern, Switzerland
| | - George C M Siontis
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, CH-3010 Bern, Switzerland
| | - Stephan Windecker
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, CH-3010 Bern, Switzerland
| | - Thomas Pilgrim
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, CH-3010 Bern, Switzerland
| |
Collapse
|
59
|
Guzzetti E, Oh JK, Shen M, Dweck MR, Poh KK, Abbas AE, Mando R, Pressman GS, Brito D, Tastet L, Pawade T, Falconi ML, de Arenaza DP, Kong W, Tay E, Pibarot P, Song JK, Clavel MA. Validation of aortic valve calcium quantification thresholds measured by computed tomography in Asian patients with calcific aortic stenosis. Eur Heart J Cardiovasc Imaging 2021; 23:717-726. [PMID: 34172988 DOI: 10.1093/ehjci/jeab116] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Accepted: 05/20/2021] [Indexed: 11/14/2022] Open
Abstract
AIMS Sex-specific thresholds of aortic valve calcification (AVC) have been proposed and validated in Caucasians. Thus, we aimed to validate their accuracy in Asians. METHODS AND RESULTS Patients with calcific aortic stenosis (AS) from seven international centres were included. Exclusion criteria were ≥moderate aortic/mitral regurgitation and bicuspid valve. Optimal AVC and AVC-density sex-specific thresholds for severe AS were obtained in concordant grading and normal flow patients (CG/NF). We included 1263 patients [728 (57%) Asians, 573 (45%) women, 837 (66%) with CG/NF]. Mean gradient was 48 (26-64) mmHg and peak aortic velocity 4.5 (3.4-5.1) m/s. Optimal AVC thresholds were: 2145 Agatston Units (AU) in men and 1301 AU in women for Asians; and 1885 AU in men and 1129 AU in women for Caucasians. Overall, accuracy (% correctly classified) was high and comparable either using optimal or guidelines' thresholds (2000 AU in men, 1200 AU in women). However, accuracy was lower in Asian women vs. Caucasian women (76-78% vs. 94-95%; P < 0.001). Accuracy of AVC-density (476 AU/cm2 in men and 292 AU/cm2 in women) was comparable to absolute AVC in Caucasians (91% vs. 91%, respectively, P = 0.74), but higher than absolute AVC in Asians (87% vs. 81%, P < 0.001). There was no interaction between AVC/AVC-density and ethnicity (all P > 0.41) with regards to AS haemodynamic severity. CONCLUSION AVC thresholds defining severe AS are comparable in Asian and Caucasian populations, and similar to those proposed in the guidelines. However, accuracy of AVC to identify severe AS in Asians (especially women) is sub-optimal. Therefore, the use of AVC-density is preferable in Asians.
Collapse
Affiliation(s)
- Ezequiel Guzzetti
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Quebec Heart & Lung Institute, Laval University, 2725 Chemin Sainte-Foy, Quebec City, Quebec G1V-4G5, Canada
| | - Jin Kyung Oh
- Division of Cardiology, Department of Internal Medicine, Chungnam National University Sejong Hospital, Chungnam National University College of Medicine, Sejong 30099, Korea
| | - Mylène Shen
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Quebec Heart & Lung Institute, Laval University, 2725 Chemin Sainte-Foy, Quebec City, Quebec G1V-4G5, Canada
| | - Marc R Dweck
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Kian Keong Poh
- Department of Cardiology, National University Heart Centre, National University Health System, Singapore 119074, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
| | - Amr E Abbas
- Department of Cardiovascular Medicine, Beaumont Hospital Royal Oak, Royal Oak, MI 48073, USA
| | - Ramy Mando
- Department of Cardiovascular Medicine, Beaumont Hospital Royal Oak, Royal Oak, MI 48073, USA
| | - Gregg S Pressman
- Division of Cardiology, Einstein Medical Center, Philadelphia, PA 19141, USA
| | - Daniel Brito
- Division of Cardiology, Einstein Medical Center, Philadelphia, PA 19141, USA
| | - Lionel Tastet
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Quebec Heart & Lung Institute, Laval University, 2725 Chemin Sainte-Foy, Quebec City, Quebec G1V-4G5, Canada
| | - Tania Pawade
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Mariano Luis Falconi
- Department of Cardiology, Hospital Italiano de Buenos Aires, Buenos Aires C1199, Argentina
| | - Diego Perez de Arenaza
- Department of Cardiology, Hospital Italiano de Buenos Aires, Buenos Aires C1199, Argentina
| | - William Kong
- Department of Cardiology, National University Heart Centre, National University Health System, Singapore 119074, Singapore
| | - Edgar Tay
- Department of Cardiology, National University Heart Centre, National University Health System, Singapore 119074, Singapore
| | - Philippe Pibarot
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Quebec Heart & Lung Institute, Laval University, 2725 Chemin Sainte-Foy, Quebec City, Quebec G1V-4G5, Canada
| | - Jae-Kwan Song
- Valvular Heart Disease Center, Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Seoul 138736, Korea
| | - Marie-Annick Clavel
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Quebec Heart & Lung Institute, Laval University, 2725 Chemin Sainte-Foy, Quebec City, Quebec G1V-4G5, Canada
| |
Collapse
|
60
|
Saito Y, Lewis EE, Raval A, Gimelli G, Jacobson K, Osaki S. Prognosis of paradoxical low-flow low-gradient aortic stenosis after transcatheter aortic valve replacement. J Cardiovasc Med (Hagerstown) 2021; 22:486-491. [PMID: 33229861 DOI: 10.2459/jcm.0000000000001139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS In paradoxical low-flow low-gradient severe aortic stenosis (PLFLG AS) patients, stroke volume index (SVI) is reduced despite preserved left ventricular ejection fraction (LVEF). Although reduced SVI is already known as a poor prognostic predictor, the outcomes of PLFLG AS patients after transcatheter aortic valve replacement (TAVR) have not been clearly defined. We retrospectively investigated the post-TAVR outcomes of PLFLG AS patients in comparison with normal-flow high-gradient aortic stenosis (NFHG AS) patients. METHODS The current observational study included 245 patients with NFHG AS (mean transaortic pressure gradient ≥40 mmHg and LVEF ≥ 50%) and 48 patients with PLFLG AS (mean transaortic pressure gradient <40 mmHg, LVEF ≥ 50% and SVI < 35 ml/m2). The endpoints were all-cause mortality, hospitalization for valve-related symptoms or worsening congestive heart failure and New York Heart Association functional class III or IV. RESULTS PLFLG AS patients had a significantly higher proportion with a history of atrial fibrillation/flutter as compared with NFHG AS patients. All-cause mortality of PLFLG AS patients was worse than that of NFHG AS patients (P = 0.047). Hospitalization for valve-related symptoms or worsening congestive heart failure was more frequent in PLFLG AS patients than in NFHG AS patients (P = 0.041). New York Heart Association functional class III-IV after TAVR was more frequently observed in PLFLG AS patients (P = 0.019). CONCLUSION The outcomes of PLFLG AS patients were worse than those of NFHG AS patients in this study. Preexisting atrial fibrillation/flutter was frequent in PLFLG AS patients, and may affect their post-TAVR outcomes. Therefore, closer post-TAVR follow-up should be considered for these patients.
Collapse
Affiliation(s)
| | - Erik E Lewis
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | | | | | | | - Satoru Osaki
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| |
Collapse
|
61
|
Jean G, Van Mieghem NM, Gegenava T, van Gils L, Bernard J, Geleijnse ML, Vollema EM, El Azzouzi I, Spitzer E, Delgado V, Bax JJ, Pibarot P, Clavel MA. Moderate Aortic Stenosis in Patients With Heart Failure and Reduced Ejection Fraction. J Am Coll Cardiol 2021; 77:2796-2803. [PMID: 34082909 DOI: 10.1016/j.jacc.2021.04.014] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 04/02/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND The study investigators previously reported that moderate aortic stenosis (AS) is associated with a poor prognosis in patients with heart failure (HF) with reduced left ventricular ejection fraction (LVEF) (HFrEF). However, the respective contribution of moderate AS versus HFrEF to the outcomes of these patients is unknown. OBJECTIVES This study sought to determine the impact of moderate AS on outcomes in patients with HFrEF. METHODS The study included 262 patients with moderate AS (aortic valve area >1.0 and <1.5 cm2; and peak aortic jet velocity >2 and <4 m/s, at rest or after dobutamine stress echocardiography) and HFrEF (LVEF <50%). These patients were matched 1:1 for sex, age, estimated glomerular filtration rate, New York Heart Association functional class III to IV, presence of diabetes, LVEF, and body mass index with patients with HFrEF but no AS (i.e., peak aortic jet velocity <2 m/s). The endpoints were all-cause mortality and the composite of death and HF hospitalization. RESULTS A total of 262 patients with HFrEF and moderate AS were matched with 262 patients with HFrEF and no AS. Mean follow-up was 2.9 ± 2.2 years. In the moderate AS group, mean aortic valve area was 1.2 ± 0.2 cm2, and mean gradient was 14.5 ± 4.7 mm Hg. Moderate AS was associated with an increased risk of mortality (hazard ratio [HR]: 2.98; 95% confidence interval [CI]: 2.08 to 4.31; p < 0.0001) and of the composite of HF hospitalization and mortality (HR: 2.34; 95% CI: 1. 72 to 3.21; p < 0.0001). In the moderate AS group, aortic valve replacement (AVR) performed in 44 patients at a median follow-up time of 10.9 ± 16 months during follow-up was associated with improved survival (HR: 0.59; 95% CI: 0.35 to 0.98; p = 0.04). Notably, surgical AVR was not significantly associated with improved survival (p = 0.92), whereas transcatheter AVR was (HR: 0.43; 95% CI: 0.18 to 1.00; p = 0.05). CONCLUSIONS In this series of patients with HFrEF, moderate AS was associated with a marked incremental risk of mortality. AVR, and especially transcatheter AVR during follow-up, was associated with improved survival in patients with HFrEF and moderate AS. These findings provide support to the realization of a randomized trial to assess the effect of early transcatheter AVR in patients with HFrEF and moderate AS.
Collapse
Affiliation(s)
- Guillaume Jean
- Institut universitaire de cardiologie et de pneumologie, Université Laval, Québec, Québec, Canada
| | - Nicolas M Van Mieghem
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Tea Gegenava
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Lennart van Gils
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Jeremy Bernard
- Institut universitaire de cardiologie et de pneumologie, Université Laval, Québec, Québec, Canada
| | - Marcel L Geleijnse
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - E Mara Vollema
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Ikram El Azzouzi
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Ernest Spitzer
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Victoria Delgado
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Philippe Pibarot
- Institut universitaire de cardiologie et de pneumologie, Université Laval, Québec, Québec, Canada
| | - Marie-Annick Clavel
- Institut universitaire de cardiologie et de pneumologie, Université Laval, Québec, Québec, Canada.
| |
Collapse
|
62
|
Guía ESC 2020 sobre cardiología del deporte y el ejercicio en pacientes con enfermedad cardiovascular. Rev Esp Cardiol 2021. [DOI: 10.1016/j.recesp.2020.11.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
|
63
|
Pelliccia A, Sharma S, Gati S, Bäck M, Börjesson M, Caselli S, Collet JP, Corrado D, Drezner JA, Halle M, Hansen D, Heidbuchel H, Myers J, Niebauer J, Papadakis M, Piepoli MF, Prescott E, Roos-Hesselink JW, Graham Stuart A, Taylor RS, Thompson PD, Tiberi M, Vanhees L, Wilhelm M. 2020 ESC Guidelines on sports cardiology and exercise in patients with cardiovascular disease. Eur Heart J 2021; 42:17-96. [PMID: 32860412 DOI: 10.1093/eurheartj/ehaa605] [Citation(s) in RCA: 714] [Impact Index Per Article: 238.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
|
64
|
Shroff GR, Bangalore S, Bhave NM, Chang TI, Garcia S, Mathew RO, Rangaswami J, Ternacle J, Thourani VH, Pibarot P. Evaluation and Management of Aortic Stenosis in Chronic Kidney Disease: A Scientific Statement From the American Heart Association. Circulation 2021; 143:e1088-e1114. [PMID: 33980041 DOI: 10.1161/cir.0000000000000979] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aortic stenosis with concomitant chronic kidney disease (CKD) represents a clinical challenge. Aortic stenosis is more prevalent and progresses more rapidly and unpredictably in CKD, and the presence of CKD is associated with worse short-term and long-term outcomes after aortic valve replacement. Because patients with advanced CKD and end-stage kidney disease have been excluded from randomized trials, clinicians need to make complex management decisions in this population that are based on retrospective and observational evidence. This statement summarizes the epidemiological and pathophysiological characteristics of aortic stenosis in the context of CKD, evaluates the nuances and prognostic information provided by noninvasive cardiovascular imaging with echocardiography and advanced imaging techniques, and outlines the special risks in this population. Furthermore, this statement provides a critical review of the existing literature pertaining to clinical outcomes of surgical versus transcatheter aortic valve replacement in this high-risk population to help guide clinical decision making in the choice of aortic valve replacement and specific prosthesis. Finally, this statement provides an approach to the perioperative management of these patients, with special attention to a multidisciplinary heart-kidney collaborative team-based approach.
Collapse
|
65
|
Impact of Surgical and Transcatheter Aortic Valve Replacement in Low-Gradient Aortic Stenosis: A Meta-Analysis. JACC Cardiovasc Interv 2021; 14:1481-1492. [PMID: 33939605 DOI: 10.1016/j.jcin.2021.04.038] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 04/21/2021] [Accepted: 04/27/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVES The aim of this study was to assess the impact of aortic valve replacement (AVR) on survival in patients with each subclass of low-gradient (LG) aortic stenosis (AS) and to compare outcomes following surgical AVR (SAVR) and transcatheter AVR (TAVR). BACKGROUND LG severe AS encompasses a wide variety of pathophysiology, including classical low-flow, LG (LF-LG), paradoxical LF-LG, and normal-flow, LG (NF-LG) AS, and uncertainty exists regarding the impact of AVR on each subclass of LG AS. METHODS PubMed and Embase were queried through October 2020 to identify studies comparing survival with different management strategies (SAVR, TAVR, and conservative) in patients with LG AS. Pairwise meta-analysis comparing AVR versus conservative management and network meta-analysis comparing SAVR versus TAVR versus conservative management were performed. RESULTS Thirty-two studies with a total of 6,515 patients and a median follow-up time of 24.2 months (interquartile range: 36.5 months) were included. AVR was associated with a significant decrease in all-cause mortality in classical LF-LG (hazard ratio [HR]: 0.42; 95% confidence interval [CI]: 0.36 to 0.48), paradoxical LF-LG (HR: 0.41; 95% CI: 0.29 to 0.57), and NF-LG (HR: 0.41; 95% CI: 0.27 to 0.62) AS compared with conservative management. SAVR and TAVR were each associated with a decrease in all-cause mortality in classical LF-LG (HR: 0.46 [95% CI: 0.38 to 0.55] and 0.49 [95% CI: 0.37 to 0.64], respectively), paradoxical LF-LG (HR: 0.42 [95% CI: 0.28 to 0.65] and 0.42 [95% CI: 0.25 to 0.72], respectively), and NF-LG (HR: 0.40 [95% CI: 0.21 to 0.77] and 0.46 [95% CI: 0.26 to 0.84], respectively) AS compared with conservative management. No significant difference was observed between SAVR and TAVR. CONCLUSIONS In all subclasses of LG AS, AVR was associated with a significant decrease in all-cause mortality regardless of surgical or transcatheter approach.
Collapse
|
66
|
van Buuren F, Gati S, Sharma S, Papadakis M, Adami PE, Niebauer J, Pelliccia A, Rudolph V, Börjesson M, Carre F, Solberg E, Heidbuchel H, Caselli S, Corrado D, Serratosa L, Biffi A, Pressler A, Schmied C, Panhuyzen-Goedkoop NM, Rasmussen HK, La Gerche A, Faber L, Bogunovic N, D'Ascenzi F, Mellwig KP. Athletes with valvular heart disease and competitive sports: a position statement of the Sport Cardiology Section of the European Association of Preventive Cardiology. Eur J Prev Cardiol 2021; 28:1569-1578. [PMID: 33846742 DOI: 10.1093/eurjpc/zwab058] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/23/2021] [Indexed: 12/18/2022]
Abstract
This article provides an overview of the recommendations from the Sports Cardiology section of the European Association of Preventive Cardiology on sports participation in individuals with valvular heart disease (VHD). The aim of these recommendations is to encourage regular physical activity including sports participation, with reasonable precaution to ensure a high level of safety for all affected individuals. Valvular heart disease is usually an age-related degenerative process, predominantly affecting individuals in their fifth decade and onwards. However, there is an increasing group of younger individuals with valvular defects. The diagnosis of cardiac disorders during routine cardiac examination often raises questions about on-going participation in competitive sport with a high dynamic or static component and the level of permissible physical effort during recreational exercise. Although the natural history of several valvular diseases has been reported in the general population, little is known about the potential influence of chronic intensive physical activity on valve function, left ventricular remodelling pulmonary artery pressure, and risk of arrhythmia. Due to the sparsity of data on the effects of exercise on VHD, the present document is largely based on clinical experience and expert opinion.
Collapse
Affiliation(s)
- Frank van Buuren
- Clinic for General and Interventional Cardiology/Angiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany.,Catholic Hospital Southwestfalia, St. Martinus Hospital Olpe, Germany
| | - Sabiha Gati
- National Heart and Lung Institute, Imperial College, London, UK.,Department of Cardiology, Royal Brompton Hospital, London, SW3 6NP, UK
| | - Sanjay Sharma
- Cardiovascular Clinical Academic Group, St. George's, University of London, UK
| | - Michael Papadakis
- Cardiovascular Clinical Academic Group, St. George's, University of London, UK
| | - Paolo Emilio Adami
- Cardiovascular Medicine Center Zurich, Hirslanden Klinik im Park, Zurich Switzerland
| | - Josef Niebauer
- University Institute of Sports Medicine, Prevention and Rehabilitation, Paracelsus Medical University, Salzburg, Austria
| | - Antonio Pelliccia
- Cardiovascular Medicine Center Zurich, Hirslanden Klinik im Park, Zurich Switzerland
| | - Volker Rudolph
- Clinic for General and Interventional Cardiology/Angiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Mats Börjesson
- Department of Molecular and Clinical Medicine, Institute of Medicine; Center for Health and Performance, Gothenburg University.,Department of Medicine, Sahlgrenzska University Hospital/Östra, Gothenburg, Sweden
| | - Francois Carre
- Sport Medicine Department, Rennes University Hospital, LTSI INSERM UMR 1099, France
| | - Erik Solberg
- Department of Medicine, Diakonhjemmet Hospital, Oslo, Norway
| | - Hein Heidbuchel
- Antwerp University and University Hospital, Cardiology, Antwerp, Belgium
| | - Stefano Caselli
- Cardiovascular Medicine Center Zurich, Hirslanden Klinik im Park, Zurich Switzerland.,Ospedale San Pietro Fatebenefratelli, Rome, Italy
| | - Domenico Corrado
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua Medical School, Padova, Italy
| | - Luis Serratosa
- Hospital Universitario Quironsalud Madrid, Spain.,Ripoll y De Prado Sport Clinic, FIFA Medical Centre of Excellence, Madrid, Spain
| | - Alessandro Biffi
- Cardiovascular Medicine Center Zurich, Hirslanden Klinik im Park, Zurich Switzerland
| | - Axel Pressler
- Centre for General, Sports and Preventive Cardiology, Munich, Germany.,Department of Prevention, Rehabilitation and Sports Medicine, Technical University of Munich, Germany
| | - Christian Schmied
- Kardiologisches Ambulatorium, Sportmedizin/Sportkardiologie, University Heart Center, Zurich, Switzerland
| | | | | | | | - Lothar Faber
- Clinic for General and Interventional Cardiology/Angiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Nikola Bogunovic
- Clinic for General and Interventional Cardiology/Angiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Flavio D'Ascenzi
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Klaus Peter Mellwig
- Clinic for General and Interventional Cardiology/Angiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| |
Collapse
|
67
|
Lloyd JW, Eleid MF. Simplifying the approach to classical low-flow low-gradient severe aortic stenosis: A renewed emphasis on the resting transthoracic echocardiogram. Int J Cardiol 2021; 333:159-160. [PMID: 33766625 DOI: 10.1016/j.ijcard.2021.03.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 03/15/2021] [Indexed: 10/21/2022]
Affiliation(s)
- James W Lloyd
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, United States of America
| | - Mackram F Eleid
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, United States of America.
| |
Collapse
|
68
|
Sen J, Huynh Q, Stub D, Neil C, Marwick TH. Prognosis of Severe Low-Flow, Low-Gradient Aortic Stenosis by Stroke Volume Index and Transvalvular Flow Rate. JACC Cardiovasc Imaging 2021; 14:915-927. [PMID: 33744157 DOI: 10.1016/j.jcmg.2020.12.029] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 12/10/2020] [Accepted: 12/21/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVES This study determined whether flow state classified by stroke volume index (SVi) or transvalvular flow rate (FR) improved risk stratification of all-cause mortality, hospitalization due to heart failure, and aortic valvular interventions for patients with severe aortic stenosis (AS). BACKGROUND SVi is a widely accepted classification for flow state in severe low-flow, low-gradient (LFLG) AS. Recent studies suggest that FR more closely approximates true AS severity and provides more useful prognostication than SVi. METHODS Patients with severe AS over a 7-year period were subclassified by echocardiographic parameters. LFLG-AS was defined as severe AS (aortic valve area index [AVAi]: <0.6 cm2/m2), with a mean transvalvular pressure gradient of <40 mm Hg in the setting of low flow state: SVi of <35 ml/m2 and/or FR of <200 ml/s and subclassified into preserved (≥50%; paradoxical) or reduced (<50%; classical) left ventricular ejection fraction (LVEF). RESULTS Among 621 consecutive patients with severe AS, the proportions of patients classified as LFLG-AS were different between SVi and FR (p < 0.001). Classification using SVi, FR, and LVEF was a strong predictor of the composite endpoint at the 2-year follow-up. The addition of SVi to the echocardiographic and clinical model provided significant improvement in reclassification (net reclassification improvement: 0.089; 95% confidence interval [CI]: 0.045 to 0.133; p = 0.04), whereas addition of FR did not (net reclassification improvement: 0.061; 95% CI: 0.016 to 0.106; p = 0.17). C-statistics indicated improved risk discrimination when AVAi, LVEF, and SVi or FR were added as predictive variables to the clinical model (p = 0.006). CONCLUSIONS Low SVi or FR was associated with adverse cardiovascular events and showed improvement in discrimination, but only SVi, not FR, significantly improved risk reclassification compared to other conventional clinical and echocardiographic predictors. This suggests that FR is not superior to SVi in distinguishing true severe from pseudosevere forms of AS and identification of patients with LFLG-AS who have worse outcomes.
Collapse
Affiliation(s)
- Jonathan Sen
- Baker Heart and Diabetes Institute, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia; Western Health, Melbourne, Australia
| | - Quan Huynh
- Baker Heart and Diabetes Institute, Melbourne, Australia; Monash University Alfred Health, Melbourne, Australia
| | - Dion Stub
- Baker Heart and Diabetes Institute, Melbourne, Australia; Western Health, Melbourne, Australia; Monash University Alfred Health, Melbourne, Australia
| | - Christopher Neil
- Baker Heart and Diabetes Institute, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia; Western Health, Melbourne, Australia
| | - Thomas H Marwick
- Baker Heart and Diabetes Institute, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia; Western Health, Melbourne, Australia; Monash University Alfred Health, Melbourne, Australia.
| |
Collapse
|
69
|
Development of a deep learning-based algorithm for the automatic detection and quantification of aortic valve calcium. Eur J Radiol 2021; 137:109582. [PMID: 33578089 DOI: 10.1016/j.ejrad.2021.109582] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 01/07/2021] [Accepted: 02/01/2021] [Indexed: 01/18/2023]
Abstract
PURPOSE We aimed to develop a deep learning (DL)-based algorithm for automated quantification of aortic valve calcium (AVC) from non-enhanced electrocardiogram-gated cardiac CT scans and compare performance of DL-measured AVC volume and Agatston score with those of visual gradings by radiologist readers for classification of AVC severity. METHOD A total of 589 CT examinations performed at a single center between March 2010 and August 2017 were retrospectively included. The DL algorithm was designed to segment AVC and to quantify AVC volume, and Agatston score was calculated using attenuation values. Manually measured AVC volume and Agatston score were used as ground truth. To validate AVC segmentation performance, the Dice coefficient was calculated. For observer performance testing, four radiologists determined AVC grade in two reading rounds. The diagnostic performance of DL-measured AVC volume and Agaston score for classifying severe AVC was compared with that of each reader's assessment. RESULTS After applying the DL algorithm, the Dice coefficient score was 0.807. In patients with AVC, accuracy of DL-measured AVC volume for AVC grading was 97.0 % with area under the curve (AUC) of 0.964 (95 % confidence interval [CI] 0.923-1) in the test set, which was better than the radiologist readers (accuracy 69.7 %-91.9 %, AUC 0.762-0.923) with manually measured AVC volume as ground truth. When manually measured AVC Agatston score was used as ground truth, accuracy of DL-measured AVC Agatston score for AVC grading was 92.9 % with AUC of 0.933 (95 % CI 0.885-0.981) in the test set, which was also better than the radiologist readers (accuracy 77.8-89.9 %, AUC 0.791-0.903). CONCLUSIONS DL-based automated AVC quantification may be comparable with manual measurements. The diagnostic performance of the DL-measured AVC volume and Agatston score for classification of severe AVC outperforms radiologist readers.
Collapse
|
70
|
The Usefulness of [ 18F]F-Fluorodeoxyglucose and [ 18F]F-Sodium Fluoride Positron Emission Tomography Imaging in the Assessment of Early-Stage Aortic Valve Degeneration after Transcatheter Aortic Valve Implantation (TAVI)-Protocol Description and Preliminary Results. J Clin Med 2021; 10:jcm10030431. [PMID: 33499425 PMCID: PMC7866182 DOI: 10.3390/jcm10030431] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 01/09/2021] [Accepted: 01/19/2021] [Indexed: 01/30/2023] Open
Abstract
Transcatheter aortic valve implantation (TAVI) is now a well-established treatment for severe aortic stenosis. As the number of procedures and indications increase, the age of patients decreases. However, their durability and factors accelerating the process of degeneration are not well-known. The aim of the study was to verify the possibility of using [18F]F-sodium fluoride ([18F]F-NaF) and [18F]F-fluorodeoxyglucose ([18F]F-FDG) positron emission tomography/computed tomography (PET/CT) in assessing the intensity of TAVI valve degenerative processes. In 73 TAVI patients, transthoracic echocardiography (TTE) at initial (before TAVI), baseline (after TAVI), and during follow-up, as well as transesophageal echocardiography (TEE) and PET/CT, were performed using [18F]F-NaF and [18F]F-FDG at the six-month follow-up (FU) visit as a part of a two-year FU period. The morphology of TAVI valve leaflets were assessed in TEE, transvalvular gradients and effective orifice area (EOA) in TTE. Calcium scores and PET tracer activity were counted. We assessed the relationship between [18F]F-NaF and [18F]F-FDG PET/CT uptake at the 6 = month FU with selected indices e.g.,: transvalvular gradient, valve type, EOA and insufficiency grade at following time points after the TAVI procedure. We present the preliminary PET/CT ([18F]F-NaF, [18F]F-FDG) results at the six-month follow-up period as are part of an ongoing study, which will last two years FU. We enrolled 73 TAVI patients with the mean age of 82.49 ± 7.11 years. A significant decrease in transvalvular gradient and increase of effective orifice area and left ventricle ejection fraction were observed. At six months, FU valve thrombosis was diagnosed in four patients, while 7.6% of patients refused planned controls due to the COVID-19 pandemic. We noticed significant correlations between valve types, EOA and transaortic valve gradients, as well as [18F]F-NaF and [18F]F-FDG uptake in PET/CT. PET/CT imaging with the use of [18F]F-FDG and [18F]F-NaF is intended to be feasible, and it practically allows the standardized uptake value (SUV) to differentiate the area containing the TAVI leaflets from the SUV directly adjacent to the ring calcifications and the calcified native leaflets. This could become the seed for future detection and evaluation capabilities regarding the progression of even early degenerative lesions to the TAVI valve, expressed as local leaflet inflammation and microcalcifications.
Collapse
|
71
|
Guzzetti E, Annabi MS, Pibarot P, Clavel MA. Multimodality Imaging for Discordant Low-Gradient Aortic Stenosis: Assessing the Valve and the Myocardium. Front Cardiovasc Med 2020; 7:570689. [PMID: 33344514 PMCID: PMC7744378 DOI: 10.3389/fcvm.2020.570689] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 10/12/2020] [Indexed: 01/29/2023] Open
Abstract
Aortic stenosis (AS) is a disease of the valve and the myocardium. A correct assessment of the valve disease severity is key to define the need for aortic valve replacement (AVR), but a better understanding of the myocardial consequences of the increased afterload is paramount to optimize the timing of the intervention. Transthoracic echocardiography remains the cornerstone of AS assessment, as it is universally available, and it allows a comprehensive structural and hemodynamic evaluation of both the aortic valve and the rest of the heart. However, it may not be sufficient as a significant proportion of patients with severe AS presents with discordant grading (i.e., an AVA ≤ 1 cm2 and a mean gradient <40 mmHg) which raises uncertainty about the true severity of AS and the need for AVR. Several imaging modalities (transesophageal or stress echocardiography, computed tomography, cardiovascular magnetic resonance, positron emission tomography) exist that allow a detailed assessment of the stenotic aortic valve and the myocardial remodeling response. This review aims to provide an updated overview of these multimodality imaging techniques and seeks to highlight a practical approach to help clinical decision making in the challenging group of patients with discordant low-gradient AS.
Collapse
Affiliation(s)
- Ezequiel Guzzetti
- Institut Universitaire de Cardiologie et de Pneumologie de Québec (Quebec Heart & Lung Institute), Quebec, QC, Canada
| | - Mohamed-Salah Annabi
- Institut Universitaire de Cardiologie et de Pneumologie de Québec (Quebec Heart & Lung Institute), Quebec, QC, Canada
| | - Philippe Pibarot
- Institut Universitaire de Cardiologie et de Pneumologie de Québec (Quebec Heart & Lung Institute), Quebec, QC, Canada
| | - Marie-Annick Clavel
- Institut Universitaire de Cardiologie et de Pneumologie de Québec (Quebec Heart & Lung Institute), Quebec, QC, Canada
| |
Collapse
|
72
|
Donal E, Dweck MR, Galli E. Definition of severe aortic stenosis: 'A wise man points at the moon, the fool looks at the finger' (Chinese proverb). Eur Heart J Cardiovasc Imaging 2020; 21:744-746. [PMID: 32567664 DOI: 10.1093/ehjci/jeaa087] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Erwan Donal
- Cardiologie, CHU de Rennes, LTSI, Inserm 1099, Rennes, France
| | - Marc R Dweck
- Centre for Cardiovascular Science, Univeristy of Edinburgh, Edinburgh, EH16 4SB, UK
| | - Elena Galli
- Cardiologie, CHU de Rennes, LTSI, Inserm 1099, Rennes, France
| |
Collapse
|
73
|
Ludwig S, Pellegrini C, Gossling A, Rheude T, Voigtländer L, Bhadra OD, Linder M, Kalbacher D, Koell B, Waldschmidt L, Schirmer J, Seiffert M, Reichenspurner H, Blankenberg S, Westermann D, Conradi L, Joner M, Schofer N. Prognostic value of the H 2 FPEF score in patients undergoing transcatheter aortic valve implantation. ESC Heart Fail 2020; 8:461-470. [PMID: 33215870 PMCID: PMC7835574 DOI: 10.1002/ehf2.13096] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 10/02/2020] [Accepted: 10/22/2020] [Indexed: 02/06/2023] Open
Abstract
Aims The aim of this study was to assess the prognostic value of the H2FPEF score in patients undergoing transcatheter aortic valve implantation (TAVI) for severe aortic stenosis (AS) and preserved left ventricular ejection fraction (EF). Methods and results In this multicentre study, a total of 832 patients from two German high‐volume centres, who received TAVI for severe AS and preserved EF (≥50%), were identified for calculation of the H2FPEF score. Patients were dichotomized according to low (0–5 points; n = 570) and high (6–9 points; n = 262) H2FPEF scores. Kaplan–Meier and Cox regression analyses were applied to assess the prognostic impact of the H2FPEF score. We observed a decrease in stroke volume index (−2.04 mL/m2/point) and mean transvalvular gradients (−1.14 mmHg/point) with increasing H2FPEF score translating into a higher prevalence of paradoxical low‐flow, low‐gradient AS among patients with high H2FPEF score. One year after TAVI, the rates of all‐cause (low vs. high H2FPEF score: 8.0% vs. 19.4%, P < 0.0001) and cardiovascular (CV) mortality (1.9% vs. 9.0%, P < 0.0001) as well as the rate of CV mortality or rehospitalization for congestive heart failure (6.4% vs. 23.2%, P < 0.0001) were higher in patients with high H2FPEF score compared with those with low H2FPEF score. After multivariable analysis, a high H2FPEF score remained independently predictive of all‐cause mortality [hazard ratio 1.59 (1.28–2.35), P = 0.018] and CV mortality or rehospitalization for congestive heart failure [hazard ratio 2.92 (1.65–5.15), P < 0.001]. Among the H2FPEF score variables, atrial fibrillation, pulmonary hypertension, and elevated left ventricular filling pressure were the strongest outcome predictors. Conclusions The H2FPEF score serves as an independent predictor of adverse CV and heart failure outcome among TAVI patients with preserved EF. A high H2FPEF score is associated with the presence of paradoxical low‐flow, low‐gradient AS, the HFpEF in patients with AS. By identifying patients in advanced stages of HFpEF, the H2FPEF score might be useful as a risk prediction tool in patients with preserved EF scheduled for TAVI.
Collapse
Affiliation(s)
- Sebastian Ludwig
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Berlin, Germany
| | | | - Alina Gossling
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Tobias Rheude
- Department of Cardiology, German Heart Centre Munich, Munich, Germany
| | - Lisa Voigtländer
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Berlin, Germany
| | - Oliver D Bhadra
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Matthias Linder
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Daniel Kalbacher
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Berlin, Germany
| | - Benedikt Koell
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Lara Waldschmidt
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Johannes Schirmer
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Moritz Seiffert
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Berlin, Germany
| | - Hermann Reichenspurner
- DZHK (German Centre for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Berlin, Germany.,Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Stefan Blankenberg
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Berlin, Germany
| | - Dirk Westermann
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Berlin, Germany
| | - Lenard Conradi
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Michael Joner
- DZHK (German Centre for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Niklas Schofer
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
| |
Collapse
|
74
|
Ranjan S, Grewal HK, Kasliwal RR, Trehan N, Bansal M. Aortic pulse wave velocity and its relationship with transaortic flow and gradients in patients with severe aortic stenosis undergoing aortic valve replacement. Indian Heart J 2020; 72:421-426. [PMID: 33189205 PMCID: PMC7670240 DOI: 10.1016/j.ihj.2020.06.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 05/30/2020] [Accepted: 06/21/2020] [Indexed: 11/20/2022] Open
Abstract
Background Low-flow, low-gradient severe aortic stenosis (LFLGAS) is a common clinical entity and is associated with poor prognosis. Increased left ventricular (LV) afterload is one of the mechanisms contributing to low LV stroke volume index (SVi) in these patients. Aortic stiffness is an important determinant of LV afterload, but no previous study has evaluated its relationship with LVSVi in patients with AS. Methods Fifty-seven patients (mean age 66 ± 8 years, 71.9% men) with severe AS [aortic valve area (AVA) < 1.0 cm2] undergoing aortic valve replacement (AVR) were included in this study. Echocardiographic parameters of AS were correlated with carotid-femoral pulse wave velocity (cfPWV), a measure of aortic stiffness, derived using PeriScope® device. Results Mean AVA was 0.63 ± 0.17 cm2 with mean and peak transvalvular gradient 56.5 ± 18.8 mmHg and 83.2 ± 25.2 mmHg, respectively. Nearly half (26 of 57, 45.6%) of the subjects had SVi <35 mL/m2, indicative of low-flow severe AS. These subjects had lower AVA, lower aortic valve gradient, and LV ejection fraction. CfPWV was numerically lower in these subjects [median 1467 (interquartile range 978, 2259) vs 1588 (1106, 2167)] but the difference was not statistically significant (p = 0.66). However, when analyzed as a continuous variable, cfPWV had significant positive correlation with SVi (Pearson's r 0.268, p = 0.048) and mean aortic valve gradient (Pearson's r 0.274, p = 0.043). Conclusions In patients with severe AS undergoing AVR, aortic stiffness measured using cfPWV is not a determinant of low-flow state. Instead, an increasing cfPWV tends to be associated with increasing transvalvular flow and gradient in these patients.
Collapse
Affiliation(s)
- Shraddha Ranjan
- Department of Cardiology, Medanta-The Medicity, Gurgaon, India
| | | | - Ravi R Kasliwal
- Department of Cardiology, Medanta-The Medicity, Gurgaon, India
| | - Naresh Trehan
- Department of Cardiothoracic Surgery, Medanta-The Medicity, Gurgaon, India
| | - Manish Bansal
- Department of Cardiology, Medanta-The Medicity, Gurgaon, India.
| |
Collapse
|
75
|
Komlev AE, Saidova MA, Imaev TE, Shitov VN, Akchurin RS. Haemodynamic Patterns of Severe Aortic Stenosis. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2020. [DOI: 10.20996/1819-6446-2020-10-06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The authors present up-to-date review of clinical pathophysiology of aortic stenosis (AS) based on differentiation of its haemodynamic patterns, and some actual issues of instrumental diagnostics and classification of AS. The variety of clinical presentations of AS is based on diverse combination of pathological changes of haemodynamics. In Russian cardiology, there is no clear pathophysiological classification of AS despite of its relevance under the progress of surgical and transcatheter treatment of AS. The authors suggest the pilot haemodynamic classification of AS which includes 6 types (0-5) based on different combination of the following variables: left ventricle ejection fraction, stroke volume, mean aortic systolic pressure gradient. Severe AS with low transaortic pressure gradient in patients with depressed systolic function of the left ventricle (so called «low flow-low» gradient phenomenon) is referred to as the most frequent, classical haemodynamic pattern of low-gradient AS. The prevalence of this variant is about 10% among European population of patients with severe AS. The inconsistence between aortic valve area and mean pressure gradient is as common as in 35-40% of patients with AS, however, in 30-50% of these cases, AS is not severe. Severe AS is a surgical disease that should be treated in a surgical way in all patients but those in whom predicted risk overbalances potential benefits of the procedure. The use of integrated clinical and instrumental approach for identification of a true sever AS is the matter of great concern, as both overestimation and underestimation can misguide the clinical decision-making process. Verification of severe AS in patients with classical and paradoxical low flow-low gradient AS with specific indications for surgical treatment regarded is further emphasized in the paper. Since transcatheter aortic valve implantation has become a commonly recognized alternative to surgical aortic valve replacement, its role in the treatment of severe AS with different haemodynamic patterns is also discussed. The authors stress on the necessity of using tailored approach for treatment of AS regarding different clinical and pathophysiological scenarios: high gradient AS with preserved ejection fraction, classical and paradoxical low flow-low gradient AS.
Collapse
Affiliation(s)
| | | | - T. E. Imaev
- National Medical Research Center of Cardiology
| | | | | |
Collapse
|
76
|
Kang NG, Suh YJ, Han K, Kim YJ, Choi BW. Performance of Prediction Models for Diagnosing Severe Aortic Stenosis Based on Aortic Valve Calcium on Cardiac Computed Tomography: Incorporation of Radiomics and Machine Learning. Korean J Radiol 2020; 22:334-343. [PMID: 33236537 PMCID: PMC7909863 DOI: 10.3348/kjr.2020.0099] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 05/12/2020] [Accepted: 06/04/2020] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE We aimed to develop a prediction model for diagnosing severe aortic stenosis (AS) using computed tomography (CT) radiomics features of aortic valve calcium (AVC) and machine learning (ML) algorithms. MATERIALS AND METHODS We retrospectively enrolled 408 patients who underwent cardiac CT between March 2010 and August 2017 and had echocardiographic examinations (240 patients with severe AS on echocardiography [the severe AS group] and 168 patients without severe AS [the non-severe AS group]). Data were divided into a training set (312 patients) and a validation set (96 patients). Using non-contrast-enhanced cardiac CT scans, AVC was segmented, and 128 radiomics features for AVC were extracted. After feature selection was performed with three ML algorithms (least absolute shrinkage and selection operator [LASSO], random forests [RFs], and eXtreme Gradient Boosting [XGBoost]), model classifiers for diagnosing severe AS on echocardiography were developed in combination with three different model classifier methods (logistic regression, RF, and XGBoost). The performance (c-index) of each radiomics prediction model was compared with predictions based on AVC volume and score. RESULTS The radiomics scores derived from LASSO were significantly different between the severe AS and non-severe AS groups in the validation set (median, 1.563 vs. 0.197, respectively, p < 0.001). A radiomics prediction model based on feature selection by LASSO + model classifier by XGBoost showed the highest c-index of 0.921 (95% confidence interval [CI], 0.869-0.973) in the validation set. Compared to prediction models based on AVC volume and score (c-indexes of 0.894 [95% CI, 0.815-0.948] and 0.899 [95% CI, 0.820-0.951], respectively), eight and three of the nine radiomics prediction models showed higher discrimination abilities for severe AS. However, the differences were not statistically significant (p > 0.05 for all). CONCLUSION Models based on the radiomics features of AVC and ML algorithms may perform well for diagnosing severe AS, but the added value compared to AVC volume and score should be investigated further.
Collapse
Affiliation(s)
- Nam Gyu Kang
- Department of Radiology, Research Institute of Radiological Science, Center for Clinical Imaging Data Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Young Joo Suh
- Department of Radiology, Research Institute of Radiological Science, Center for Clinical Imaging Data Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
| | - Kyunghwa Han
- Department of Radiology, Research Institute of Radiological Science, Center for Clinical Imaging Data Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Young Jin Kim
- Department of Radiology, Research Institute of Radiological Science, Center for Clinical Imaging Data Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Byoung Wook Choi
- Department of Radiology, Research Institute of Radiological Science, Center for Clinical Imaging Data Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| |
Collapse
|
77
|
Smiseth OA, Larsen CK. Finding the "Golden Moment" for TAVR: Look Below the Valve. JACC Cardiovasc Imaging 2020; 13:2573-2575. [PMID: 33129727 DOI: 10.1016/j.jcmg.2020.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 08/26/2020] [Accepted: 08/27/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Otto A Smiseth
- Institute for Surgical Research and Department of Cardiology, Oslo University Hospital and University of Oslo, Oslo, Norway.
| | - Camilla K Larsen
- Institute for Surgical Research and Department of Cardiology, Oslo University Hospital and University of Oslo, Oslo, Norway
| |
Collapse
|
78
|
Prognostic Value of Computed Tomography-Derived Extracellular Volume in TAVR Patients With Low-Flow Low-Gradient Aortic Stenosis. JACC Cardiovasc Imaging 2020; 13:2591-2601. [PMID: 33129731 DOI: 10.1016/j.jcmg.2020.07.045] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 07/06/2020] [Accepted: 07/09/2020] [Indexed: 01/01/2023]
Abstract
OBJECTIVES The association between extracellular volume (ECV) measured by computed tomography angiography (CTA) and clinical outcomes was evaluated in low-flow low-gradient (LFLG) aortic stenosis (AS) patients undergoing transcatheter aortic valve replacement (TAVR). BACKGROUND Patients with LFLG AS comprise a high-risk group with respect to clinical outcomes. Although ECV, a marker of myocardial fibrosis, is traditionally measured with cardiac magnetic resonance, it can also be measured using cardiac CTA. The authors hypothesized that in LFLG AS, increased ECV may be associated with adverse clinical outcomes. METHODS In 150 LFLG patients with AS who underwent TAVR, ECV was quantified using pre-TAVR CTA. Echocardiographic and clinical information including all-cause death and heart failure rehospitalization (HFH) was obtained from electronic medical records. A Cox proportional hazards model was used to evaluate the association between ECV and death+HFH. RESULTS During a median follow-up of 13.9 months (range 0.07 to 28.9 months), there were 31 death+HFH events (21%). Patients who experienced death+HFH had a greater median Society of Thoracic Surgery score (9.9 vs. 4.7; p < 0.01), lower left ventricular ejection fraction (42.3 ± 20.2% vs. 52.7 ± 17.2%; p < 0.01), lower mean transvalvular gradient (24.9 ± 8.9 mm Hg vs. 28.1 ± 7.3 mm Hg; p = 0.04) and increased mean ECV (35.5 ± 9.6% vs. 29.9 ± 8.2%; p < 0.01) compared with patients who did not experience death+HFH. In a multivariable Cox proportional hazards model, increase in ECV was associated with increase in death+HFH, (hazard ratio per 1% increase: 1.04, 95% confidence interval: 1.01 to 1.09; p < 0.01). CONCLUSIONS In patients with LFLG AS, CTA measured increase in ECV is associated with increased risk of adverse clinical outcomes post-TAVR and may thus serve as a useful noninvasive marker for prognostication.
Collapse
|
79
|
El Faquir N, Vollema ME, Delgado V, Ren B, Spitzer E, Rasheed M, Rahhab Z, Geleijnse ML, Budde RPJ, de Jaegere PP, Bax JJ, Van Mieghem NM. Reclassification of aortic stenosis by fusion of echocardiography and computed tomography in low-gradient aortic stenosis. Neth Heart J 2020; 30:212-226. [PMID: 33052577 PMCID: PMC8941065 DOI: 10.1007/s12471-020-01501-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2020] [Indexed: 01/05/2023] Open
Abstract
Background The integration of computed tomography (CT)-derived left ventricular outflow tract area into the echocardiography-derived continuity equation results in the reclassification of a significant proportion of patients with severe aortic stenosis (AS) into moderate AS based on aortic valve area indexed to body surface area determined by fusion imaging (fusion AVAi). The aim of this study was to evaluate AS severity by a fusion imaging technique in patients with low-gradient AS and to compare the clinical impact of reclassified moderate AS versus severe AS. Methods We included 359 consecutive patients who underwent transcatheter aortic valve implantation for low-gradient, severe AS at two academic institutions and created a joint database. The primary endpoint was a composite of all-cause mortality and rehospitalisations for heart failure at 1 year. Results Overall, 35% of the population (n = 126) were reclassified to moderate AS [median fusion AVAi 0.70 (interquartile range, IQR 0.65–0.80) cm2/m2] and severe AS was retained as the classification in 65% [median fusion AVAi 0.49 (IQR 0.43–0.54) cm2/m2]. Lower body mass index, higher logistic EuroSCORE and larger aortic dimensions characterised patients reclassified to moderate AS. Overall, 57% of patients had a left ventricular ejection fraction (LVEF) <50%. Clinical outcome was similar in patients with reclassified moderate or severe AS. Among patients reclassified to moderate AS, non-cardiac mortality was higher in those with LVEF <50% than in those with LVEF ≥50% (log-rank p = 0.029). Conclusions The integration of CT and transthoracic echocardiography to obtain fusion AVAi led to the reclassification of one third of patients with low-gradient AS to moderate AS. Reclassification did not affect clinical outcome, although patients reclassified to moderate AS with a LVEF <50% had worse outcomes owing to excess non-cardiac mortality.
Collapse
Affiliation(s)
- N El Faquir
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - M E Vollema
- Department of Cardiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - V Delgado
- Department of Cardiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - B Ren
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - E Spitzer
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - M Rasheed
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Z Rahhab
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - M L Geleijnse
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - R P J Budde
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - P P de Jaegere
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - J J Bax
- Department of Cardiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - N M Van Mieghem
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, The Netherlands.
| |
Collapse
|
80
|
Guzzetti E, Clavel MA. Measuring progression of aortic stenosis: computed tomography versus echocardiography. Heart 2020; 106:1873-1875. [PMID: 33037021 DOI: 10.1136/heartjnl-2020-317340] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Ezequiel Guzzetti
- Universitaire de Cardiologie et de Pneumologie de Québec/Quebec Heart and Lung Institute, Université Laval, Quebec, Quebec, Canada
| | - Marie-Annick Clavel
- Universitaire de Cardiologie et de Pneumologie de Québec/Quebec Heart and Lung Institute, Université Laval, Quebec, Quebec, Canada
| |
Collapse
|
81
|
Beneduce A, Capogrosso C, Moroni F, Ancona F, Falasconi G, Pannone L, Stella S, Ingallina G, Melillo F, Ancona MB, Romano Rt V, Palmisano A, Latib A, Colombo A, Montorfano M, Esposito A, Agricola E. Aortic valve area calculation using 3D transesophageal echocardiography: Implications for aortic stenosis severity grading. Echocardiography 2020; 37:2071-2081. [PMID: 33026122 DOI: 10.1111/echo.14883] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 09/10/2020] [Accepted: 09/18/2020] [Indexed: 12/18/2022] Open
Abstract
AIMS Aortic stenosis (AS) grading by 2D-transthoracic echocardiography (2D-TTE) aortic valve area (AVA) calculation is limited by left ventricular outflow tract (LVOT) area underestimation. The combination of Doppler parameters with 3D LVOT area obtained by multidetector computed tomography (MDCT) can improve AS grading, reconciling discordant 2D-TTE findings. This study aimed to systematically evaluate the role of 3D-transesophageal echocardiography (3D-TEE) in AS grading using MDCT as reference standard. METHODS AND RESULTS 288 patients (81 ± 6.3 years, 52.4% female) with symptomatic AS underwent 2D-TTE, 3D-TEE, and MDCT for transcatheter aortic valve implantation. Doppler parameters were combined with 3D LVOT areas measured by manual and semi-automated software 3D-TEE and by MDCT to calculate AVA, reassessing AS severity. Both 3D-TEE modalities demonstrated good correlation with MDCT, with excellent intra-observer and inter-observer variability. Compared to MDCT, 3D-TEE measurements significantly underestimated AVA (PANOVA < .0001), although the difference was clinically acceptable. Compared to 2D-TTE, 3D-TEE manual and semi-automated software reclassified severe AS in 21.9% and 25.2% of cases, respectively (P < .0001), overcame grading parameters discordance in more than 40% of cases in patients with low-gradient AS (P < .0001) and reduced the proportion of low-flow states in nearly 75% of cases when combined to stroke volume index assessment (P < .0001). 3D-TEE imaging modalities showed a reduction in the proportion of patients with low-gradient and pathological AVA as defined by 2D-TTE, and improved AVA and mean pressure gradient agreement with current guidelines cutoff values. CONCLUSION 3D-TEE AVA calculation is a reliable tool for AS grading with excellent reproducibility and good correlation with MDCT measurements.
Collapse
Affiliation(s)
- Alessandro Beneduce
- Interventional Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy
| | - Cristina Capogrosso
- Cardiovascular Imaging Unit, Cardio-Thoracic-Vascular Department, San Raffaele, Scientific Institute Milan, Milan, Italy
| | - Francesco Moroni
- Interventional Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Ancona
- Cardiovascular Imaging Unit, Cardio-Thoracic-Vascular Department, San Raffaele, Scientific Institute Milan, Milan, Italy
| | - Giulio Falasconi
- Cardiovascular Imaging Unit, Cardio-Thoracic-Vascular Department, San Raffaele, Scientific Institute Milan, Milan, Italy
| | - Luigi Pannone
- Cardiovascular Imaging Unit, Cardio-Thoracic-Vascular Department, San Raffaele, Scientific Institute Milan, Milan, Italy
| | - Stefano Stella
- Cardiovascular Imaging Unit, Cardio-Thoracic-Vascular Department, San Raffaele, Scientific Institute Milan, Milan, Italy
| | - Giacomo Ingallina
- Cardiovascular Imaging Unit, Cardio-Thoracic-Vascular Department, San Raffaele, Scientific Institute Milan, Milan, Italy
| | - Francesco Melillo
- Cardiovascular Imaging Unit, Cardio-Thoracic-Vascular Department, San Raffaele, Scientific Institute Milan, Milan, Italy
| | - Marco Bruno Ancona
- Interventional Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy
| | - Vittorio Romano Rt
- Interventional Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy
| | - Anna Palmisano
- Cardiovascular Radiology, Radiology Department and Experimental Imaging Center, San Raffaele Scientific Institute, Milan, Italy
| | - Azeem Latib
- Interventional Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy.,Department of Cardiology, Montefiore Medical Center, Bronx, NY, USA
| | - Antonio Colombo
- Interventional Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy.,Interventional Cardiology Unit, GVM Care and Research Maria Cecilia Hospital, Cotignola, Italy
| | - Matteo Montorfano
- Interventional Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy
| | - Antonio Esposito
- Cardiovascular Radiology, Radiology Department and Experimental Imaging Center, San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Eustachio Agricola
- Cardiovascular Imaging Unit, Cardio-Thoracic-Vascular Department, San Raffaele, Scientific Institute Milan, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| |
Collapse
|
82
|
Abstract
INTRODUCTION Ventricular function in elderly patients with aortic stenosis is impeded both by restricted aortic flow and arterial stiffening. A number of patients continue to have exertional intolerance after relief of aortic valvular obstruction due to unrecognized ventriculo-arterial coupling mismatch. HYPOTHESIS Quantification of valvulo-arterial load (VAL), using a simultaneous applanation tonometry/cardiac magnetic resonance (CMR) technique, can accurately assess the relative contributions of aortic stiffness and valve gradient in older patients with aortic stenosis. METHODS Elderly patients with aortic stenosis underwent a simultaneous applanation tonometry/CMR protocol. CMR provided left ventricular volume and aortic flow simultaneously with radial applanation tonometry pressure acquisition. Central aortic pressure was derived by transformation of the radial applanation tonometry waveform. VAL was determined as the relationship of derived aortic pressure to CMR aortic flow in frequency domain (central illustration). RESULTS Twenty patients (age 80 ± 9 years; 12 males; blood pressure 140/75 ± 20 mmHg) with aortic stenosis on transthoracic echocardiogram (16 severe; mean gradient 45 ± 16 mmHg; aortic valve area 0.8 ± 0.2 cm2) were enrolled. Derived aortic pressure and flow waveforms correlated well with invasive data. Increased VAL was significantly associated with advanced age (P = 0.04) and raised SBP (P < 0.01), irrespective of aortic stenosis severity. CONCLUSION Difficulties in the measurement and accuracy of ventriculo-arterial coupling means that it is not routinely measured in patients with aortic stenosis. We describe a new noninvasive index that provides an accurate assessment of valvular and arterial load on the left ventricle. VAL may help detect those at risk of ventriculo-arterial coupling mismatch and assist in selection of those most likely to benefit from an invasive procedure.
Collapse
|
83
|
Fischer-Rasokat U, Renker M, Liebetrau C, Weferling M, Rolf A, Doss M, Möllmann H, Walther T, Hamm CW, Kim WK. Does the severity of low-gradient aortic stenosis classified by computed tomography-derived aortic valve calcification determine the outcome of patients after transcatheter aortic valve implantation (TAVI)? Eur Radiol 2020; 31:549-558. [PMID: 32770378 DOI: 10.1007/s00330-020-07121-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 05/22/2020] [Accepted: 07/29/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Aortic valve calcification (AVC) determined by computed tomography has emerged as a complementary measure of aortic stenosis (AS) severity and as a predictor of adverse events. Thus, AVC can guide further treatment decisions in patients with low-gradient AS (LG-AS). We compared the symptomatic and prognostic outcome of patients with low vs. high AVC after transcatheter aortic valve implantation (TAVI). METHODS Patients with an aortic valve area index ≤ 0.6 cm2/m2 and a mean pressure gradient (MPG) < 40 mmHg were classified as low-flow, low-gradient AS (LFLG-AS; stroke volume index [SVI] ≤ 35 ml/m2, left ventricular ejection fraction [LVEF] < 50%, n = 173), paradoxical LFLG-AS (pLFLG-AS, SVI ≤ 35 ml/m2, LVEF ≥ 50%, n = 233), or normal-flow, low-gradient AS (NFLG-AS, SVI > 35 ml/m2, LVEF ≥ 50%, n = 244); patients with MPG ≥ 40 mmHg (n = 1142) served as controls. Patients were further categorized according to published AVC thresholds. RESULTS Demographic characteristics and cardiovascular risk were not different between patients with high vs. low AVC in any of the subgroups. Patients with low AVC had a lower MPG. Symptom improvement at 30 days was observed in the majority of patients but was less pronounced in LFLG-AS patients with low vs. those with high AVC. Kaplan-Meier 1-year survival curves were identical between patients with low and high AVC in all three LG-AS groups. CONCLUSIONS The severity of LG-AS based on AVC has no impact on 1-year prognosis once TAVI has been performed. KEY POINTS • Aortic valve calcification (AVC) determined by computed tomography has emerged as a complementary measure of aortic stenosis (AS) severity and is of prognostic value in selected patients. • Patients with inconsistent echocardiographic measures can be classified as having severe or nonsevere AS by the computed tomography-derived AVC score. • The prognostic value of AVC in patients with low-gradient AS is abrogated after correction of afterload by TAVI.
Collapse
Affiliation(s)
- Ulrich Fischer-Rasokat
- Department of Cardiology, Kerckhoff Heart Center, Benekestr. 2-8, 61231, Bad Nauheim, Germany. .,Medical Clinic I (Cardiology and Angiology), University Hospital of Giessen, Klinikstr. 33, 35392, Giessen, Germany.
| | - Matthias Renker
- Department of Cardiology, Kerckhoff Heart Center, Benekestr. 2-8, 61231, Bad Nauheim, Germany.,Department of Cardiac Surgery, Kerckhoff Heart Center, Benekestr. 2-8, 61231, Bad Nauheim, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site RhineMain, Bad Nauheim, Germany
| | - Christoph Liebetrau
- Department of Cardiology, Kerckhoff Heart Center, Benekestr. 2-8, 61231, Bad Nauheim, Germany.,Medical Clinic I (Cardiology and Angiology), University Hospital of Giessen, Klinikstr. 33, 35392, Giessen, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site RhineMain, Bad Nauheim, Germany
| | - Maren Weferling
- Department of Cardiology, Kerckhoff Heart Center, Benekestr. 2-8, 61231, Bad Nauheim, Germany
| | - Andreas Rolf
- Department of Cardiology, Kerckhoff Heart Center, Benekestr. 2-8, 61231, Bad Nauheim, Germany.,Medical Clinic I (Cardiology and Angiology), University Hospital of Giessen, Klinikstr. 33, 35392, Giessen, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site RhineMain, Bad Nauheim, Germany
| | - Mirko Doss
- Department of Cardiac Surgery, Kerckhoff Heart Center, Benekestr. 2-8, 61231, Bad Nauheim, Germany
| | - Helge Möllmann
- Department of Cardiology, Medical Clinic I, St. Johannes Hospital, Johannesstr. 9-17, 44137, Dortmund, Germany
| | - Thomas Walther
- Department of Cardiac Surgery, Kerckhoff Heart Center, Benekestr. 2-8, 61231, Bad Nauheim, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site RhineMain, Bad Nauheim, Germany.,Department of Cardiac, Thoracic and Thoracic Vascular Surgery, University Hospital of the Goethe University, Theodor-Stern-Kai 7, 60596, Frankfurt/Main, Germany
| | - Christian W Hamm
- Department of Cardiology, Kerckhoff Heart Center, Benekestr. 2-8, 61231, Bad Nauheim, Germany.,Medical Clinic I (Cardiology and Angiology), University Hospital of Giessen, Klinikstr. 33, 35392, Giessen, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site RhineMain, Bad Nauheim, Germany
| | - Won-Keun Kim
- Department of Cardiology, Kerckhoff Heart Center, Benekestr. 2-8, 61231, Bad Nauheim, Germany.,Medical Clinic I (Cardiology and Angiology), University Hospital of Giessen, Klinikstr. 33, 35392, Giessen, Germany.,Department of Cardiac Surgery, Kerckhoff Heart Center, Benekestr. 2-8, 61231, Bad Nauheim, Germany
| |
Collapse
|
84
|
Anand V, Mankad SV, Eleid M. What Is New in Low Gradient Aortic Stenosis: Surgery, TAVR, or Medical Therapy? Curr Cardiol Rep 2020; 22:78. [DOI: 10.1007/s11886-020-01341-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
|
85
|
Tzolos E, Dweck MR. 18F-Sodium Fluoride ( 18F-NaF) for Imaging Microcalcification Activity in the Cardiovascular System. Arterioscler Thromb Vasc Biol 2020; 40:1620-1626. [PMID: 32375543 PMCID: PMC7310305 DOI: 10.1161/atvbaha.120.313785] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Accepted: 04/15/2020] [Indexed: 01/23/2023]
Abstract
Accumulating preclinical and clinical evidence suggests that calcification is one of the body's primary responses to injury and a key pathological feature of cardiovascular disease. Calcification activity can now be imaged using 18F-sodium fluoride (18F-NaF) positron emission tomography (PET) in combination with either computed tomography or magnetic resonance. These techniques allow visualization of calcification activity and, therefore, provide different information to the established macroscopic calcium imaged with computed tomography. Indeed, 18F-NaF PET has been used to investigate a wide range of valvular conditions, including aortic stenosis, mitral annular calcification, and bioprosthetic valve disease, as well as vascular conditions, including abdominal aortic aneurysm disease, coronary, and carotid atherosclerosis, peripheral vascular disease, and erectile dysfunction. In this brief review, we will focus on how 18F-NaF PET has improved our pathophysiological understanding of cardiovascular calcification and how it can be used as a marker of vascular calcification, providing a useful tool that can be utilized in clinical trials investigating the prediction of both disease progression and clinical events. Finally, we will discuss how 18F-NaF might be employed clinically to improve patient assessment and to guide decision-making.
Collapse
Affiliation(s)
- Evangelos Tzolos
- From the BHF Centre for Cardiovascular Science, University of Edinburgh, United Kingdom
| | - Marc R. Dweck
- From the BHF Centre for Cardiovascular Science, University of Edinburgh, United Kingdom
| |
Collapse
|
86
|
|
87
|
Pawade T, Sheth T, Guzzetti E, Dweck MR, Clavel MA. Why and How to Measure Aortic Valve Calcification in Patients With Aortic Stenosis. JACC Cardiovasc Imaging 2020; 12:1835-1848. [PMID: 31488252 DOI: 10.1016/j.jcmg.2019.01.045] [Citation(s) in RCA: 125] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 01/30/2019] [Accepted: 01/31/2019] [Indexed: 10/26/2022]
Abstract
The first-line evaluation of aortic stenosis severity is Doppler echocardiography. However, in up to 40% of patients, resting echocardiographic assessment of aortic stenosis severity is discordant, leading to clinical uncertainty. Interest has therefore grown in aortic valve calcium scoring by multidetector computed tomography (CT-AVC) as an alternative load independent assessment of aortic stenosis severity. This paper will briefly review the pathophysiology of aortic stenosis and the crucial role that calcification plays in driving progressive obstruction of the valve. Subsequently, it will describe published reports that have investigated CT-AVC, validating this parameter against histology, and establishing its diagnostic accuracy versus echocardiography as well as its powerful independent prognostic capability. Finally, this review seeks to provide a practical guide about how best to acquire and interpret CT-AVC with a close focus on potential pitfalls and how these might be best avoided as this technique becomes more widely adopted in to clinical practice.
Collapse
Affiliation(s)
- Tania Pawade
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Tej Sheth
- Division of Cardiology, McMaster University, Hamilton General Hospital, Hamilton, Ontario, Canada
| | - Ezequiel Guzzetti
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada
| | - Marc R Dweck
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Marie-Annick Clavel
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada.
| |
Collapse
|
88
|
Guzzetti E, Clavel MA, Pibarot P. Usefulness of the energy loss index in the adjudication of low-gradient aortic stenosis severity. Eur Heart J Cardiovasc Imaging 2020; 21:616-618. [PMID: 32259845 DOI: 10.1093/ehjci/jeaa052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Ezequiel Guzzetti
- Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, 2725 Chemin Sainte-Foy, Quebec City, Quebec G1V-4G5, Canada
| | - Marie-Annick Clavel
- Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, 2725 Chemin Sainte-Foy, Quebec City, Quebec G1V-4G5, Canada
| | - Philippe Pibarot
- Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, 2725 Chemin Sainte-Foy, Quebec City, Quebec G1V-4G5, Canada
| |
Collapse
|
89
|
Jiang T, Hasan SM, Faluk M, Patel J. Evolution of Transcatheter Aortic Valve Replacement | Review of Literature. Curr Probl Cardiol 2020; 46:100600. [PMID: 32522375 DOI: 10.1016/j.cpcardiol.2020.100600] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 04/06/2020] [Indexed: 11/18/2022]
Abstract
Aortic valve stenosis is the most common primary valvular heart disease leading to either surgical or transcatheter valve replacement in the United States with its prevalence on the rise due to the elderly population. Over the recent years, the rise of transcatheter aortic valve replacement has been exponential due to technologic developments and randomized control trials. In this review article, we aim to review current literature on transcatheter aortic valve replacements.
Collapse
|
90
|
Paradoxical Low Flow Aortic Stenosis: More Differences Between Men and Women. J Am Coll Cardiol 2020; 75:1910-1912. [PMID: 32327101 DOI: 10.1016/j.jacc.2020.03.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 03/17/2020] [Indexed: 11/23/2022]
|
91
|
Lindman BR, Arnold SV, Bagur R, Clarke L, Coylewright M, Evans F, Hung J, Lauck SB, Peschin S, Sachdev V, Tate LM, Wasfy JH, Otto CM. Priorities for Patient-Centered Research in Valvular Heart Disease: A Report From the National Heart, Lung, and Blood Institute Working Group. J Am Heart Assoc 2020; 9:e015975. [PMID: 32326818 PMCID: PMC7428554 DOI: 10.1161/jaha.119.015975] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Over the past decade, the field of valvular heart disease (VHD) has rapidly transformed, largely as a result of the development and improvement of less invasive transcatheter approaches to valve repair or replacement. This transformation has been supported by numerous well-designed randomized trials, but they have centered almost entirely on devices and procedures. Outside this scope of focus, however, myriad aspects of therapy and management for patients with VHD have either no guidelines or recommendations based only on expert opinion and observational studies. Further, research in VHD has often failed to engage patients to inform study design and identify research questions of greatest importance and relevance from a patient perspective. Accordingly, the National Heart, Lung, and Blood Institute convened a Working Group on Patient-Centered Research in Valvular Heart Disease, composed of clinician and research experts and patient advocacy experts to identify gaps and barriers to research in VHD and identify research priorities. While recognizing that important research remains to be done to test the safety and efficacy of devices and procedures to treat VHD, we intentionally focused less attention on these areas of research as they are more commonly pursued and supported by industry. Herein, we present the patient-centered research gaps, barriers, and priorities in VHD and organized our report according to the "patient journey," including access to care, screening and diagnosis, preprocedure therapy and management, decision making when a procedure is contemplated (clinician and patient perspectives), and postprocedure therapy and management. It is hoped that this report will foster collaboration among diverse stakeholders and highlight for funding bodies the pressing patient-centered research gaps, opportunities, and priorities in VHD in order to produce impactful patient-centered research that will inform and improve patient-centered policy and care.
Collapse
Affiliation(s)
- Brian R Lindman
- Cardiovascular Medicine Division Structural Heart and Valve Center Vanderbilt University Medical Center Nashville TN
| | | | - Rodrigo Bagur
- Division of Cardiology University Hospital London Health Sciences Centre London Ontario Canada
| | | | - Megan Coylewright
- Heart and Vascular Center Dartmouth-Hitchcock Medical Center Lebanon NH
| | - Frank Evans
- National Heart, Lung, and Blood Institute of the National Institutes of Health, Bethesda MD
| | - Judy Hung
- Cardiology Division Massachusetts General Hospital Harvard Medical School Boston MA
| | - Sandra B Lauck
- Centre for Heart Valve Innovation St. Paul's Hospital University of British Columbia Vancouver British Columbia Canada
| | | | - Vandana Sachdev
- National Heart, Lung, and Blood Institute of the National Institutes of Health, Bethesda MD
| | | | - Jason H Wasfy
- Cardiology Division Massachusetts General Hospital Harvard Medical School Boston MA
| | | |
Collapse
|
92
|
Liu S, Churchill J, Hua L, Zeng X, Rhoades V, Namasivayam M, Baliyan V, Ghoshhajra BB, Dong T, Dal-Bianco JP, Passeri JJ, Levine RA, Hung J. Direct Planimetry of Left Ventricular Outflow Tract Area by Simultaneous Biplane Imaging: Challenging the Need for a Circular Assumption of the Left Ventricular Outflow Tract in the Assessment of Aortic Stenosis. J Am Soc Echocardiogr 2020; 33:461-468. [PMID: 32248906 DOI: 10.1016/j.echo.2019.12.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 11/20/2019] [Accepted: 12/02/2019] [Indexed: 01/14/2023]
Abstract
BACKGROUND Evaluation of aortic stenosis (AS) requires calculation of aortic valve area (AVA), which relies on the assumption of a circular-shaped left ventricular outflow tract (LVOT). However, the LVOT is often elliptical, and the circular assumption underestimates the true LVOT area (LVOTA). Biplane imaging using transthoracic echocardiography allows direct planimetry of LVOTA. The aim of this study was to assess the feasibility of obtaining LVOTA using this technique and its impact on the discordance between AVA and gradient criteria in AS grading. METHODS We prospectively studied 134 patients (median age, 80 years; interquartile range, 73-87 years; 39% women) with AS, including 82 (61%) with severe AS and 52 (39%) with mild or moderate AS. LVOTA was traced using direct planimetry (LVOTAbiplane) and compared with LVOTA calculated using the circular assumption (LVOTAcirc). In a subset of patients who underwent cardiac computed tomography, direct planimetry of LVOTA was used as a reference standard. RESULTS LVOTAbiplane was significantly larger than LVOTAcirc (4.20 cm2 [interquartile range, 3.66-4.90 cm2] vs 3.73 cm2 [interquartile range, 3.14-4.15 cm2], P < .001). Among 30 patients who underwent cardiac computed tomography, LVOTAbiplane had better agreement with LVOTA by direct planimetry than LVOTAcirc (mean bias, -0.45 ± 0.63 vs -1.02 ± 0.63 cm2; P < .0001). Of 82 patients with severe AS (AVA ≤ 1 cm2 using LVOTAcirc), 40 (49%) had discordant mean gradient (<40 mm Hg). By using LVOTAbiplane, patients with discordant AVA and mean gradient decreased from 49% to 27% (P = .004), and 29% of patients with severe AS were reclassified with moderate AS, with the highest percentage of reclassification in the group with low-gradient AS with preserved left ventricular ejection fraction. CONCLUSIONS Direct planimetry using biplane imaging avoids the inherent underestimation of LVOTA using the circular assumption. LVOTA obtained by biplane planimetry can lead to better concordance between AVA and mean gradient and classification of AS severity.
Collapse
Affiliation(s)
- Shiying Liu
- Division of Cardiology, Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jessica Churchill
- Division of Cardiology, Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lanqi Hua
- Division of Cardiology, Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Xin Zeng
- Division of Cardiology, Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Valerie Rhoades
- Division of Cardiology, Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mayooran Namasivayam
- Division of Cardiology, Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Vinit Baliyan
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Brian B Ghoshhajra
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Tony Dong
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Jacob P Dal-Bianco
- Division of Cardiology, Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jonathan J Passeri
- Division of Cardiology, Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Robert A Levine
- Division of Cardiology, Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Judy Hung
- Division of Cardiology, Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
| |
Collapse
|
93
|
Altes A, Ringle A, Bohbot Y, Bouchot O, Appert L, Guerbaai RA, Gun M, Ennezat PV, Tribouilloy C, Maréchaux S. Clinical significance of energy loss index in patients with low-gradient severe aortic stenosis and preserved ejection fraction. Eur Heart J Cardiovasc Imaging 2020; 21:608-615. [DOI: 10.1093/ehjci/jeaa010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Revised: 07/31/2019] [Accepted: 01/10/2020] [Indexed: 11/14/2022] Open
Abstract
Abstract
Aims
We hypothesized that among patients with low-gradient severe aortic stenosis (AS) and preserved left ventricular ejection fraction (LVEF), reclassification of AS severity as moderate by pressure recovery adjusted indexed aortic valve area (AVAi) = energy loss index (ELI), may identify a subgroup of patients with a better outcome.
Methods and results
Three hundred and seventy-nine patients with low-gradient AS (defined by AVAi ≤ 0.6 cm2/m2 and mean aortic pressure gradient < 40 mmHg) and preserved LVEF ≥50% were studied. Reclassification as moderate AS by ELI was defined as AVAi ≤0.6 cm2/m2 but with an ELI >0.6 cm2/m2. Cardiac events [cardiac mortality and/or need for aortic valve replacement (AVR)] during follow-up were studied. One hundred and forty-eight patients (39%) were reclassified as moderate AS by ELI. Reclassification as moderate AS was independently associated with decreased body surface area, normal flow status, decreased left ventricular mass index, and left atrial volume index (all P < 0.05). After adjustment for variables of prognostic interest, reclassification as moderate AS by ELI was associated with a considerable reduction of risk of cardiac events {adjusted hazard ratio (HR) 0.49 [95% confidence interval (CI) 0.33–0.72]; P < 0.001}, need for AVR [adjusted HR 0.52 (95% CI 0.34–0.81); P = 0.004], and cardiac mortality [adjusted HR 0.46 (95% CI 0.22–0.98); P = 0.044].
Conclusion
In patients with low-gradient severe AS and preserved LVEF, calculation of ELI permits to reclassify almost 40% of patients as having moderate AS. These reclassified patients have a considerable reduction of the risk of cardiac events during follow-up. Calculation of ELI is useful for decision-making in patients with low-gradient severe AS and preserved ejection fraction.
Collapse
Affiliation(s)
- Alexandre Altes
- Cardiology Department, Echocardiography Laboratory, Heart Valve Center, GCS-Groupement des Hôpitaux de l’Institut Catholique Lillois/Faculté de médecine et de maïeutique, UCLille, Rue du Grand But - BP 249 59462 Lomme Cedex, France
| | - Anne Ringle
- Cardiology Department, Echocardiography Laboratory, Heart Valve Center, GCS-Groupement des Hôpitaux de l’Institut Catholique Lillois/Faculté de médecine et de maïeutique, UCLille, Rue du Grand But - BP 249 59462 Lomme Cedex, France
| | - Yohann Bohbot
- Cardiology Department, Centre Hospitalier Universitaire d’Amiens, Avenue Rene Laennec, 80054 Amiens Cedex 1, France
| | - Océane Bouchot
- Cardiology Department, Centre Hospitalier Universitaire de Grenoble, Avenue Maquis du Grésivaudan, 38700 La Tronche, France
| | - Ludovic Appert
- Cardiology Department, Echocardiography Laboratory, Heart Valve Center, GCS-Groupement des Hôpitaux de l’Institut Catholique Lillois/Faculté de médecine et de maïeutique, UCLille, Rue du Grand But - BP 249 59462 Lomme Cedex, France
| | - Raphaëlle A Guerbaai
- Department Public Health (DPH), Faculty of Medicine, University of Basel, Petersplatz 10, 4051 Basel, Switzerland
| | - Mesut Gun
- Cardiology Department, Centre Hospitalier Universitaire d’Amiens, Avenue Rene Laennec, 80054 Amiens Cedex 1, France
| | - Pierre Vladimir Ennezat
- Cardiology Department, Centre Hospitalier Universitaire de Grenoble, Avenue Maquis du Grésivaudan, 38700 La Tronche, France
| | - Christophe Tribouilloy
- Cardiology Department, Centre Hospitalier Universitaire d’Amiens, Avenue Rene Laennec, 80054 Amiens Cedex 1, France
- UR UPJV 7517, CURS-UFR de pharmacie, Laboratoire UPJCV, Université de Picardie, 1 chemin du Thil, 80000 Amiens, France
| | - Sylvestre Maréchaux
- Cardiology Department, Echocardiography Laboratory, Heart Valve Center, GCS-Groupement des Hôpitaux de l’Institut Catholique Lillois/Faculté de médecine et de maïeutique, UCLille, Rue du Grand But - BP 249 59462 Lomme Cedex, France
- UR UPJV 7517, CURS-UFR de pharmacie, Laboratoire UPJCV, Université de Picardie, 1 chemin du Thil, 80000 Amiens, France
| |
Collapse
|
94
|
Allometric versus ratiometric normalization of left ventricular stroke volume by Doppler-echocardiography for outcome prediction in severe aortic stenosis with preserved ejection fraction. Int J Cardiol 2020; 301:235-241. [DOI: 10.1016/j.ijcard.2019.09.056] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 08/16/2019] [Accepted: 09/25/2019] [Indexed: 01/11/2023]
|
95
|
Moderate Aortic Stenosis and Heart Failure With Reduced Ejection Fraction: Can Imaging Guide Us to Therapy? JACC Cardiovasc Imaging 2020; 12:172-184. [PMID: 30621989 DOI: 10.1016/j.jcmg.2018.10.021] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 10/17/2018] [Accepted: 10/18/2018] [Indexed: 11/21/2022]
Abstract
Clinical management of patients with only moderate aortic stenosis (AS) but symptoms of heart failure with a reduced left ventricular ejection fraction (HFrEF) is challenging. Current guidelines recommend clinical surveillance with multimodality imaging; aortic valve replacement (AVR) is deferred until the stenosis becomes severe. Given the known benefits of afterload reduction in management of patients with HFrEF, it has been hypothesized that AVR may be beneficial in patients with only moderate AS who present with HFrEF. In this article, we first review the current approach for management of patients with moderate AS and HFrEF based on close clinical and imaging surveillance with AVR delayed until AS is severe. We then discuss the case for transcatheter AVR (TAVR) earlier in the disease course, when AS is moderate, based on stress echocardiographic data. We conclude with a detailed summary of the TAVR UNLOAD (Transcatheter Aortic Valve Replacement to UNload the Left Ventricle in Patients With ADvanced Heart Failure) trial, in which patients with moderate AS and HFrEF are randomized to guideline-directed heart failure therapy alone versus guideline-directed heart failure therapy plus TAVR.
Collapse
|
96
|
Pibarot P, Sengupta P, Chandrashekhar Y. Imaging Is the Cornerstone of the Management of Aortic Valve Stenosis. JACC Cardiovasc Imaging 2020; 12:220-223. [PMID: 30621995 DOI: 10.1016/j.jcmg.2018.12.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Philippe Pibarot
- Department of Cardiology, Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Partho Sengupta
- Division of Cardiology, West Virginia University Heart and Vascular Institute, West Virginia University, Morgantown, West Virginia
| | - Y Chandrashekhar
- Division of Cardiology, University of Minnesota and Veterans Affairs Medical Center, Minneapolis, Minnesota.
| |
Collapse
|
97
|
Schewel J, Schlüter M, Schmidt T, Kuck KH, Frerker C, Schewel D. Early haemodynamic changes and long-term outcome of patients with severe low-gradient aortic stenosis after transcatheter aortic valve replacement. EUROINTERVENTION 2020; 15:1181-1189. [DOI: 10.4244/eij-d-19-00399] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
|
98
|
Altes A, Thellier N, Bohbot Y, Marsou W, Chadha G, Binda C, Ringle A, Mailliet A, Marotte N, Riolet C, Tribouilloy C, Maréchaux S. Prognostic Impact of the Ratio of Acceleration Time to Ejection Time in Patients With Low Gradient Severe Aortic Stenosis and Preserved Ejection Fraction. Am J Cardiol 2019; 124:1594-1600. [PMID: 31522771 DOI: 10.1016/j.amjcard.2019.07.064] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 07/30/2019] [Accepted: 07/31/2019] [Indexed: 11/17/2022]
Abstract
The clinical management of patients with low gradient severe aortic stenosis (LG-SAS) and preserved left ventricular ejection fraction (LVEF) remains challenging owing to their heterogeneity. The aim to this study was to evaluate the relation between an ejection dynamic parameter linked to AS severity and outcome, the ratio of acceleration time (AT) to ejection time (ET), in a cohort of patients with LG-SAS and preserved LVEF. Three hundred and fifty-six patients with LG-AS (defined by AVA ≤1 cm² and/or AVAi ≤0.6 cm²/m² and mean aortic pressure gradient <40 mm Hg) and preserved LVEF ≥50% were studied. The relation between AT/ET and all-cause and cardiac mortality during follow-up was studied. Median follow-up was 41 months (interquartile range, 35 to 47 months). Median AT/ET was 0.32 (interquartile range, 0.29 to 0.36). The 5-year estimates of all-cause and cardiac mortality were respectively 57 ± 7%, 36 ± 7% for patients with AT/ET >0.36 versus 43 ± 4%, 16 ± 3% for patients with AT/ET ≤0.36 (p = 0.024 and p <0.001, respectively). After adjustment on known predictors of outcome including aortic valve replacement used as a time-dependent covariate, there was a significant increase in all-cause mortality risk for patients with AT/ET >0.36 (adjusted hazard ratio 2.04 [95% confidence interval, 1.32 to 3.13]; p = 0.001) and cardiac mortality risk (adjusted hazard ratio 2.89 [95% confidence interval, 1.54 to 5.43]; p<0.001) compared with patients with AT/ET ≤0.36. The association of AT/ET >0.36 and all-cause or cardiac mortality risk was consistent in subgroups of patients with LG-SAS and preserved EF. In conclusion, an AT/ET ratio of more than 0.36 is an independent predictor of mortality in patients with LG-SAS and preserved EF.
Collapse
Affiliation(s)
- Alexandre Altes
- Université Lille Nord de France, GCS-Groupement des Hôpitaux de l'Institut Catholique de Lille, Laboratoire d'échocardiographie, service de cardiologie, Centre des Valvulopathies, Faculté de Médecine et de Maïeutique, Université Catholique de Lille, Lille, France
| | - Nicolas Thellier
- Université Lille Nord de France, GCS-Groupement des Hôpitaux de l'Institut Catholique de Lille, Laboratoire d'échocardiographie, service de cardiologie, Centre des Valvulopathies, Faculté de Médecine et de Maïeutique, Université Catholique de Lille, Lille, France; Laboratoire UPJCV, Université de Picardie, Amiens, France
| | - Yohann Bohbot
- Centre Hospitalier Universitaire d'Amiens, Amiens, France; Laboratoire UPJCV, Université de Picardie, Amiens, France
| | - Wassima Marsou
- Université Lille Nord de France, GCS-Groupement des Hôpitaux de l'Institut Catholique de Lille, Laboratoire d'échocardiographie, service de cardiologie, Centre des Valvulopathies, Faculté de Médecine et de Maïeutique, Université Catholique de Lille, Lille, France
| | | | - Camille Binda
- Université Lille Nord de France, GCS-Groupement des Hôpitaux de l'Institut Catholique de Lille, Laboratoire d'échocardiographie, service de cardiologie, Centre des Valvulopathies, Faculté de Médecine et de Maïeutique, Université Catholique de Lille, Lille, France
| | - Anne Ringle
- Université Lille Nord de France, GCS-Groupement des Hôpitaux de l'Institut Catholique de Lille, Laboratoire d'échocardiographie, service de cardiologie, Centre des Valvulopathies, Faculté de Médecine et de Maïeutique, Université Catholique de Lille, Lille, France
| | - Amandine Mailliet
- Université Lille Nord de France, GCS-Groupement des Hôpitaux de l'Institut Catholique de Lille, Laboratoire d'échocardiographie, service de cardiologie, Centre des Valvulopathies, Faculté de Médecine et de Maïeutique, Université Catholique de Lille, Lille, France
| | - Nathalie Marotte
- Université Lille Nord de France, GCS-Groupement des Hôpitaux de l'Institut Catholique de Lille, Laboratoire d'échocardiographie, service de cardiologie, Centre des Valvulopathies, Faculté de Médecine et de Maïeutique, Université Catholique de Lille, Lille, France
| | - Clemence Riolet
- Université Lille Nord de France, GCS-Groupement des Hôpitaux de l'Institut Catholique de Lille, Laboratoire d'échocardiographie, service de cardiologie, Centre des Valvulopathies, Faculté de Médecine et de Maïeutique, Université Catholique de Lille, Lille, France
| | - Christophe Tribouilloy
- Centre Hospitalier Universitaire d'Amiens, Amiens, France; Laboratoire UPJCV, Université de Picardie, Amiens, France
| | - Sylvestre Maréchaux
- Université Lille Nord de France, GCS-Groupement des Hôpitaux de l'Institut Catholique de Lille, Laboratoire d'échocardiographie, service de cardiologie, Centre des Valvulopathies, Faculté de Médecine et de Maïeutique, Université Catholique de Lille, Lille, France; Laboratoire UPJCV, Université de Picardie, Amiens, France.
| |
Collapse
|
99
|
Bridonneau V, Galli E, Auffret V, Lederlin M, Campion M, Le Breton H, Boulmier D, Hubert A, Lenz PA, Leclercq C, Oger E, Donal E. Management of aortic valve replacement according to the gradient across symptomatic aortic valve stenosis and its prognostic impact. Echocardiography 2019; 36:2136-2144. [PMID: 31705575 DOI: 10.1111/echo.14531] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Revised: 10/14/2019] [Accepted: 10/15/2019] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Treatment strategy for low-gradient (LG) aortic stenosis (AS) remains an unresolved issue. The presence of a low aortic gradient and preserved left ventricular ejection fraction (LVEF) might lead toward the underestimation of aortic stenosis severity and a more conservative management. We sought (a) to describe the nature and timing of intervention according to flow/gradient subgroups in patibents with LG-AS, (2) to determine the factors associated with the decision to intervene, and (c) to describe prognosis. METHODS AND RESULTS One hundred and ten patients prospectively included in this study underwent a standardized clinical and imaging evaluation at inclusion and at 1-year follow-up. According to aortic flow, gradient and LVEF, patients were divided into 4 groups: LG-normal flow [n = 27], LG-low flow-low LVEF [n = 27], LG-low flow-normal LVEF [n = 16], and high gradient (HG) [n = 40]). 73% of patients underwent AVR 86 ± 59 days after the initial assessment. The HG subgroup had significantly higher intervention rates (P < .001). In multivariable analysis, four parameters were associated with the AVR: aortic gradient (HR 1.52 [1.10-2.11], P = .012), LVEF (HR 0.58 [0.40-0.85], P = .006), atrial fibrillation (HR 0.43 [0.021-0.87], P = .019), and NT-proBNP (HR 0.92[0.86-0.98), P = .008]. Patients operated earlier had better outcomes than those having a delayed AVR (P = .042). LG-AS patients had worse outcomes than HG-AS patients (P < .001). CONCLUSION Compared to HG-AS, LG-AS is less likely to benefit from an AVR and had a significantly worse outcome. Further interventional studies are needed to investigate the timing of AVR in these patients.
Collapse
Affiliation(s)
- Valentin Bridonneau
- Service de Cardiologie, Inserm LTSI-UMR1099, CHU Rennes, Université Rennes 1, Rennes, France.,Imagerie médicale, CHU Rennes, Rennes, France.,Pharmacologie Clinique et CIC-IP 1414, CHU Rennes et Université Rennes-1, Rennes, France
| | - Elena Galli
- Service de Cardiologie, Inserm LTSI-UMR1099, CHU Rennes, Université Rennes 1, Rennes, France.,Imagerie médicale, CHU Rennes, Rennes, France.,Pharmacologie Clinique et CIC-IP 1414, CHU Rennes et Université Rennes-1, Rennes, France
| | - Vincent Auffret
- Service de Cardiologie, Inserm LTSI-UMR1099, CHU Rennes, Université Rennes 1, Rennes, France.,Imagerie médicale, CHU Rennes, Rennes, France.,Pharmacologie Clinique et CIC-IP 1414, CHU Rennes et Université Rennes-1, Rennes, France
| | - Mathieu Lederlin
- Service de Cardiologie, Inserm LTSI-UMR1099, CHU Rennes, Université Rennes 1, Rennes, France.,Imagerie médicale, CHU Rennes, Rennes, France.,Pharmacologie Clinique et CIC-IP 1414, CHU Rennes et Université Rennes-1, Rennes, France
| | - Marine Campion
- Service de Cardiologie, Inserm LTSI-UMR1099, CHU Rennes, Université Rennes 1, Rennes, France.,Imagerie médicale, CHU Rennes, Rennes, France.,Pharmacologie Clinique et CIC-IP 1414, CHU Rennes et Université Rennes-1, Rennes, France
| | - Herve Le Breton
- Service de Cardiologie, Inserm LTSI-UMR1099, CHU Rennes, Université Rennes 1, Rennes, France.,Imagerie médicale, CHU Rennes, Rennes, France.,Pharmacologie Clinique et CIC-IP 1414, CHU Rennes et Université Rennes-1, Rennes, France
| | - Dominique Boulmier
- Service de Cardiologie, Inserm LTSI-UMR1099, CHU Rennes, Université Rennes 1, Rennes, France.,Imagerie médicale, CHU Rennes, Rennes, France.,Pharmacologie Clinique et CIC-IP 1414, CHU Rennes et Université Rennes-1, Rennes, France
| | - Arnaud Hubert
- Service de Cardiologie, Inserm LTSI-UMR1099, CHU Rennes, Université Rennes 1, Rennes, France.,Imagerie médicale, CHU Rennes, Rennes, France.,Pharmacologie Clinique et CIC-IP 1414, CHU Rennes et Université Rennes-1, Rennes, France
| | - Pierre-Axel Lenz
- Service de Cardiologie, Inserm LTSI-UMR1099, CHU Rennes, Université Rennes 1, Rennes, France.,Imagerie médicale, CHU Rennes, Rennes, France.,Pharmacologie Clinique et CIC-IP 1414, CHU Rennes et Université Rennes-1, Rennes, France
| | - Christophe Leclercq
- Service de Cardiologie, Inserm LTSI-UMR1099, CHU Rennes, Université Rennes 1, Rennes, France.,Imagerie médicale, CHU Rennes, Rennes, France.,Pharmacologie Clinique et CIC-IP 1414, CHU Rennes et Université Rennes-1, Rennes, France
| | - Emmanuel Oger
- Service de Cardiologie, Inserm LTSI-UMR1099, CHU Rennes, Université Rennes 1, Rennes, France.,Imagerie médicale, CHU Rennes, Rennes, France.,Pharmacologie Clinique et CIC-IP 1414, CHU Rennes et Université Rennes-1, Rennes, France
| | - Erwan Donal
- Service de Cardiologie, Inserm LTSI-UMR1099, CHU Rennes, Université Rennes 1, Rennes, France.,Imagerie médicale, CHU Rennes, Rennes, France.,Pharmacologie Clinique et CIC-IP 1414, CHU Rennes et Université Rennes-1, Rennes, France
| |
Collapse
|
100
|
Low Gradient Aortic Stenosis: Role of Echocardiography. CURRENT CARDIOVASCULAR IMAGING REPORTS 2019. [DOI: 10.1007/s12410-019-9518-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|