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Galusko V, Thornton G, Jozsa C, Sekar B, Aktuerk D, Treibel TA, Petersen SE, Ionescu A, Ricci F, Khanji MY. Aortic regurgitation management: a systematic review of clinical practice guidelines and recommendations. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2022; 8:113-126. [PMID: 35026012 DOI: 10.1093/ehjqcco/qcac001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 01/05/2022] [Indexed: 11/13/2022]
Abstract
Guidelines for the diagnosis and management of aortic regurgitation (AR) contain recommendations that do not always match. We systematically reviewed clinical practice guidelines and summarized similarities and differences in the recommendations as well as gaps in evidence on the management of AR. We searched MEDLINE and Embase (1 January 2011 to 1 September 2021), Google Scholar, and websites of relevant organizations for contemporary guidelines that were rigorously developed as assessed by the Appraisal of Guidelines for Research and Evaluation II tool. Three guidelines met our inclusion criteria. There was consensus on the definition of severe AR and use of echocardiography and of multimodality imaging for diagnosis, with emphasis on comprehensive assessment by the heart valve team to assess suitability and choice of intervention. Surgery is indicated in all symptomatic patients and aortic valve replacement is the cornerstone of treatment. There is consistency in the frequency of follow-up of patients, and safety of non-cardiac surgery in patients without indications for surgery. Discrepancies exist in recommendations for 3D imaging and the use of global longitudinal strain and biomarkers. Cut-offs for left ventricular ejection fraction and size for recommending surgery in severe asymptomatic AR also vary. There are no specific AR cut-offs for high-risk surgery and the role of percutaneous intervention is yet undefined. Recommendations on the treatment of mixed valvular disease are sparse and lack robust prospective data.
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Affiliation(s)
- Victor Galusko
- Department of Cardiology, King's College Hospital, London SE5 9RS, UK
| | - George Thornton
- Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London EC1A 7BE, UK
- Institute of Cardiovascular Science, University College London, London WC1E 6DD, UK
| | - Csilla Jozsa
- Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London EC1A 7BE, UK
- Department of Cardiology, Newham University Hospital, Barts Health NHS Trust, Glen Road, London E13 8SL, UK
| | - Baskar Sekar
- Department of Cardiology, Gloucestershire Hospitals NHS Foundation Trust, Gloucester GL1 3NN, UK
| | - Dincer Aktuerk
- Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London EC1A 7BE, UK
| | - Thomas A Treibel
- Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London EC1A 7BE, UK
- Institute of Cardiovascular Science, University College London, London WC1E 6DD, UK
| | - Steffen E Petersen
- Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London EC1A 7BE, UK
- NIHR Barts Biomedical Research Centre, William Harvey Research Institute, Queen Mary University of London, London EC1A 7BE, UK
| | - Adrian Ionescu
- Morriston Hospital, UK Cardiac Regional Centre, Swansea Bay Health Board, Swansea SA6 6NL, UK
| | - Fabrizio Ricci
- Department of Neuroscience, Imaging and Clinical Sciences, 'G.d'Annunzio' University of Chieti-Pescara, 66100 Chieti, Italy
- Department of Clinical Sciences, Lund University, Jan Waldenströms gata 35, -205 02, Malmö, Sweden
- Casa di Cura Villa Serena, 65013 Città Sant'Angelo, Pescara, Italy
| | - Mohammed Y Khanji
- Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London EC1A 7BE, UK
- Department of Cardiology, Newham University Hospital, Barts Health NHS Trust, Glen Road, London E13 8SL, UK
- NIHR Barts Biomedical Research Centre, William Harvey Research Institute, Queen Mary University of London, London EC1A 7BE, UK
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Tower-Rader A, Mathias IS, Obuchowski NA, Kocyigit D, Kumar Y, Donnellan E, Bolen M, Phelan D, Flamm S, Griffin B, Cho L, Svensson LG, Pettersson G, Popovic Z, Kwon D. Sex-based differences in left ventricular remodeling in patients with chronic aortic regurgitation: a multi-modality study. J Cardiovasc Magn Reson 2022; 24:12. [PMID: 35193584 PMCID: PMC8862390 DOI: 10.1186/s12968-022-00845-5] [Citation(s) in RCA: 1] [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: 08/20/2021] [Accepted: 01/16/2022] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Significant aortic regurgitation (AR) leads to left ventricular (LV) remodeling; however, little data exist regarding sex-based differences in LV remodeling in this setting. We sought to compare LV remodeling and AR severity, assessed by echocardiography and cardiovascular magnetic resonance (CMR), to discern sex-based differences. METHODS Patients with ≥ moderate chronic AR by echocardiography who underwent CMR within 90 days between December 2005 and October 2015 were included. Nonlinear regression models were built to assess the effect of AR regurgitant fraction (RF) on LV remodeling. A generalized linear model and Bland Altman analyses were constructed to evaluate differences between CMR and echocardiography. Referral for surgical intervention based on symptoms and LV remodeling was evaluated. RESULTS Of the 243 patients (48.3 ± 16.6 years, 58 (24%) female), 119 (49%) underwent surgical intervention with a primary indication of severe AR, 97 (82%) men, 22 (18%) women. Significant sex differences in LV remodeling emerged on CMR. Women demonstrated significantly smaller LV end-diastolic volume index (LVEDVI) (96.8 ml/m2 vs 125.6 ml/m2, p < 0.001), LV end-systolic volume index (LVESVI) (41.1 vs 54.5 ml/m2, p < 0.001), blunted LV dilation in the setting of increasing AR severity (LVEDVI p value < 0.001, LVESVI p value 0.011), and LV length indexed (8.32 vs 9.69 cm, p < 0.001). On Bland Altman analysis, a significant interaction with sex and LV diameters was evident, demonstrating a significant increase in the difference between CMR and echocardiography measurements as the LV enlarged in women: LVEDVI (p = 0.006), LVESVI (p < 0.001), such that echocardiographic measurements increasingly underestimated LV diameters in women as the LV enlarged. LV length was higher for males with a linear effect from RF (p < 0.001), with LV length increasing at a higher rate with increasing RF for males compared to females (two-way interaction with sex p = 0.005). Sphericity volume index was higher for men after adjusting for a relative wall thickness (p = 0.033). CONCLUSIONS CMR assessment of chronic AR revealed significant sex differences in LV remodeling and significant echocardiographic underestimation of LV dilation, particularly in women. Defining optimal sex-based CMR thresholds for surgical referral should be further developed. TRIAL REGISTRATION NA.
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Affiliation(s)
- Albree Tower-Rader
- Department of Cardiology, Harvard Medical School, Massachusetts General Hospital, 55 Fruit St, Yawkey 5B, Boston, MA, 02114, USA
| | - Isadora Sande Mathias
- Department of Cardiology, Houston Methodist Hospital, Weill Cornell Medical College, 6565 Fannin St., Houston, TX, 77030, USA
| | - Nancy A Obuchowski
- Quantitative Health Sciences, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
| | - Duygu Kocyigit
- Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
| | - Yash Kumar
- Case Western University, 10900 Euclid Ave, Cleveland, OH, 44106-7017, USA
| | - Eoin Donnellan
- Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
| | - Michael Bolen
- Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
| | - Dermot Phelan
- Sanger Heart & Vascular Institute, Atrium Health, 1237 Harding Place, MOB1 Suite 5000, Charlotte, NC, 28204, USA
| | - Scott Flamm
- Imaging Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
| | - Brian Griffin
- Imaging Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
| | - Leslie Cho
- Imaging Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
| | - Lars G Svensson
- Imaging Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
| | - Gosta Pettersson
- Imaging Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
| | - Zoran Popovic
- Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
- Imaging Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
| | - Deborah Kwon
- Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA.
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Kubala M, de Chillou C, Bohbot Y, Lancellotti P, Enriquez-Sarano M, Tribouilloy C. Arrhythmias in Patients With Valvular Heart Disease: Gaps in Knowledge and the Way Forward. Front Cardiovasc Med 2022; 9:792559. [PMID: 35242822 PMCID: PMC8885812 DOI: 10.3389/fcvm.2022.792559] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 01/19/2022] [Indexed: 11/13/2022] Open
Abstract
The prevalence of both organic valvular heart disease (VHD) and cardiac arrhythmias is high in the general population, and their coexistence is common. Both VHD and arrhythmias in the elderly lead to an elevated risk of hospitalization and use of health services. However, the relationships of the two conditions is not fully understood and our understanding of their coexistence in terms of contemporary management and prognosis is still limited. VHD-induced left ventricular dysfunction/hypertrophy and left atrial dilation lead to both atrial and ventricular arrhythmias. On the other hand, arrhythmias can be considered as an independent condition resulting from a coexisting ischemic or non-ischemic substrate or idiopathic ectopy. Both atrial and ventricular VHD-induced arrhythmias may contribute to clinical worsening and be a turning point in the natural history of VHD. Symptoms developed in patients with VHD are not specific and may be attributable to hemodynamical consequences of valve disease but also to other cardiac conditions including arrhythmias which are notably prevalent in this population. The issue how to distinguish symptoms related to VHD from those related to atrial fibrillation (AF) during decision making process remains challenging. Moreover, AF is a traditional limit of echocardiography and an important source of errors in assessment of the severity of VHD. Despite recent progress in understanding the pathophysiology and prognosis of postoperative AF, many questions remain regarding its prevention and management. Furthermore, life-threatening ventricular arrhythmias can predispose patients with VHD to sudden cardiac death. Evidence for a putative link between arrhythmias and outcome in VHD is growing but available data on targeted therapies for VHD-related arrhythmias, including monitoring and catheter ablation, is scarce. Despite growing evidences, more research focused on the prognosis and optimal management of VHD-related arrhythmias is still required. We aimed to review the current evidence and identify gaps in knowledge about the prevalence, prognostic considerations, and treatment of atrial and ventricular arrhythmias in common subtypes of organic VHD.
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Affiliation(s)
- Maciej Kubala
- Department of Cardiology, Amiens University Hospital, Amiens, France
- Jules Verne University of Picardie, Amiens, France
| | - Christian de Chillou
- Department of Cardiology, University Hospital Nancy, Vandœuvre lès Nancy, France
| | - Yohann Bohbot
- Department of Cardiology, Amiens University Hospital, Amiens, France
- Jules Verne University of Picardie, Amiens, France
| | - Patrizio Lancellotti
- Department of Cardiology, GIGA Cardiovascular Sciences, University of Liège Hospital, Valvular Disease Clinic, CHU Sart Tilman, Liège, Belgium
| | - Maurice Enriquez-Sarano
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, MN, United States
| | - Christophe Tribouilloy
- Department of Cardiology, Amiens University Hospital, Amiens, France
- Jules Verne University of Picardie, Amiens, France
- *Correspondence: Christophe Tribouilloy
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54
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Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W. 2021 ESC/EACTS Guidelines for the management of valvular heart disease. EUROINTERVENTION 2022; 17:e1126-e1196. [PMID: 34931612 PMCID: PMC9725093 DOI: 10.4244/eij-e-21-00009] [Citation(s) in RCA: 106] [Impact Index Per Article: 53.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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55
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Lu Y, Yang Y, Liu H, Wang W, Chen J, Liu S, Dong L, Huang L, Zhu L, Wang C, Wang C, Wei L. Short-Term Outcomes After Transcatheter Aortic Valve Replacement in Predominant Aortic Regurgitation with Left Ventricular Dysfunction. Int Heart J 2022; 63:30-35. [DOI: 10.1536/ihj.21-360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Yuntao Lu
- Department of Cardiac Surgery, Zhongshan Hospital, Fudan University
| | - Ye Yang
- Department of Cardiac Surgery, Zhongshan Hospital, Fudan University
| | - Huan Liu
- Department of Cardiac Surgery, Zhongshan Hospital, Fudan University
| | - Wenshuo Wang
- Department of Cardiac Surgery, Zhongshan Hospital, Fudan University
| | - Jinmiao Chen
- Department of Cardiac Surgery, Zhongshan Hospital, Fudan University
| | - Shun Liu
- Shanghai Engineering Research Center of Heart Valve
| | - Lili Dong
- Department of Echocardiography, Zhongshan Hospital, Fudan University
| | - Liqi Huang
- Department of Cardiac Surgery, Zhongshan Hospital, Fudan University
| | - Liming Zhu
- Department of Cardiac Surgery, Zhongshan Hospital, Fudan University
| | - Chenghao Wang
- Department of Nursing, Zhongshan Hospital Fudan University
| | - Chunsheng Wang
- Department of Cardiac Surgery, Zhongshan Hospital, Fudan University
| | - Lai Wei
- Shanghai Engineering Research Center of Heart Valve
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56
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Liu L, Yao X, Peng Y, Huang W, Jun S, Qian H, Chen Y, Guo Y. One-year outcome after transcatheter aortic valve replacement for aortic regurgitation: A single-center study. J Card Surg 2022; 37:882-892. [PMID: 35043502 DOI: 10.1111/jocs.16238] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 11/12/2021] [Accepted: 12/22/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Presently, there are limited reports in the literature on the postoperative (midterm) clinical outcome for pure aortic regurgitation (AR) following transcatheter aortic valve replacement (TAVR). METHODS Between March 2014 and June 2019, a total of 134 high-risk patients with pure, symptomatic severe AR patients were enrolled in the current study. The outcome was assessed according to the Valve Academic Research Consortium-2 criteria. Procedural results, clinical outcomes, and the patients' hemodynamics for a period of 1 year were analyzed. RESULTS The patient mean was 73.1 ± 6.4 years and 25.4% were female. The average Society of Thoracic Surgeons score was 9.8 ± 5.3%. Procedural success was 97.1% (130/134), and the device success rate was 96.3% (129/134). Five cases were converted to open surgery, while two patients underwent valvular reinterventions (surgical aortic valve replacement for thrombosis and increasing paravalvular regurgitation). The mean aortic valve gradient was 10.2 ± 4.1 mmHg, while the moderate and severe AR was 1.6% at 1 year. Paravalvular regurgitation was none/trivial in 79.8% and mild in 18.5%. The 1-year all-cause mortality rate was 7.4%. At 1 year, the stroke incidence rate was 2.2%, and a pacemaker was implanted in 8.9% of the enrolled patients. CONCLUSIONS In high-risk patients undergoing transapical TAVR for AR, the use of the J-Valve is safe, and effective TAVR should be considered as a reasonable option for high-risk patients with pure AR.
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Affiliation(s)
- Lulu Liu
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xiaoling Yao
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Ying Peng
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Weina Huang
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Shi Jun
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Hong Qian
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yilong Chen
- Biomedical Big Data Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yingqiang Guo
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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57
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Soong EL, Ong YJ, Ho JS, Chew NW, Kong WK, Yeo TC, Chai P, Tay EL, Tan K, Lim Y, Kuntjoro I, Sia CH. Transcatheter aortic valve replacement for aortic regurgitation in Asians: TAVR for aortic regurgitation in Asians. ASIAINTERVENTION 2021; 7:103-111. [PMID: 34913014 PMCID: PMC8670568 DOI: 10.4244/aij-d-21-00007] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 09/10/2021] [Indexed: 04/26/2023]
Abstract
AIMS Although surgical aortic valve replacement (SAVR) is currently the recommended intervention for patients with native AR without aortic stenosis, a significant proportion of Asian patients undergo transcatheter aortic valve replacement (TAVR), which has not been studied fully for safety and outcomes. This systematic review aims to examine the characteristics and outcomes of Asian patients with pure native aortic regurgitation (AR) undergoing TAVR. METHODS AND RESULTS PubMed, Embase, Scopus, Web of Science and Cochrane CENTRAL were systematically searched for randomised controlled trials, observational studies and case reports published from inception to 2 April 2020, involving patients of Asian ethnicity with pure native aortic regurgitation who had undergone TAVR. Our primary outcome was all-cause mortality, with secondary outcomes including all major complications. Five studies (n=274 patients) and eight case reports were included. Device success was reported in 94.9% of the patients, the all-cause mortality rate was 4.4%, 2.5% were converted to SAVR, 1.7% had post-operative paravalvular leak and 6.7% required permanent pacemaker implantation. CONCLUSIONS TAVR has demonstrated acceptable safety and efficacy in Asian patients with pure AR displaying low mortality rates and few adverse outcomes.
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Affiliation(s)
- Erica L. Soong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Yi Jing Ong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Jamie S.Y Ho
- Academic Foundation Programme, North Middlesex University Hospital NHS Trust, London, United Kingdom
| | - Nichola W.S. Chew
- Department of Cardiology, National University Heart Centre Singapore, Singapore
| | - William K.F. Kong
- Department of Cardiology, National University Heart Centre Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Tiong-Cheng Yeo
- Department of Cardiology, National University Heart Centre Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Ping Chai
- Department of Cardiology, National University Heart Centre Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Edgar L.W. Tay
- Department of Cardiology, National University Heart Centre Singapore, Singapore
| | - Kent Tan
- Department of Cardiology, National University Heart Centre Singapore, Singapore
| | - Yinghao Lim
- Department of Cardiology, National University Heart Centre Singapore, Singapore
| | - Ivandito Kuntjoro
- Department of Cardiology, National University Heart Centre Singapore, Singapore
| | - Ching-Hui Sia
- National University Heart Centre Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 9, Singapore 119228. E-mail:
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Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W. 2021 ESC/EACTS Guidelines for the management of valvular heart disease. Eur J Cardiothorac Surg 2021; 60:727-800. [PMID: 34453161 DOI: 10.1093/ejcts/ezab389] [Citation(s) in RCA: 301] [Impact Index Per Article: 100.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
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Bredin F, Franco-Cereceda A. Long-term follow-up of passive containment surgery in patients with aortic regurgitation. Interact Cardiovasc Thorac Surg 2021; 34:999-1001. [PMID: 34664073 PMCID: PMC9159436 DOI: 10.1093/icvts/ivab273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 07/23/2021] [Accepted: 08/13/2021] [Indexed: 11/20/2022] Open
Abstract
The goal of this case-control study was to evaluate the long-term effects on cardiac dimensions, cardiac function and coronary circulation in patients with aortic regurgitation (AR) and left ventricular dilatation undergoing aortic valve replacement and application of the Acorn CorCap cardiac support device Of 10 patients with AR and ventricular dilatation who had a mechanical aortic valve implanted, 5 in addition received the cardiac support device. Cardiac dimensions and cardiac function were measured by echocardiography preoperatively and 1, 5 and 10 years postoperatively. The coronary circulation was assessed by computed tomography angiography. After aortic valve replacement, there was a rapid and sustained decrease in cardiac dimensions. This result did not differ after application of the cardiac support device. Improvement in cardiac function remained unchanged in both groups at the 10-year follow-up. None of the patients had developed any signs of coronary artery disease. Application of the Acorn CorCap cardiac support device in patients with AR and left ventricular dilatation did not add to the reversed remodelling or cardiac function at the long-term follow-up compared to aortic valve replacement alone.
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Affiliation(s)
- Fredrik Bredin
- Section of Cardiothoracic Surgery, Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - Anders Franco-Cereceda
- Section of Cardiothoracic Surgery, Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
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Lagerstrand KM, Truedsson F, Gao SA, Johansson A, Bech-Hanssen O, Polte CL, Johnsson ÅA. Importance of through-plane heart motion correction for the assessment of aortic regurgitation severity using phase contrast magnetic resonance imaging. Magn Reson Imaging 2021; 84:69-75. [PMID: 34560232 DOI: 10.1016/j.mri.2021.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 09/11/2021] [Accepted: 09/16/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE To elucidate the influence of through-plane heart motion on the assessment of aortic regurgitation (AR) severity using phase contrast magnetic resonance imaging (PC-MRI). APPROACH A patient cohort with chronic AR (n = 34) was examined with PC-MRI. The regurgitant volume (RVol) and fraction (RFrac) were extracted from the PC-MRI data before and after through-plane heart motion correction and was then used for assessment of AR severity. RESULTS The flow volume errors were strongly correlated to aortic diameter (R = 0.80, p < 0.001) with median (IQR 25%;75%): 16 (14; 17) ml for diameter>40mm, compared with 9 (7; 10) ml for normal aortic size (p < 0.001). RVol and RFrac were underestimated (uncorrected:64 ± 37 ml and 39 ± 17%; corrected:76 ± 37 ml and 44 ± 15%; p < 0.001) and ~ 20% of the patients received lower severity grade without correction. CONCLUSION Through-plane heart motion introduces relevant flow volume errors, especially in patients with aortic dilatation that may result in underestimation of the severity grade in patients with chronic AR.
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Affiliation(s)
- Kerstin M Lagerstrand
- Department of Radiation Physics, Institute of Clinical Sciences, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden; Department of Medical Physics and Biomedical Engineering, Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - Frida Truedsson
- Department of Radiation Physics, Institute of Clinical Sciences, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden; Department of Medical Physics and Biomedical Engineering, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Sinsia A Gao
- Department of Molecular and Clinical Medicine, Institute of Medicine, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden; Department of Clinical Physiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Alexander Johansson
- Department of Radiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Odd Bech-Hanssen
- Department of Molecular and Clinical Medicine, Institute of Medicine, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden; Department of Clinical Physiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Christian L Polte
- Department of Molecular and Clinical Medicine, Institute of Medicine, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden; Department of Clinical Physiology, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Åse A Johnsson
- Department of Radiology, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Radiology, Institute of Clinical Sciences, The Sahlgrenska Academy at University of Gothenburg, Sweden
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Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W. 2021 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J 2021; 43:561-632. [PMID: 34453165 DOI: 10.1093/eurheartj/ehab395] [Citation(s) in RCA: 2034] [Impact Index Per Article: 678.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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62
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Amano M, Izumi C. Optimal Management of Chronic Severe Aortic Regurgitation - How to Determine Cutoff Values for Surgical Intervention? Circ J 2021; 86:1691-1698. [PMID: 34456205 DOI: 10.1253/circj.cj-21-0652] [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] [Indexed: 11/09/2022]
Abstract
Aortic regurgitation (AR) is a common valvular heart disease, but the optimal timing of surgical intervention remains controversial. In the natural history of chronic severe AR, sudden death is rare, and the annual mortality rate is comparatively low. Considering the hemodynamic features of combined volume and pressure overload and long-term compensation in patients with chronic AR, symptoms related to AR do not frequently occur. Therefore, the progression of left ventricular (LV) dysfunction is a key factor in determining the timing of surgical intervention in patients with severe chronic AR. In addition to symptoms, an ejection fraction <50% and an LV endsystolic diameter (LVESD) >45 mm are appropriate cutoff values for surgical intervention in Japanese patients, whereas LV end-diastolic diameter is not a good indicator. An LVESD index of 25 mm/m2is controversial, because adjusting for body size may cause overcorrection in Japanese patients who have a small body size compared with Westerners. Accumulation of data from the Japanese population is indispensable for establishing guidelines on optimal management of patients with chronic AR.
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Affiliation(s)
- Masashi Amano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Chisato Izumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
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63
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Reil JC, Reil GH, Hecker N, Sequeira V, Borer JS, Stierle U, Lavall D, Marquetand C, Busch C, Patzelt J, Heringlake M, Schäfers HJ, Sievers HH, Ensminger S, Aboud A. Reduced left ventricular contractility, increased diastolic operant stiffness and high energetic expenditure in patients with severe aortic regurgitation without indication for surgery. Interact Cardiovasc Thorac Surg 2021; 32:29-38. [PMID: 33221839 DOI: 10.1093/icvts/ivaa232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 08/13/2020] [Accepted: 09/06/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Recent mortality studies showed worse prognosis in patients (ARNS) with severe aortic regurgitation and preserved ejection fraction (EF) not fulfilling the criteria of current guidelines for surgery. The aim of our study was to analyse left ventricular (LV) systolic and diastolic function and mechanical energetics to find haemodynamic explanations for the reduced prognosis of these patients and to seek a new concept for surgery. METHODS Global longitudinal strain (GLS) and echo-based single-beat pressure-volume analyses were performed in patients with ARNS (LV end-diastolic diameter <70 mm, EF >50%, GLS > -19% n = 41), with indication for surgery (ARS; n = 19) and in mild hypertensive controls (C; n = 20). Additionally, end-systolic elastance (LV contractility), stroke work and total energy (pressure-volume area) were calculated. RESULTS ARNS demonstrated significantly depressed LV contractility versus C: end-systolic elastance (1.58 ± 0.7 vs 2.54 ± 0.8 mmHg/ml; P < 0.001), despite identical EF (EF: 59 ± 6% vs 59 ± 7%). Accordingly, GLS was decreased [-15.7 ± 2.7% (n = 31) vs -21.2 ± 2.4%; P < 0.001], end-diastolic volume (236 ± 90 vs 136 ± 30 ml; P < 0.001) and diastolic operant stiffness were markedly enlarged, as were pressure-volume area and stroke work, indicating waste of energy. The correlation of GLS versus end-systolic elastance was good (r = -0.66; P < 0.001). ARNS and ARS patients demonstrated similar haemodynamic disorders, whereas only GLS was worse in ARS. CONCLUSIONS ARNS patients almost matched the ARS patients in their haemodynamic and energetic deterioration, thereby explaining poor prognosis reported in literature. GLS has been shown to be a reliable surrogate for LV contractility, possibly overestimating contractility due to exhausted preload reserve in aortic regurgitation patients. GLS may outperform conventional echo parameters to predict more precisely the timing of surgery.
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Affiliation(s)
- Jan-Christian Reil
- Klinik für Innere Medizin II, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitäres Herzzentrum Lübeck, Universitätsklinikum Schleswig-Holstein, Lübeck, Germany
| | - Gert-Hinrich Reil
- Klinik für Innere Medizin I, Kardiologie und Internistische Intensivmedizin, Klinikum Oldenburg, Oldenburg, Germany
| | - Nora Hecker
- Klinik für Innere Medizin II, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitäres Herzzentrum Lübeck, Universitätsklinikum Schleswig-Holstein, Lübeck, Germany
| | - Vasco Sequeira
- Comprehensive Heart Failure Center (CHFC), University Clinic Würzburg, Würzburg, Germany
| | - Jeffrey S Borer
- The Howard Gilman Institute for Heart Valve Disease and the Schiavone Institute for Cardiovascular Translational Research, State University of New York Downstate Medical Center, Brooklyn, NY, USA
| | - Ulrich Stierle
- Klinik für Herzchirurgie, Universitäres Herzzentrum Lübeck, Universitätsklinikum Schleswig-Holstein, Lübeck, Germany
| | - Daniel Lavall
- Klinik und Polikliinik für Kardiologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Christoph Marquetand
- Klinik für Innere Medizin II, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitäres Herzzentrum Lübeck, Universitätsklinikum Schleswig-Holstein, Lübeck, Germany
| | - Claudia Busch
- Klinik für Herzchirurgie, Universitäres Herzzentrum Lübeck, Universitätsklinikum Schleswig-Holstein, Lübeck, Germany
| | - Johannes Patzelt
- Klinik für Innere Medizin II, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitäres Herzzentrum Lübeck, Universitätsklinikum Schleswig-Holstein, Lübeck, Germany
| | - Matthias Heringlake
- Klinik für Anästhesie, Universitätsklinikum Schleswig-Holstein, Lübeck, Germany
| | - Hans-Joachim Schäfers
- Klinik für Herz-und Thoraxchirurgie, Universitätsklinikum des Saarlandes, Homburg Saar, Germany
| | - Hans-Hinrich Sievers
- Klinik für Herzchirurgie, Universitäres Herzzentrum Lübeck, Universitätsklinikum Schleswig-Holstein, Lübeck, Germany
| | - Stephan Ensminger
- Klinik für Herzchirurgie, Universitäres Herzzentrum Lübeck, Universitätsklinikum Schleswig-Holstein, Lübeck, Germany
| | - Anas Aboud
- Klinik für Herzchirurgie, Universitäres Herzzentrum Lübeck, Universitätsklinikum Schleswig-Holstein, Lübeck, Germany
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64
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Abstract
Heart failure with preserved ejection fraction (HFpEF) is a clinical syndrome of shortness of breath and/or exercise intolerance secondary to elevated left ventricular filling pressures at rest or with exertion either as a result of primary diastolic dysfunction (primary HFpEF) or secondary to specific underlying causes (secondary HFpEF). In secondary HFpEF, early intervention of underlying valvular heart disease generally improves symptoms and prolongs survival. In primary HFpEF, there is increasing awareness of the existence and prognostic implications of secondary atrioventricular valve regurgitation. Further studies will clarify their mechanisms and the effectiveness of valvular intervention in this intriguing HFpEF subgroup.
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Affiliation(s)
- Yiting Fan
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, 241 West Huaihai Road, Xu Hui District, Shanghai, China
| | - Alex Pui-Wai Lee
- Laboratory of Cardiac Imaging and 3D Printing, Li Ka Shing Institute of Health Science, The Chinese University of Hong Kong, Hong Kong SAR, China; Division of Cardiology, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China.
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65
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Halliday BP, Senior R, Pennell DJ. Assessing left ventricular systolic function: from ejection fraction to strain analysis. Eur Heart J 2021; 42:789-797. [PMID: 32974648 DOI: 10.1093/eurheartj/ehaa587] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 05/04/2020] [Accepted: 07/02/2020] [Indexed: 12/22/2022] Open
Abstract
The measurement of left ventricular ejection fraction (LVEF) is a ubiquitous component of imaging studies used to evaluate patients with cardiac conditions and acts as an arbiter for many management decisions. This follows early trials investigating heart failure therapies which used a binary LVEF cut-off to select patients with the worst prognosis, who may gain the most benefit. Forty years on, the cardiac disease landscape has changed. Left ventricular ejection fraction is now a poor indicator of prognosis for many heart failure patients; specifically, for the half of patients with heart failure and truly preserved ejection fraction (HF-PEF). It is also recognized that LVEF may remain normal amongst patients with valvular heart disease who have significant myocardial dysfunction. This emphasizes the importance of the interaction between LVEF and left ventricular geometry. Guidelines based on LVEF may therefore miss a proportion of patients who would benefit from early intervention to prevent further myocardial decompensation and future adverse outcomes. The assessment of myocardial strain, or intrinsic deformation, holds promise to improve these issues. The measurement of global longitudinal strain (GLS) has consistently been shown to improve the risk stratification of patients with heart failure and identify patients with valvular heart disease who have myocardial decompensation despite preserved LVEF and an increased risk of adverse outcomes. To complete the integration of GLS into routine clinical practice, further studies are required to confirm that such approaches improve therapy selection and accordingly, the outcome for patients.
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Affiliation(s)
- Brian P Halliday
- National Heart Lung Institute, Imperial College, Dovehouse St, London SW3 6NP, UK.,Cardiovascular Magnetic Resonance Unit, Royal Brompton and Harefield NHS Foundation Trust, Sydney St, London SW3 6NP, UK
| | - Roxy Senior
- National Heart Lung Institute, Imperial College, Dovehouse St, London SW3 6NP, UK.,Department of Echocardiography, Royal Brompton and Harefield NHS Foundation Trust, Sydney St, London SW3 6NP, UK
| | - Dudley J Pennell
- National Heart Lung Institute, Imperial College, Dovehouse St, London SW3 6NP, UK.,Cardiovascular Magnetic Resonance Unit, Royal Brompton and Harefield NHS Foundation Trust, Sydney St, London SW3 6NP, UK
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66
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Jamart L, Ducharme A, Garceau P, Basmadjian A, Dorval JF, Bouchard D, Pellerin M, Asgar AW. Optimizing Timing of Valve Intervention in Patients With Asymptomatic Severe Valvular Heart Disease. Can J Cardiol 2021; 37:1041-1053. [PMID: 33989710 DOI: 10.1016/j.cjca.2021.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 05/03/2021] [Accepted: 05/03/2021] [Indexed: 12/12/2022] Open
Abstract
The management of valvular heart disease has changed dramatically over the past decade with advances in cardiac imaging, the use of novel biomarkers, and the development of transcatheter valve repair and replacement technology. International society guidelines have kept pace to provide recommendations for diagnosis, follow-up, and timing of intervention. The most challenging patient cohort for clinicians are patients with asymptomatic severe disease in whom the optimal timing of intervention can be ill-defined. It is a fine balance between the risks of early intervention on asymptomatic patients and improving patient outcomes by preventing long-term cardiac complications. The key in optimal patient management is gathering the necessary information on patient risk and combining that with the risk, efficacy, and durability of valve interventions to arrive at the appropriate timing for intervention. This group of patients will be the focus of this review as we delve into the natural history, recommended follow-up, and indications for intervention in patients with degenerative aortic and mitral valve disease.
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Affiliation(s)
- Laurent Jamart
- Department of Cardiology, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Anique Ducharme
- Department of Cardiology, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Patrick Garceau
- Department of Cardiology, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Arsène Basmadjian
- Department of Cardiology, Montreal Heart Institute, Montreal, Quebec, Canada
| | | | - Denis Bouchard
- Department of Cardiac Surgery, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Michel Pellerin
- Department of Cardiac Surgery, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Anita W Asgar
- Department of Cardiology, Montreal Heart Institute, Montreal, Quebec, Canada.
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67
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Lin SL, Lin M, Wang KL, Kuo HW, Tak T. l -Arginine Can Enhance the Beneficial Effect of Losartan in Patients with Chronic Aortic Regurgitation and Isolated Systolic Hypertension. Int J Angiol 2021; 30:122-131. [PMID: 34054270 DOI: 10.1055/s-0041-1723948] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Information about the effects of angiotensin II receptor blocker (ARB) therapy on the hemodynamic and cardiac structure in patients with chronic aortic regurgitation (CAR) and isolated systolic hypertension (ISH) is limited. This study planned to test the hypothesis that l -arginine could further enhance the beneficial effect of an ARB, losartan, and provide a favorable effect on the natural history of CAR and ISH. Sixty patients with CAR and ISH were enrolled in a randomized, double-blind trial comparing hemodynamic and ultrasonic change in two treatment arms: losartan + l -arginine and losartan-only treated groups. Serial echocardiographic and hemodynamic studies were evaluated before and after treatment. Both groups had a significant reduction in systolic blood pressure (SBP) and diastolic blood pressure (DBP), left ventricular end-diastolic volume index (LVEDVI), LV end-systolic volume index (LVESVI), LV mass index (LVMI), and LV mean wall stress after 6- and 12-month treatment ( p <0.01 in all comparisons). Both groups had a significant increase in LV ejection fraction and exercise duration after 6- and 12-month treatment ( p < 0.01 in all comparisons). Using multivariate linear regression analysis, only losartan + l -arginine therapy achieved a significantly lower LVESVI (38.89 ± 0.23 mL/m 2 ), LVEDVI (102.3 ± 0.3 mL/m 2 ), LVMI (107.6 ± 0.3 g/m 2 ), SBP (123.5 ± 1.0 mm Hg), and greater exercise duration (7.38 ± 0.02 minutes) than those of the losartan-only treated groups ( p <0.01 in all comparisons). These findings suggest that early co-administrative strategy provides a beneficial approach to favorably influence the natural history of CAR.
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Affiliation(s)
- Shoa-Lin Lin
- Division of Cardiology, Yuan's General Hospital, Kaohsiung City, Taiwan
| | - Mike Lin
- Department of Medicine, Gou-Zen Hospital, Pingtong City, Taiwan
| | | | - Hsien-Wen Kuo
- Institute of Occupation and Environment Health Science, National Yang-Ming University, Taipei, Taiwan
| | - Tahir Tak
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
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68
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2020 ACC/AHA guideline for the management of patients with valvular heart disease: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Thorac Cardiovasc Surg 2021; 162:e183-e353. [PMID: 33972115 DOI: 10.1016/j.jtcvs.2021.04.002] [Citation(s) in RCA: 68] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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69
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YÜCEL O, GÜNEŞ H, YILMAZ MB. KRONİK AORT YETMEZLİĞİ OLAN HASTALARDA HİPERTANSİYON SIKLIĞI. KAHRAMANMARAŞ SÜTÇÜ İMAM ÜNIVERSITESI TIP FAKÜLTESI DERGISI 2021. [DOI: 10.17517/ksutfd.848436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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70
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Khan SA, Baron SJ. Point: patients with native aortic regurgitation can be treated with transcatheter aortic valve implantation. Heart 2021; 107:1938-1941. [PMID: 33863759 DOI: 10.1136/heartjnl-2021-319179] [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: 02/10/2021] [Revised: 03/28/2021] [Accepted: 04/04/2021] [Indexed: 11/04/2022] Open
Abstract
Approximately 2% of people between the ages of 70 and 83 suffer from moderate or greater aortic regurgitation (AR) in the United States. Left untreated, this disease is progressive and fatal; however, up to 8% of patients with AR, who meet the criteria for surgical intervention, do not receive treatment. As such, there is a pressing need to address the lack of treatment options for the thousands of patients with AR who meet a class I indication for aortic valve replacement but who still do not receive surgery. The advent of transcatheter aortic valve implantation (TAVI) has significantly altered the paradigm of treatment for valvular heart disease and is now a well-established therapeutic option for patients with severe aortic stenosis. While transcatheter devices dedicated for the treatment of AR are under investigation, they are not commercially available at this time. Nevertheless, there is a growing body of data that demonstrate acceptable safety and efficacy for the off-label use of current TAVI devices for the treatment of severe AR. Given the dearth of treatment options for inoperable patients with severe AR, available TAVI devices should be considered for this patient population.
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Affiliation(s)
- Sahoor A Khan
- Division of Cardiology, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Suzanne J Baron
- Division of Cardiology, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
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71
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Jenner J, Ilami A, Petrini J, Eriksson P, Franco-Cereceda A, Eriksson MJ, Caidahl K. Pre- and postoperative left atrial and ventricular volumetric and deformation analyses in severe aortic regurgitation. Cardiovasc Ultrasound 2021; 19:14. [PMID: 33583414 PMCID: PMC7883437 DOI: 10.1186/s12947-021-00243-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 01/31/2021] [Indexed: 11/10/2022] Open
Abstract
Background The impact of volume overload due to aortic regurgitation (AR) on systolic and diastolic left ventricular (LV) indices and left atrial remodeling is unclear. We assessed the structural and functional effects of severe AR on LV and left atrium before and after aortic valve replacement. Methods Patients with severe AR scheduled for aortic valve replacement (n = 65) underwent two- and three-dimensional echocardiography, including left atrial strain imaging, before and 1 year after surgery. A control group was selected, and comprised patients undergoing surgery for thoracic aortic aneurysm without aortic valve replacement (n = 20). Logistic regression analysis was used to assess predictors of impaired left ventricular functional and structural recovery, defined as a composite variable of diastolic dysfunction grade ≥ 2, EF < 50%, or left ventricular end-diastolic volume index above the gender-specific normal range. Results Diastolic dysfunction was present in 32% of patients with AR at baseline. Diastolic LV function indices and left atrial strain improved, and both left atrial and LV volumes decreased in the AR group following aortic valve replacement. Preoperative left atrial strain during the conduit phase added to left ventricular end-systolic volume index for the prediction of impaired LV functional and structural recovery after aortic valve replacement (model p < 0.001, accuracy 70%; addition of left atrial strain during the conduit phase to end-systolic volume index p = 0.006). Conclusions One-third of patients with severe AR had signs of diastolic dysfunction. Aortic valve surgery reduced LV and left atrial volumes and improved diastolic indices. Left atrial strain during the conduit phase added to the well-established left ventricular end-diastolic dimension for the prediction of impaired left ventricular functional and structural recovery at follow-up. However, long-term follow-up studies with hard endpoints are needed to assess the value of left atrial strain as predictor of myocardial recovery in aortic regurgitation.
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Affiliation(s)
- Jonas Jenner
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden. .,Department of Clinical Physiology, Södersjukhuset, Stockholm, Sweden. .,Department of Clinical Physiology, Karolinska University Hospital, 171 76, Stockholm, Sweden.
| | - Ali Ilami
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Physiology, Karolinska University Hospital, 171 76, Stockholm, Sweden
| | - Johan Petrini
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Physiology, Södersjukhuset, Stockholm, Sweden
| | - Per Eriksson
- Division of Cardiovascular Medicine, Department of Medicine Solna, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Anders Franco-Cereceda
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Unit of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Maria J Eriksson
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Physiology, Karolinska University Hospital, 171 76, Stockholm, Sweden
| | - Kenneth Caidahl
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Departments of Molecular and Clinical Medicine, Gothenburg University, and Clinical Physiology, Sahlgrenska University Hospital, Gothenburg, Sweden
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72
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Toya T, Fukushima S, Shimahara Y, Kasahara S, Kobayashi J, Fujita T. Reverse left ventricular remodelling after aortic valve replacement for severe aortic insufficiency. Interact Cardiovasc Thorac Surg 2021; 32:846-854. [PMID: 33582790 DOI: 10.1093/icvts/ivab020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 08/24/2020] [Accepted: 12/12/2020] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES The goal of this study was to investigate the long-term outcome of aortic valve replacement (AVR) for severe aortic insufficiency with a focus on pre- and postoperative left ventricular (LV) function to explore predictive factors that influence the recovery of LV function and clinical outcome. METHODS A total of 478 patients who underwent AVR for pure severe aortic insufficiency were grouped according to the preoperative echocardiographical LV ejection fraction (EF): low (LO) EF <35% (n = 43), moderate EF 35-50% (n = 150) or normal EF >50% (n = 285). RESULTS Actuarial survival at 10 years post-AVR was 64% with a LO EF, 92% with a moderate EF and 93% with a normal EF (P = 0.016), whereas 10-year rates of freedom from major adverse cerebral and cardiovascular events were 47%, 79% and 84%, respectively (P < 0.0001). Echocardiography at 1 year post-AVR demonstrated that EF substantially improved in all groups. We noted a significant difference in survival (P = 0.0086) and in freedom from major adverse cerebral and cardiovascular events (P = 0.024) between patients with an EF ≥35% and those with an EF <35% in the LO EF group. The multivariable logistic regression model showed that predictive factors for lack of improvement in EF 1 year post-AVR in the LO EF group included plasma brain natriuretic peptide >365 pg/mL (P = 0.0022) and echocardiographic LV mass index) >193 g/m2 (P = 0.0018). CONCLUSIONS Long-term outcome post-AVR for severe aortic insufficiency was largely influenced by preoperative LV function. Predictive factors of failure to recover ventricular function post-AVR included EF <25%, pre-brain natriuretic peptide >365 pg/mL or LV mass index >193 g/m2.
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Affiliation(s)
- Teppei Toya
- Department of Cardiac Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan.,Department of Cardiovascular Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Satsuki Fukushima
- Department of Cardiac Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Yusuke Shimahara
- Department of Cardiac Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Shingo Kasahara
- Department of Cardiovascular Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Junjiro Kobayashi
- Department of Cardiac Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Tomoyuki Fujita
- Department of Cardiac Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
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73
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Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2021; 77:e25-e197. [PMID: 33342586 DOI: 10.1016/j.jacc.2020.11.018] [Citation(s) in RCA: 721] [Impact Index Per Article: 240.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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74
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Schott JP, Dixon SR, Goldstein JA. Disparate impact of severe aortic and mitral regurgitation on left ventricular dilation. Catheter Cardiovasc Interv 2021; 97:1301-1308. [PMID: 33471957 DOI: 10.1002/ccd.29455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 12/16/2020] [Accepted: 12/27/2020] [Indexed: 11/11/2022]
Abstract
In asymptomatic severe aortic (AR) and mitral regurgitation (MR), left ventricular (LV) dimension criteria were established to guide timing of valve replacement to prevent irreversible LV dysfunction. Given both lesions are primary LV volume overload ''leaks'', it might be expected that both lesions would induce similar impact on the LV and result in equivalent dimension criteria for intervention. However, the dimension-based intervention criteria for AR versus MR (developed through natural history studies), differ markedly. The pathophysiological foundations for such discordance have neither been fully elucidated nor emphasized. This case-based treatise compares the two regurgitant lesions with respect to: (a) ''total regurgitant circuits''; (b) ''driving pressures'' resulting in LV volume overload from each respective ''leak''; and (c) volume and afterload wall stresses imposed on the LV.Key points The ''total circuits'' of volume overload differ: The AR circuit includes the LV and systemic vasculature, whereas MR includes the LV ejecting into the left atrium/pulmonary veins and systemic circulation. The ''driving pressure'' of regurgitation and afterload are high with AR and low with MR. Differing ''total circuits'' and ''driving pressures'' impose disparate wall stresses upon the LV. Parallel and serial sarcomere replication occurs in AR, while only serial replication occurs in MR. It therefore follows that for regurgitation of similar severities, AR results in greater LV dilation at the point of irreversible myocardial dysfunction compared to MR. These considerations may explain, at least in part, the disparate dimension criteria employed for valve intervention for severe AR vs MR.
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Affiliation(s)
- Jason P Schott
- Department of Cardiovascular Medicine, Beaumont Hospital Royal Oak, Royal Oak, Michigan, USA
| | - Simon R Dixon
- Department of Cardiovascular Medicine, Beaumont Hospital Royal Oak, Royal Oak, Michigan, USA.,Department of Internal Medicine, Oakland University William Beaumont School of Medicine, Rochester, Michigan, USA
| | - James A Goldstein
- Department of Cardiovascular Medicine, Beaumont Hospital Royal Oak, Royal Oak, Michigan, USA.,Department of Internal Medicine, Oakland University William Beaumont School of Medicine, Rochester, Michigan, USA
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75
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Fernández-Golfín C, Hinojar-Baydes R, González-Gómez A, Monteagudo JM, Esteban A, Alonso-Salinas G, Fernández MA, García-Martín A, Santoro C, Pascual-Izco M, Jiménez-Nacher JJ, Zamorano JL. Prognostic implications of cardiac magnetic resonance feature tracking derived multidirectional strain in patients with chronic aortic regurgitation. Eur Radiol 2021; 31:5106-5115. [PMID: 33449184 DOI: 10.1007/s00330-020-07651-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 11/25/2020] [Accepted: 12/18/2020] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Speckle-tracking echocardiography (STE) deformation parameters detect latent LV dysfunction in chronic aortic regurgitation (AR) and are associated with outcomes. The aim of the study was to evaluate cardiac magnetic resonance (CMR) feature tracking (FT) deformation parameters in asymptomatic patients with AR and implications in outcomes. METHODS Fifty-five patients with AR and 54 controls were included. Conventional functional CMR parameters, aortic regurgitant volume, and fraction were assessed. CMR-FT analysis was performed with a dedicated software. Clinical data was obtained from hospital records. A combined endpoint included all-cause mortality, cardiovascular mortality, aortic valve surgery, or cardiovascular hospital admission due to heart failure. RESULTS Left ventricular (LV) mechanics is impaired in patients with significant AR. Significant differences were noted in global longitudinal strain (GLS) between controls and AR patients (- 19.1 ± 2.9% vs - 16.5 ± 3.2%, p < 0.001) and among AR severity groups (- 18.3 ± 3.1% vs - 16.2 ± 1.6% vs - 15 ± 3.5%; p = 0.02 for AR grades I-II, III, and IV). In univariate and multivariate analyses, circumferential strain (GCS) and global radial strain (GRS) but not GLS were associated with and increased risk of the end point with a HR of 1.26 (p = 0.016, 1.04-1.52) per 1% worsening for GCS and 0.90 (p = 0.012, 0.83-0.98) per 1% worsening for GRS. CONCLUSIONS CMR-FT myocardial deformation parameters are impaired in patients with AR not meeting surgical criteria. GLS decreases early in the course of the disease and is a marker of AR severity while GCS and GRS worsen later but predict a bad prognosis, mainly the need of aortic valve surgery. KEY POINTS • CMR feature tracking LV mechanic parameters may be reduced in significant chronic AR with normal EF. • LV mechanics, mainly global longitudinal strain, worsens as AR severity increases. • LV mechanics, specially global radial and circumferential strain, is associated with a worse prognosis in AR patients.
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Affiliation(s)
- Covadonga Fernández-Golfín
- Cardiology Department, University Hospital Ramón y Cajal, Carretera de Colmenar km 9, 100 28034, Madrid, Spain.
- CIBERCV, Instituto de Salud Carlos III (ISCIII), Majadahonda, Spain.
| | - Rocío Hinojar-Baydes
- Cardiology Department, University Hospital Ramón y Cajal, Carretera de Colmenar km 9, 100 28034, Madrid, Spain
| | - Ariana González-Gómez
- Cardiology Department, University Hospital Ramón y Cajal, Carretera de Colmenar km 9, 100 28034, Madrid, Spain
| | - Juan Manuel Monteagudo
- Cardiology Department, University Hospital Ramón y Cajal, Carretera de Colmenar km 9, 100 28034, Madrid, Spain
| | - Amparo Esteban
- Radiology Department, University Hospital Ramón y Cajal, Madrid, Spain
| | - Gonzalo Alonso-Salinas
- Cardiology Department, University Hospital Ramón y Cajal, Carretera de Colmenar km 9, 100 28034, Madrid, Spain
| | | | - Ana García-Martín
- Cardiology Department, University Hospital Ramón y Cajal, Carretera de Colmenar km 9, 100 28034, Madrid, Spain
| | - Ciro Santoro
- Cardiology Department, University Hospital Ramón y Cajal, Carretera de Colmenar km 9, 100 28034, Madrid, Spain
| | - Marina Pascual-Izco
- Cardiology Department, University Hospital Ramón y Cajal, Carretera de Colmenar km 9, 100 28034, Madrid, Spain
| | - Jose Julio Jiménez-Nacher
- Cardiology Department, University Hospital Ramón y Cajal, Carretera de Colmenar km 9, 100 28034, Madrid, Spain
| | - Jose Luis Zamorano
- Cardiology Department, University Hospital Ramón y Cajal, Carretera de Colmenar km 9, 100 28034, Madrid, Spain
- CIBERCV, Instituto de Salud Carlos III (ISCIII), Majadahonda, Spain
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Patel KM, Desai RG, Krishnan S. Mitral Regurgitation in Patients With Coexisting Chronic Aortic Regurgitation: An Evidence-Based Narrative Review. J Cardiothorac Vasc Anesth 2021; 35:3404-3415. [PMID: 33558134 DOI: 10.1053/j.jvca.2021.01.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 01/03/2021] [Accepted: 01/04/2021] [Indexed: 11/11/2022]
Abstract
Chronic aortic regurgitation (AR) frequently leads to significant downstream changes to the left ventricle and pulmonary vasculature; these structural and physiologic changes result in lower- than expected patient survival. Progressive, uncorrected AR can lead to left ventricle dilation and subsequent mitral valve leaflet tethering, as well as mitral annular dilation, resulting in secondary mitral regurgitation (MR) in up to 45% of patients. Surgical aortic valve replacement (AVR) improves secondary MR in most patients, but survival is significantly lower in those patients who do not show improvement in MR after AVR. Thus, there is considerable debate on whether the mitral valve should be intervened upon at the time of the AVR. In this review, the authors address the long-term outlook for patients with chronic AR and concurrent MR. The authors also review the available evidence on concomitant mitral valve surgery in patients undergoing AVR for AR. Lastly, this narrative review examines the recent advances in transcatheter mitral valve repair and replacement, and explores the potential role of transcatheter mitral therapies in patients with secondary MR due to AR.
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Affiliation(s)
- Kinjal M Patel
- Adult Cardiothoracic Anesthesiology, Cooper University Healthcare, Cooper Medical School of Rowan University, Camden, NJ.
| | - Ronak G Desai
- Adult Cardiothoracic Anesthesiology, Cooper University Healthcare, Cooper Medical School of Rowan University, Camden, NJ
| | - Sandeep Krishnan
- Wayne State University School of Medicine, St. Joseph Mercy Oakland Medical Office Building, Pontiac, MI
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Sex Differences in Left Ventricular Remodeling and Outcomes in Chronic Aortic Regurgitation. J Clin Med 2020; 9:jcm9124100. [PMID: 33353247 PMCID: PMC7767247 DOI: 10.3390/jcm9124100] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 12/05/2020] [Accepted: 12/15/2020] [Indexed: 11/24/2022] Open
Abstract
Background: Left ventricular (LV) dilatation is a key compensatory feature in patients with chronic aortic regurgitation (AR). However, sex-differences in LV remodeling and outcomes in chronic AR have been poorly investigated so far. Methods: We performed cardiovascular magnetic resonance imaging (CMR) including phase-contrast velocity-encoded imaging for the measurement of regurgitant fraction (RegF) at the sinotubular junction, in consecutive patients with at least mild AR on echocardiography. We assessed LV size (end-diastolic volume indexed to body surface area, LVEDV/BSA) and investigated sex differences between LV remodeling and increasing degrees of AR severity. Cox-regression models were used to test differences in outcomes between men and women using a composite of heart failure hospitalization, unscheduled AR intervention, and cardiovascular death. Results: 270 consecutive patients (59.6% male, 59.8 ± 20.8 y/o, 59.6% with at least moderate AR on echocardiography) were included. On CMR, mean RegF was 18.1 ± 17.9% and a total of 65 (24.1%) had a RegF ≥ 30%. LVEDV/BSA was markedly closer related with AR severity (RegF) in men compared to women. Each 1-SD increase in LVEDV/BSA (mL/m2) was associated with a 9.7% increase in RegF in men and 5.9% in women, respectively (p-value for sex-interaction < 0.001). Based on previously published reference values, women—in contrast to men—frequently had a normal LV size despite severe AR (e.g., for LVEDV/BSA on CMR: 35.3% versus 8.7%, p < 0.001). In a Cox-regression model adjusted for age, LVEDV/BSA and RegF, women were at significantly higher risk for the composite endpoint when compared to men (adj. HR 1.81 (95%CI 1.09–3.03), p = 0.022). Conclusion: In patients with chronic AR, LV remodeling is a hallmark feature in men but not in women. Severity of AR may be underdiagnosed in female patients in the absence of LV dilatation. Future studies need to address the dismal prognosis in female patients with chronic AR.
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Postigo A, Pérez-David E, Revilla A, Raquel LA, González-Mansilla A, Prieto-Arévalo R, Espinosa MÁ, López-Jimenez RA, Sevilla T, Urueña N, Martínez-Legazpi P, Oliver JM, Fernández-Avilés F, J Alberto SR, Bermejo J. A comparison of the clinical efficacy of echocardiography and magnetic resonance for chronic aortic regurgitation. Eur Heart J Cardiovasc Imaging 2020; 23:392-401. [PMID: 33332549 DOI: 10.1093/ehjci/jeaa338] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 11/25/2020] [Indexed: 12/25/2022] Open
Abstract
AIMS Timing surgery in chronic aortic regurgitation (AR) relies mostly on echocardiography. However, cardiac magnetic resonance (CMR) may be more accurate for quantifying regurgitation and left ventricular (LV) remodelling. We aimed to compare the technical and clinical efficacies of echocardiography and CMR to account for the severity of the disease, the degree of LV remodelling, and predict AR-related outcomes. METHODS AND RESULTS We studied 263 consecutive patients with isolated AR undergoing echocardiography and CMR. After a median follow-up of 33 months, 76 out of 197 initially asymptomatic patients reached the primary endpoint of AR-related events: 6 patients (3%) were admitted for heart failure, and 70 (36%) underwent surgery. Adjusted survival models based on CMR improved the predictions of the primary endpoint based on echocardiography: R2 = 0.37 vs. 0.22, χ2 = 97 vs. 49 (P < 0.0001), and C-index = 0.80 vs. 0.70 (P < 0.001). This resulted in a net classification index of 0.23 (0.00-0.46, P = 0.046) and an integrated discrimination improvement of 0.12 (95% confidence interval 0.08-0.58, P = 0.02). CMR-derived regurgitant fraction (<28, 28-37, or >37%) and LV end-diastolic volume (<83, 183-236, or >236 mL) adequately stratified patients with normal EF. The agreement between techniques for grading AR severity and assessing LV dilatation was poor, and CMR showed better reproducibility. CONCLUSIONS CMR improves the clinical efficacy of ultrasound for predicting outcomes of patients with AR. This is due to its better reproducibility and accuracy for grading the severity of the disease and its impact on the LV. Regurgitant fraction, LV ejection fraction, and end-diastolic volume obtained by CMR most adequately predict AR-related events.
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Affiliation(s)
- Andrea Postigo
- Department of Cardiology, Hospital General Universitario Gregorio Marañón; Facultad de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Gregorio Marañón, and CIBERCV, Madrid, Spain
| | - Esther Pérez-David
- Department of Cardiology, Hospital General Universitario Gregorio Marañón; Facultad de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Gregorio Marañón, and CIBERCV, Madrid, Spain
| | - Ana Revilla
- Instituto de Ciencias del Corazón. Hospital Clínico Universitario de Valladolid, and CIBERCV, Valladolid, Spain
| | - Ladrón Abia Raquel
- Instituto de Ciencias del Corazón. Hospital Clínico Universitario de Valladolid, and CIBERCV, Valladolid, Spain
| | - Ana González-Mansilla
- Department of Cardiology, Hospital General Universitario Gregorio Marañón; Facultad de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Gregorio Marañón, and CIBERCV, Madrid, Spain
| | - Raquel Prieto-Arévalo
- Department of Cardiology, Hospital General Universitario Gregorio Marañón; Facultad de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Gregorio Marañón, and CIBERCV, Madrid, Spain
| | - M Ángeles Espinosa
- Department of Cardiology, Hospital General Universitario Gregorio Marañón; Facultad de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Gregorio Marañón, and CIBERCV, Madrid, Spain
| | - Rosa Ana López-Jimenez
- Department of Cardiology, Hospital General Universitario Gregorio Marañón; Facultad de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Gregorio Marañón, and CIBERCV, Madrid, Spain
| | - Teresa Sevilla
- Instituto de Ciencias del Corazón. Hospital Clínico Universitario de Valladolid, and CIBERCV, Valladolid, Spain
| | - Noelia Urueña
- Instituto de Ciencias del Corazón. Hospital Clínico Universitario de Valladolid, and CIBERCV, Valladolid, Spain
| | - Pablo Martínez-Legazpi
- Department of Cardiology, Hospital General Universitario Gregorio Marañón; Facultad de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Gregorio Marañón, and CIBERCV, Madrid, Spain
| | - José M Oliver
- Department of Cardiology, Hospital General Universitario Gregorio Marañón; Facultad de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Gregorio Marañón, and CIBERCV, Madrid, Spain
| | - Francisco Fernández-Avilés
- Department of Cardiology, Hospital General Universitario Gregorio Marañón; Facultad de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Gregorio Marañón, and CIBERCV, Madrid, Spain
| | - San Román J Alberto
- Instituto de Ciencias del Corazón. Hospital Clínico Universitario de Valladolid, and CIBERCV, Valladolid, Spain
| | - Javier Bermejo
- Department of Cardiology, Hospital General Universitario Gregorio Marañón; Facultad de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Gregorio Marañón, and CIBERCV, Madrid, Spain
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Anand V, Yang L, Luis SA, Padang R, Michelena HI, Tsay JL, Mehta RA, Scott CG, Pislaru SV, Nishimura RA, Pellikka PA. Association of Left Ventricular Volume in Predicting Clinical Outcomes in Patients with Aortic Regurgitation. J Am Soc Echocardiogr 2020; 34:352-359. [PMID: 33253815 DOI: 10.1016/j.echo.2020.11.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 11/16/2020] [Accepted: 11/18/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Aortic regurgitation (AR) is a common valvular lesion associated with increased mortality once the left ventricle enlarges significantly or develops systolic dysfunction (ejection fraction < 50%). Valve guidelines recommend aortic valve repair or replacement (AVR) for left ventricular (LV) linear end-systolic dimension ≥ 50 mm or end-diastolic dimension ≥ 65 mm. However, chamber quantification guidelines recommend using LV volume for LV size determination because linear measurements may not accurately reflect LV remodeling. The aim of this study was to evaluate the correlation of LV volumes with linear dimensions, interobserver variability in the estimation of volumes, and the association of volumes with outcomes in patients with AR. METHODS A total of 1,100 consecutive patients with chronic moderate to severe and severe AR on echocardiography between 2004 and 2019 were retrospectively analyzed. The modified Simpson disk summation method was used for LV volume estimation. The primary outcome was all-cause mortality; the secondary outcome was mortality censored at AVR. RESULTS Patients' age was 60 ± 17 years, and 198 were women (18%). Volumes were measured using the biplane method in 939 patients (85%) and the monoplane method in 161 (15%); end-systolic volume was normal in 169 (11%). Correlations between volumes and linear dimensions were 0.5 for end-diastolic volume and 0.6 for end-systolic volume. At median follow-up of 5.4 years (interquartile range, 2.4-10.0 years), 216 patients had died and 539 had undergone AVR. Indexed LV end-systolic volume (iLVESV) and indexed left ventricular end-systolic dimension were both associated with mortality and symptoms, but the association of iLVESV was stronger. iLVESV, age, male gender, Charlson comorbidity index, New York Heart Association functional class III or IV, and time-dependent AVR were independently associated with all-cause mortality. Interobserver variability in the estimation of LV volumes in 200 patients included intraclass coefficients of 0.94 (95% CI, 0.92-0.95) for end-diastolic volume and 0.88 (95% CI, 0.78-0.93) for end-systolic volume. Patients with iLVESV ≥ 45 mL/m2 had lower survival and a higher prevalence of symptoms than those with volumes < 45 mL/m2. CONCLUSIONS Echocardiographic LV volume assessment had good reproducibility in patients with moderate to severe and severe AR. The correlation between linear dimensions and volumes was limited. Both iLVESV and indexed left ventricular end-systolic dimension were associated with worse outcomes, but the association of iLVESV was stronger. iLVESV ≥ 45 mL/m2 was associated with worse outcomes.
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Affiliation(s)
- Vidhu Anand
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Litan Yang
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Sushil Allen Luis
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Ratnasari Padang
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Hector I Michelena
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Julie L Tsay
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Ramila A Mehta
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Christopher G Scott
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Sorin V Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Rick A Nishimura
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
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Alharbi AA, Khan MZ, Osman M, Khan MU, Munir MB, Syed M, Khan SU, Balla S. Transcatheter Aortic Valve Replacement vs Surgical Replacement in Patients With Pure Aortic Insufficiency. Mayo Clin Proc 2020; 95:2655-2664. [PMID: 33276838 PMCID: PMC8404150 DOI: 10.1016/j.mayocp.2020.07.030] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 06/07/2020] [Accepted: 07/02/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To compare the outcomes of transcatheter aortic valve replacement (TAVR) with surgical aortic valve replacement (SAVR) in patients with pure aortic insufficiency (PAI). BACKGROUND The treatment of choice for patients with severe symptomatic PAI is SAVR. However, not all patients are candidates for surgery because of comorbidities or are deemed high risk for surgery. As a result, TAVR is being used as an off-label procedure in some patients with PAI. PATIENTS AND METHODS We analyzed the National Inpatient Sample database from January 1, 2016, to December 31, 2017, using the International Classification of Diseases, 10th Revision. Inclusion criteria were patients with aortic valve insufficiency undergoing either TAVR or SAVR. Patients with concomitant aortic stenosis, or history of infective endocarditis, and those below the age of 18 years were excluded. RESULTS A total of 14,720 patients with PAI underwent valve replacement. Of those, 6.2% underwent TAVR. The TAVR group was significantly older (median age 78 years vs 64 years; P <.001). There was no evidence of a difference in in-hospital mortality between the 2 groups. However, after adjustment, patients in the TAVR group were associated with favorable outcomes in terms of acute kidney injury, cardiogenic shock, postoperative respiratory complications, and length of stay. On the other hand, those in the SAVR group were less likely to need permanent pacemakers. CONCLUSION There was no evidence of a significant statistical difference in in-hospital mortality between patients with PAI treated by either SAVR or TAVR, both in unmatched and propensity-matched cohorts. TAVR could be considered for patients with PAI who are not candidates for surgery.
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Affiliation(s)
- Anas A Alharbi
- Department of Medicine, West Virginia University, Morgantown, WV.
| | - Muhammad Z Khan
- Department of Medicine, West Virginia University, Morgantown, WV
| | - Mohammed Osman
- Division of Cardiovascular Medicine, West Virginia University Heart and Vascular Institute, Morgantown, WV
| | - Muhammad U Khan
- Department of Medicine, West Virginia University, Morgantown, WV
| | - Muhammad B Munir
- Division of Cardiovascular Medicine, West Virginia University Heart and Vascular Institute, Morgantown, WV; Division of Cardiovascular Medicine, University of California San Diego, La Jolla, CA
| | - Moinuddin Syed
- Division of Cardiovascular Medicine, West Virginia University Heart and Vascular Institute, Morgantown, WV
| | - Safi U Khan
- Department of Medicine, West Virginia University, Morgantown, WV
| | - Sudarshan Balla
- Division of Cardiovascular Medicine, West Virginia University Heart and Vascular Institute, Morgantown, WV
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81
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Malahfji M, Senapati A, Tayal B, Nguyen DT, Graviss EA, Nagueh SF, Reardon MJ, Quinones M, Zoghbi WA, Shah DJ. Myocardial Scar and Mortality in Chronic Aortic Regurgitation. J Am Heart Assoc 2020; 9:e018731. [PMID: 33241753 PMCID: PMC7763777 DOI: 10.1161/jaha.120.018731] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Background Chronic aortic regurgitation (AR) can be associated with myocardial scarring. It is unknown if scarring in AR is linked to poor outcomes and whether aortic valve replacement impacts this association. We investigated the relationship of myocardial scarring to mortality in chronic AR using cardiac magnetic resonance. Methods and Results We enrolled patients with moderate or greater AR between 2009 and 2019 and performed a blinded assessment of left ventricle remodeling, AR severity, and presence and extent of myocardial scarring by late gadolinium enhancement. The primary outcome was all‐cause mortality. We followed 392 patients (median age 62 [interquartile range, 51–71] years), and 78.1% were men, and 25.8% had bicuspid valves. Median aortic valve regurgitant volume was 39 mL (interquartile range, 30–60). Myocardial scar was present in 131 (33.4%) patients. Aortic valve replacement was performed in 165 (49.1%) patients. During follow‐up, up to 10.8 years (median 32.3 months [interquartile range, 9.8–69.5]), 51 patients (13%) died. Presence of myocardial scar (hazard ratio [HR], 3.62; 95% CI, 2.06–6.36; P<0.001), infarction scar (HR, 4.94; 95% CI, 2.58–9.48; P<0.001), and noninfarction scar (HR, 2.75; 95% CI, 1.39–5.44; P<0.004) were associated with mortality. In multivariable analysis, the presence of scar remained independently associated with death (HR, 2.53; 95% CI, 1.15–5.57; P=0.02). Among patients with myocardial scar, aortic valve replacement was independently associated with a lower risk of mortality (HR, 0.34; 95% CI, 0.12–0.97; P=0.03), even after adjustment for confounders. Conclusions In aortic regurgitation, myocardial scar is independently associated with a 2.5‐fold increase risk in mortality. Aortic valve replacement was associated with a reduction in risk of mortality in patients with scarring.
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Affiliation(s)
- Maan Malahfji
- Houston Methodist DeBakey Heart & Vascular Center Houston TX
| | - Alpana Senapati
- Houston Methodist DeBakey Heart & Vascular Center Houston TX
| | - Bhupendar Tayal
- Houston Methodist DeBakey Heart & Vascular Center Houston TX
| | - Duc T Nguyen
- Department of Pathology and Genomic Medicine Houston Methodist Hospital Research Institute Houston TX
| | - Edward A Graviss
- Department of Pathology and Genomic Medicine Houston Methodist Hospital Research Institute Houston TX
| | - Sherif F Nagueh
- Houston Methodist DeBakey Heart & Vascular Center Houston TX
| | | | - Miguel Quinones
- Houston Methodist DeBakey Heart & Vascular Center Houston TX
| | | | - Dipan J Shah
- Houston Methodist DeBakey Heart & Vascular Center Houston TX
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82
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Martin J, Coffey S, Whalley GA. Sex Disparity in Cardiovascular Disease Outcomes: Do Our Current Echocardiographic Reference Ranges Measure Up? Heart Lung Circ 2020; 30:e1-e5. [PMID: 33176982 DOI: 10.1016/j.hlc.2020.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 09/29/2020] [Accepted: 10/07/2020] [Indexed: 11/19/2022]
Abstract
Reducing inequity in access to health care and disparity in health outcomes remain key objectives in cardiovascular medicine. Echocardiography is often the primary diagnostic tool used to detect cardiovascular disease (CVD), and relies on comparison with published reference ranges to appropriately detect pathology. Our understanding of the contribution of age, sex and ethnicity to quantification of cardiac size is improving, but cardiovascular disease management guidelines have yet to evolve. While recently, sex, age and ethnicity-specific reference values have been produced, treatment thresholds in many clinical guidelines do not differentiate between sexes. As a result, in order to reach management thresholds, women are often required to have more severe pathology. In order to reduce potential disadvantage to women, future research efforts should be directed to develop more personalised treatment approaches by identification of sex-appropriate management thresholds.
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Affiliation(s)
- Josh Martin
- Department of Cardiology, Sunshine Coast University Hospital, Sunshine Coast, QLD, Australia.
| | - Sean Coffey
- Department of Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Gillian A Whalley
- Department of Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
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Izumi C, Eishi K, Ashihara K, Arita T, Otsuji Y, Kunihara T, Komiya T, Shibata T, Seo Y, Daimon M, Takanashi S, Tanaka H, Nakatani S, Ninami H, Nishi H, Hayashida K, Yaku H, Yamaguchi J, Yamamoto K, Watanabe H, Abe Y, Amaki M, Amano M, Obase K, Tabata M, Miura T, Miyake M, Murata M, Watanabe N, Akasaka T, Okita Y, Kimura T, Sawa Y, Yoshida K. JCS/JSCS/JATS/JSVS 2020 Guidelines on the Management of Valvular Heart Disease. Circ J 2020; 84:2037-2119. [DOI: 10.1253/circj.cj-20-0135] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Chisato Izumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Kiyoyuki Eishi
- Division of Cardiovascular Surgery, Nagasaki University Graduate School of Biomedical Sciences
| | - Kyomi Ashihara
- Department of Cardiology, Tokyo Women’s Medical University Hospital
| | - Takeshi Arita
- Division of Cardiovascular Medicine Heart & Neuro-Vascular Center, Fukuoka Wajiro
| | - Yutaka Otsuji
- Department of Cardiology, Hospital of University of Occupational and Environmental Health
| | - Takashi Kunihara
- Department of Cardiac Surgery, The Jikei University School of Medicine
| | - Tatsuhiko Komiya
- Department of Cardiovascular Surgery, Kurashiki Central Hospital
| | - Toshihiko Shibata
- Department of Cardiovascular Surgery, Osaka City University Postgraduate of Medicine
| | - Yoshihiro Seo
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences
| | - Masao Daimon
- Department of Clinical Laboratory/Cardiology, The University of Tokyo Hospital
| | | | | | - Satoshi Nakatani
- Division of Health Sciences, Osaka University Graduate School of Medicine
| | - Hiroshi Ninami
- Department of Cardiac Surgery, Tokyo Women’s Medical University
| | - Hiroyuki Nishi
- Department of Cardiovascular Surgery, Osaka General Medical Center
| | | | - Hitoshi Yaku
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine
| | | | - Kazuhiro Yamamoto
- Division of Cardiovascular Medicine, Endocrinology and Metabolism, Faculty of Medicine, Tottori University
| | | | - Yukio Abe
- Department of Cardiology, Osaka City General Hospital
| | - Makoto Amaki
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Masashi Amano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Kikuko Obase
- Division of Cardiovascular Surgery, Nagasaki University Graduate School of Biomedical Sciences
| | - Minoru Tabata
- Department of Cardiovascular Surgery, Tokyo Bay Urayasu Ichikawa Medical Center
| | - Takashi Miura
- Division of Cardiovascular Surgery, Nagasaki University Graduate School of Biomedical Sciences
| | | | - Mitsushige Murata
- Department of Laboratory Medicine, Tokai University Hachioji Hospital
| | - Nozomi Watanabe
- Department of Cardiology, Miyazaki Medical Association Hospital
| | - Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Yutaka Okita
- Department of Cardiovascular Surgery, Takatsuki Hospital
| | - Takeshi Kimura
- Department of Cardiology, Kyoto University Graduate School of Medicine
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Kiyoshi Yoshida
- Department of Cardiology, Sakakibara Heart Institute of Okayama
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Tarasoutchi F, Montera MW, Ramos AIDO, Sampaio RO, Rosa VEE, Accorsi TAD, Santis AD, Fernandes JRC, Pires LJT, Spina GS, Vieira MLC, Lavitola PDL, Ávila WS, Paixão MR, Bignoto T, Togna DJD, Mesquita ET, Esteves WADM, Atik F, Colafranceschi AS, Moises VA, Kiyose AT, Pomerantzeff PMA, Lemos PA, Brito Junior FSD, Weksler C, Brandão CMDA, Poffo R, Simões R, Rassi S, Leães PE, Mourilhe-Rocha R, Pena JLB, Jatene FB, Barbosa MDM, Abizaid A, Ribeiro HB, Bacal F, Rochitte CE, Fonseca JHDAPD, Ghorayeb SKN, Lopes MACQ, Spina SV, Pignatelli RH, Saraiva JFK. Update of the Brazilian Guidelines for Valvular Heart Disease - 2020. Arq Bras Cardiol 2020; 115:720-775. [PMID: 33111877 PMCID: PMC8386977 DOI: 10.36660/abc.20201047] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- Flavio Tarasoutchi
- Instituto do Coração (Incor) do Hospital de Clínica da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | | | - Roney Orismar Sampaio
- Instituto do Coração (Incor) do Hospital de Clínica da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Vitor Emer Egypto Rosa
- Instituto do Coração (Incor) do Hospital de Clínica da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Tarso Augusto Duenhas Accorsi
- Instituto do Coração (Incor) do Hospital de Clínica da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Antonio de Santis
- Instituto do Coração (Incor) do Hospital de Clínica da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - João Ricardo Cordeiro Fernandes
- Instituto do Coração (Incor) do Hospital de Clínica da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Lucas José Tachotti Pires
- Instituto do Coração (Incor) do Hospital de Clínica da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Guilherme S Spina
- Instituto do Coração (Incor) do Hospital de Clínica da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Marcelo Luiz Campos Vieira
- Instituto do Coração (Incor) do Hospital de Clínica da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Paulo de Lara Lavitola
- Instituto do Coração (Incor) do Hospital de Clínica da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Walkiria Samuel Ávila
- Instituto do Coração (Incor) do Hospital de Clínica da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Milena Ribeiro Paixão
- Instituto do Coração (Incor) do Hospital de Clínica da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Tiago Bignoto
- Instituto Dante Pazzanese de Cardiologia, São Paulo, SP - Brasil
| | | | | | | | - Fernando Atik
- Fundação Universitária de Cardiologia (FUC), São Paulo, SP - Brasil
| | | | | | | | | | - Pedro A Lemos
- Hospital Israelita Albert Einstein, São Paulo, SP - Brasil
| | | | - Clara Weksler
- Instituto Nacional de Cardiologia, Rio de Janeiro, RJ - Brasil
| | - Carlos Manuel de Almeida Brandão
- Instituto do Coração (Incor) do Hospital de Clínica da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Robinson Poffo
- Hospital Israelita Albert Einstein, São Paulo, SP - Brasil
| | - Ricardo Simões
- Faculdade Ciências Médicas de Minas Gerais, Belo Horizonte, MG - Brasil
| | | | | | - Ricardo Mourilhe-Rocha
- Hospital Pró-Cardíaco, Rio de Janeiro, RJ - Brasil
- Hospital Universitário Pedro Ernesto, Rio de Janeiro, RJ - Brasil
| | - José Luiz Barros Pena
- Faculdade Ciências Médicas de Minas Gerais, Belo Horizonte, MG - Brasil
- Hospital Felício Rocho, Belo Horizonte, MG - Brasil
| | - Fabio Biscegli Jatene
- Instituto do Coração (Incor) do Hospital de Clínica da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | - Alexandre Abizaid
- Instituto do Coração (Incor) do Hospital de Clínica da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Henrique Barbosa Ribeiro
- Instituto do Coração (Incor) do Hospital de Clínica da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Fernando Bacal
- Instituto do Coração (Incor) do Hospital de Clínica da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Carlos Eduardo Rochitte
- Instituto do Coração (Incor) do Hospital de Clínica da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | | | | | | | | | - José Francisco Kerr Saraiva
- Sociedade Campineira de Educação e Instrução Mantenedora da Pontifícia Universidade Católica de Campinas, Campinas, SP - Brasil
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Baumgartner H, Iung B, Otto CM. Timing of intervention in asymptomatic patients with valvular heart disease. Eur Heart J 2020; 41:4349-4356. [DOI: 10.1093/eurheartj/ehaa485] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 04/08/2020] [Accepted: 05/24/2020] [Indexed: 01/12/2023] Open
Abstract
Abstract
Current management of valvular heart disease (VHD) seeks to optimize long-term outcome by timely intervention. Recommendations for treatment of patients with symptoms due to severe valvular disease are based on a foundation of solid evidence. However, when to intervene in asymptomatic patients remains controversial and decision requires careful individual weighing of the potential benefits against the risk of intervention and its long-term consequences. The primary rationale for earlier intervention is prevention of irreversible left ventricular (LV) myocardial changes that might result in later clinical symptoms and adverse cardiac events. A number of outcome predictors have been identified that facilitate decision-making. This review summarizes current recommendations and discusses recently published data that challenge them suggesting even earlier intervention. In adults with asymptomatic aortic stenosis (AS), emerging risk markers include very severe valve obstruction, elevated serum natriuretic peptide levels, and imaging evidence of myocardial fibrosis or increased extracellular myocardial volume. Currently, transcatheter aortic valve implantation (TAVI) is not recommended for treatment of asymptomatic severe AS although this may change in the future. In patients with aortic regurgitation (AR), the potential benefit of early intervention in preventing LV dilation and dysfunction must be balanced against the long-term risk of a prosthetic valve, a particular concern because severe AR often occurs in younger patients with a congenital bicuspid valve. In patients with mitral stenosis, the option of transcatheter mitral balloon valvotomy tilts the balance towards earlier intervention to prevent atrial fibrillation, embolic events, and pulmonary hypertension. When chronic severe mitral regurgitation is due to mitral valve prolapse, anatomic features consistent with a high likelihood of a successful and durable valve repair favour early intervention. The optimal timing of intervention in adults with VHD is a constantly changing threshold that depends not only on the severity of valve disease but also on the safety, efficacy, and long-term durability of our treatment options.
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Affiliation(s)
- Helmut Baumgartner
- Department of Cardiology III – Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building A1, 48149 Muenster, Germany
| | - Bernard Iung
- Cardiology Department, Bichat Hospital, APHP, Université de Paris, 46 Rue Henri Huchard, 75018 Paris, France
| | - Catherine M Otto
- Cardiology, University of Washington Medical Center, 1959 NE Pacific St, Seattle, WA 98195, USA
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Early Valve Replacement for Severe Aortic Valve Disease: Effect on Mortality and Clinical Ramifications. J Clin Med 2020; 9:jcm9092694. [PMID: 32825345 PMCID: PMC7563468 DOI: 10.3390/jcm9092694] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 08/17/2020] [Accepted: 08/18/2020] [Indexed: 12/23/2022] Open
Abstract
Timing of aortic valve intervention for chronic aortic regurgitation (AR) and/or aortic stenosis (AS) potentially affects long-term survival. The 2014 American Heart Association/American College of Cardiology (AHA/ACC) guidelines provide recommendations for the timing of intervention. Subsequent to the guidelines' release, several studies have been published that suggest a survival benefit from earlier timing of surgery for severe AR and/or AS. The aim of this review was to determine whether patients who have chronic aortic regurgitation (AR) and/or aortic stenosis (AS) have a survival benefit from earlier timing of aortic valve surgery. Medical databases were systematically searched from January 2015 to April 2020 for randomized controlled trials (RCTs) and observational studies that examined the timing of aortic valve replacement surgery for chronic AR and/or AS. For chronic AR, four observational studies and no RCTs were identified. For chronic AS, five observational studies, one RCT and one meta-analysis were identified. One observational study examining mixed aortic valve disease (MAVD) was identified. All of these studies, for AR, AS, and MAVD, found long-term survival benefit from timing of aortic valve surgery earlier than the current guidelines. Larger prospective RCTs are required to evaluate the benefit of earlier surgical intervention.
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Abellán-Huerta J, Bonaque-González JC, Rubio-Patón R, García-Gómez J, Egea-Beneyto S, Soria-Arcos F, Consuegra-Sánchez L, Soto-Ruiz RM, Ramos-Martín JL, Castillo-Moreno JA. Integral Velocidade-Tempo da Insuficiência Aórtica: Um Novo Marcador Ecocardiográfico na Avaliação da Gravidade da Insuficiência Aórtica. Arq Bras Cardiol 2020; 115:253-260. [PMID: 32696853 PMCID: PMC8384281 DOI: 10.36660/abc.20190243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 08/18/2019] [Indexed: 11/18/2022] Open
Abstract
Fundamento A ecocardiografia é essencial para o diagnóstico e a quantificação da insuficiência aórtica (IA). A integral velocidade-tempo (IVT) do fluxo da IA pode estar relacionada à gravidade da IA. Objetivo Este estudo tem por objetivo avaliar se a IVT é um marcador ecocardiográfico de gravidade da IA. Métodos Foram incluídos todos os pacientes com IA nativa moderada ou grave e ritmo sinusal que visitaram o nosso laboratório de imagem entre janeiro e outubro de 2016. Todos os indivíduos foram submetidos a um ecocardiograma completo com medição da IVT da IA. A associação entre a IVT e a gravidade da IA foi analisada por regressão logística e modelos de regressão multivariada. Valores p<0,05 foram considerados estatisticamente significativos. Resultados Entre os 62 pacientes incluídos (68,5±14,9 anos; 64,5%: IA moderada; 35,5%: IA grave), a IVT foi maior em indivíduos com IA moderada em comparação àqueles com IA grave (2,2±0,5 m versus 1,9±0,5 m, p=0,01). Pacientes com IA grave apresentaram valores maiores de diâmetro diastólico final do ventrículo esquerdo (DDFVE) (56,1±7,1 mm versus 47,3±9,6 mm, p=0,001), volume diastólico final do ventrículo esquerdo (VDFVE) (171±36,5 mL versus 106±46,6 mL, p<0,001), orifício regurgitante efetivo (0,44±0,1 cm2 versus 0,18±0,1 cm2, p=0,002) e volume regurgitante (71,3±25,7 mL versus 42,5±10,9 mL, p=0,05), assim como menor fração de ejeção do ventrículo esquerdo (FEVE) (54,1±11,2% versus 63,2±13,3%, p=0,012). A IVT mostrou ser um marcador de gravidade da IA, independentemente do DDFVE, VDFVE e FEVE ( odds ratio 0,160, p=0,032) e da frequência cardíaca e pressão arterial diastólica (PAD) ( odds ratio 0,232, p=0,044). Conclusões A IVT do fluxo da IA apresentou associação inversa com a gravidade da IA, independentemente do diâmetro e volume do ventrículo esquerdo, frequência cardíaca, PAD e FEVE. A IVT pode ser um marcador de gravidade da IA em pacientes com IA nativa e ritmo sinusal. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0)
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88
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Dong N, Jiang W, Yin P, Hu X, Wang Y. Predictors of Long-Term Outcome of Isolated Surgical Aortic Valve Replacement in Aortic Regurgitation With Reduced Left Ventricular Ejection Fraction and Extreme Left Ventricular Dilatation. Am J Cardiol 2020; 125:1385-1390. [PMID: 32139161 DOI: 10.1016/j.amjcard.2020.01.041] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 01/20/2020] [Accepted: 01/22/2020] [Indexed: 12/16/2022]
Abstract
The management of severe aortic regurgitation (AR) in patients with reduced left ventricular function and extreme left ventricular dilatation presents a therapeutic dilemma. This study aims to assess risk factors of aortic valve replacement (AVR) for these particular population based on its performances. Two hundred twelve severe AR patients accompanied by left ventricular ejection fraction (LVEF) <50% and left ventricular end-diastolic dimension (LVEDD) ≥70 mm who underwent isolated AVR between January 2007 and December 2016 were identified retrospectively. Logistic regression and receiver operating characteristic were used to analyze prognostic indicators for in-hospital mortality while Kaplan-Meier analysis for long-term survival. Mean age was 56 ± 13 years with mean LVEF 40 ± 7% and LVEDD 78 ± 6 mm. In-hospital mortality rate was 7%, and survival rates at 5 and 10 years were 88 ± 4% and 73 ± 10%, respectively. Logistic regression analysis indicated in-hospital mortality was associated with preoperative age and LVEF. Receiver operating characteristic analysis showed LVEF = 35% was the best cut-off value at which to predict in-hospital death. Kaplan-Meier analysis revealed patients with markedly reduced LV function (LVEF <35%) had lower survival rates compared with other patients with moderate LV dysfunction (LVEF 36% to 50%) (1-, 5-, and 10-year: 90 ± 4%, 64 ± 7%, and 55 ± 14%, vs 97 ± 1%, 94 ± 3%, and 76 ± 7%, p <0.001). An age-matched analysis showed similar trend (p = 0.020). In Conclusion, AVR may be unsafe for severe AR patients with markedly reduced LV function (LVEF <35%) and extreme left ventricular dilatation (LVEDD >70 mm) due to poor postoperative early- and long-term outcomes.
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Affiliation(s)
- Nianguo Dong
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Weiwei Jiang
- Department of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ping Yin
- Department of Epidemiology and Health Statistics, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xingjian Hu
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yin Wang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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Yang LT, Pellikka PA, Enriquez-Sarano M, Scott CG, Padang R, Mankad SV, Schaff HV, Michelena HI. Diastolic Blood Pressure and Heart Rate Are Independently Associated With Mortality in Chronic Aortic Regurgitation. J Am Coll Cardiol 2020; 75:29-39. [DOI: 10.1016/j.jacc.2019.10.047] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 10/23/2019] [Accepted: 10/28/2019] [Indexed: 12/21/2022]
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90
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Vanoverschelde JL, Vancraeynest D. Progression of Aortic Regurgitation: The Missing Link Between Disease Severity and Clinical Complications. J Am Coll Cardiol 2019; 74:2493-2495. [PMID: 31727287 DOI: 10.1016/j.jacc.2019.08.1059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 08/20/2019] [Indexed: 11/19/2022]
Affiliation(s)
- Jean-Louis Vanoverschelde
- Pôle de Recherche Cardiovasculaire, Université Catholique de Louvain, Brussels, Belgium; Division of Cardiology, Cliniques Universitaires Saint-Luc, Brussels, Belgium.
| | - David Vancraeynest
- Pôle de Recherche Cardiovasculaire, Université Catholique de Louvain, Brussels, Belgium; Division of Cardiology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
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91
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Surrogates for myocardial power and power efficiency in patients with aortic valve disease. Sci Rep 2019; 9:16407. [PMID: 31712631 PMCID: PMC6848480 DOI: 10.1038/s41598-019-52909-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 10/12/2019] [Indexed: 01/05/2023] Open
Abstract
We aimed to assess surrogate markers for left ventricular (LV) myocardial power and efficiency in patients with isolated aortic stenosis (AS) and combined stenosis/regurgitation (AS/AR). In AS (n = 59), AS/AR (n = 21) and controls (n = 14), surrogates for LV myocardial power and circulatory/external myocardial efficiency were obtained from cardiac MRI. Median surrogate LV myocardial power was increased in AS, 7.7 W/m2 (interquartile range 6.0–10.2; p = 0.010) and AS/AR, 10.8 W/m2 (8.9–13.4; p < 0.001) when compared to controls, 5.4 W/m2 (4.2–6.5), and was lower in AS than AS/AR (p < 0.001). Surrogate circulatory efficiency was decreased in AS, 8.6% (6.8–11.1; p < 0.001) and AS/AR, 5.4% (4.1–6.2; p < 0.001) when compared to controls, 11.8% (9.8–16.9). Surrogate external myocardial efficiency was higher in AS, 15.2% (11.9–18.6) than in AS/AR, 12.2% (10.1–14.2; p = 0.031) and was significantly lower compared to controls, 12.2% (10.7–18.1) in patients with reduced ejection fraction (EF), 9.8% (8.1–11.7; p = 0.025). In 16% of all cases, left ventricular mass/volume indices and EF were within normal ranges, wheras surrogate LV myocardial power was elevated and patients were symptomatic. Although influenced by pressure/volume load, the myocardium is additionally affected by remodelling processes. Surrogates for circulatory efficiency and LV myocardial power gradually reflect alterations in patients with AS and AS/AR, even when surrogate external myocardial efficiency, EF, mass and volume indices still remain compensated.
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92
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Do Guideline-Based Indications Result in an Outcome Penalty for Patients With Severe Aortic Regurgitation? JACC Cardiovasc Imaging 2019; 12:2126-2138. [DOI: 10.1016/j.jcmg.2018.11.022] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 11/06/2018] [Accepted: 11/08/2018] [Indexed: 11/17/2022]
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Effect of Quinolones Versus Cefixime on International Normalized Ratio Levels After Valve Replacement Surgery with Warfarin Therapy. MEDICINA-LITHUANIA 2019; 55:medicina55100644. [PMID: 31561580 PMCID: PMC6843472 DOI: 10.3390/medicina55100644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 09/02/2019] [Accepted: 09/23/2019] [Indexed: 11/29/2022]
Abstract
Background and Objectives: A dispute over interaction of warfarin with two quinolones—i.e., moxifloxacin and levofloxacin—leading to significant increase in international normalized ratio (INR) levels and coagulopathies is currently in debate. The study objective was to compare the INR values due to addition of quinolones and cefixime in warfarin treated patients after replacement of disease valves with metallic valves. Material and Methods: A prospective evaluation of patients who undergone valve replacement surgeries in the cardiology hospital setup in Pakistan during the period 2018–2019 was done, including all those subjects treated concurrently with levofloxacin, moxifloxacin, cefixime, and warfarin for the study. Data organized included demographic information, concurrent medications, and appropriate analytical parameters, especially INR values taken before and within seven days after prescribing three antibiotics in discharged patients who had undergone valve replacement surgeries. Patients for whom laboratory INR values were not given at the time of discharge and with deranged liver function, renal function, low albumin levels, and febrile patients were removed from study. Furthermore, patients were advised on possible food interactions and evaluated to examine if these factors have any possible influence on the interaction being studied. Results: Differences in INR were analyzed statistically by means of SPSS analysis before and after the possible interaction. Following the administration of levofloxacin and moxifloxacin to warfarin therapy, statistical analysis showed remarkable increase in INR (p < 0.001) and no significant change in INR was observed after cefixime treatment (p > 0.05). Conclusion: Results showed that, after adding levofloxacin and moxifloxacin in patients on warfarin, therapy contributed to remarkable increase in INR. However, addition of cefixime prevented frequent coagulopathies; therefore, close monitoring of INR and switching to a safe antibiotic such as cefixime is recommended.
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Fava AM, Meredith D, Desai MY. Clinical Applications of Echo Strain Imaging: a Current Appraisal. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2019; 21:50. [PMID: 31473859 DOI: 10.1007/s11936-019-0761-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE OF REVIEW This article reviews recent advances in echocardiographic strain imaging, particularly in its ability to prognosticate in cardiovascular outcomes and impact clinical decision making. RECENT FINDINGS Strain has been proposed as a sensitive tool in detecting early ventricular dysfunction. Left ventricular global longitudinal strain (LV-GLS) detects subtle changes in myocardial function, often not quantifiable by ejection fraction alone. Thus, LV-GLS provides the opportunity for early decision-making, and the implementation of more effective treatments, improving outcomes in a variety of diseases such as valvular heart diseases, cardio-oncology, ischemic heart disease, cardiomyopathies, heart transplantation, and pericardial diseases and cardiomyopathies. Strain is a promising tool for the early detection of myocardial dysfunction in patients with preserved left ventricular ejection fraction and can prognosticate long-term outcomes.
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Affiliation(s)
- Agostina M Fava
- Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk J1-5, Cleveland, OH, 44195, USA
| | - Dane Meredith
- Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk J1-5, Cleveland, OH, 44195, USA
| | - Milind Y Desai
- Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk J1-5, Cleveland, OH, 44195, USA.
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96
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Nicolosi GL, Antonini-Canterin F, Pavan D, Piazza R. Simplified three-dimensional spatial approach for improving confidence in reliably measuring left ventricular linear internal dimensions. J Cardiovasc Med (Hagerstown) 2019; 20:367-371. [PMID: 31045854 DOI: 10.2459/jcm.0000000000000775] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
| | | | - Daniela Pavan
- Cardiologia, ARC, Ospedale Civile, San Vito al Tagliamento
| | - Rita Piazza
- Cardiologia, ARC, Ospedale Civile, Pordenone, Italy
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Yang LT, Michelena HI, Scott CG, Enriquez-Sarano M, Pislaru SV, Schaff HV, Pellikka PA. Outcomes in Chronic Hemodynamically Significant Aortic Regurgitation and Limitations of Current Guidelines. J Am Coll Cardiol 2019; 73:1741-1752. [DOI: 10.1016/j.jacc.2019.01.024] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 12/18/2018] [Accepted: 01/07/2019] [Indexed: 12/19/2022]
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98
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Chetrit M, Roujol S, Picard MH, Timmins L, Manning WJ, Rudski LG, Levine RA, Afilalo J. Optimal Technique for Measurement of Linear Left Ventricular Dimensions. J Am Soc Echocardiogr 2019; 32:476-483.e1. [PMID: 30826223 DOI: 10.1016/j.echo.2018.12.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Echocardiographic assessment of the left ventricle (LV) begins with the measurement of linear dimensions that approximate its ellipsoid diameter. These linear dimensions have historically been measured at the basal level of the LV, which is not representative of its true diameter. The objective of this study was to determine the optimal level to measure LV cavity dimensions to more accurately estimate its size and mass. METHODS The derivation study included 75 patients who had a clinically indicated cardiac magnetic resonance (CMR) exam for ischemic heart disease (n = 15), nonischemic cardiomyopathy (n = 25), or normal studies (n = 35). The three-chamber bright blood cine sequence was analyzed using a custom MATLAB program to measure the LV cavity diameter and wall thickness at 15 equidistant levels from base to apex. The linear measurements from each of these levels were compared against the CMR volumetric reference standard. The validation study included 100 patients who had a clinically indicated echocardiogram and CMR within 3 days for ischemic heart disease (n = 20), nonischemic cardiomyopathy (n = 44), and normal or near-normal studies (n = 36). The parasternal long-axis cine sequence was analyzed to measure the LV cavity diameter and wall thickness at the traditional basal level and the midventricular level, which were compared against the CMR volumetric reference standard. RESULTS In both the derivation and validation studies, the midventricular linear dimensions, defined as those located at the true (maximal) diameter of the LV ellipsoid cavity, were found to be more closely correlated with the volumetric reference standard for LV mass, LV end-diastolic size, and LV ejection fraction. CONCLUSIONS Measurement of linear dimensions at the midventricular level better reflects the ellipsoid geometry of the LV cavity and provides a more accurate estimate of LV mass, size, and systolic function as compared with the traditionally recommended basal level.
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Affiliation(s)
- Michael Chetrit
- Azrieli Heart Center, Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Sébastien Roujol
- School of Biomedical Engineering and Imaging Sciences, King's College, London, United Kingdom; Departments of Medicine (Cardiovascular Division) and Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Michael H Picard
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Logan Timmins
- Faculty of Sciences, Concordia University, Montreal, Quebec, Canada
| | - Warren J Manning
- Departments of Medicine (Cardiovascular Division) and Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Lawrence G Rudski
- Azrieli Heart Center, Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Robert A Levine
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Jonathan Afilalo
- Azrieli Heart Center, Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada; Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada.
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Ghorayeb N, Stein R, Daher DJ, Silveira ADD, Ritt LEF, Santos DFPD, Sierra APR, Herdy AH, Araújo CGSD, Colombo CSSDS, Kopiler DA, Lacerda FFRD, Lazzoli JK, Matos LDNJD, Leitão MB, Francisco RC, Alô ROB, Timerman S, Carvalho TD, Garcia TG. The Brazilian Society of Cardiology and Brazilian Society of Exercise and Sports Medicine Updated Guidelines for Sports and Exercise Cardiology - 2019. Arq Bras Cardiol 2019; 112:326-368. [PMID: 30916199 PMCID: PMC6424031 DOI: 10.5935/abc.20190048] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Nabil Ghorayeb
- Instituto Dante Pazzanese de Cardiologia, São Paulo, SP - Brazil
- Hospital do Coração (HCor), Associação do Sanatório Sírio, São Paulo, SP - Brazil
- Programa de Pós-Graduação em Medicina do Esporte da Universidade Federal de São Paulo (UNIFESP), São Paulo, SP - Brazil
- Instituto de Assistência Médica ao Servidor Público Estadual (IAMSPE), São Paulo, SP - Brazil
| | - Ricardo Stein
- Programa de Pós-Graduação em Cardiologia e Ciências Cardiovasculares da Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS - Brazil
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul (HCPA/UFRGS), Porto Alegre, RS - Brazil
- Vitta Centro de Bem Estar Físico, Porto Alegre, RS - Brazil
| | - Daniel Jogaib Daher
- Hospital do Coração (HCor), Associação do Sanatório Sírio, São Paulo, SP - Brazil
| | - Anderson Donelli da Silveira
- Programa de Pós-Graduação em Cardiologia e Ciências Cardiovasculares da Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS - Brazil
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul (HCPA/UFRGS), Porto Alegre, RS - Brazil
- Vitta Centro de Bem Estar Físico, Porto Alegre, RS - Brazil
| | - Luiz Eduardo Fonteles Ritt
- Hospital Cárdio Pulmonar, Salvador, BA - Brazil
- Escola Bahiana de Medicina e Saúde Pública, Salvador, BA - Brazil
| | | | | | - Artur Haddad Herdy
- Instituto de Cardiologia de Santa Catarina, Florianópolis, SC - Brazil
- Clínica Cardiosport de Prevenção e Reabilitação, Florianópolis, SC - Brazil
| | | | - Cléa Simone Sabino de Souza Colombo
- Hospital do Coração (HCor), Associação do Sanatório Sírio, São Paulo, SP - Brazil
- Sports Cardiology, Cardiology Clinical Academic Group - St George's University of London,14 London - UK
| | - Daniel Arkader Kopiler
- Sociedade Brasileira de Medicina do Esporte e do Exercício (SBMEE), São Paulo, SP - Brazil
- Instituto Nacional de Cardiologia (INC), Rio de Janeiro, RJ - Brazil
| | - Filipe Ferrari Ribeiro de Lacerda
- Programa de Pós-Graduação em Cardiologia e Ciências Cardiovasculares da Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS - Brazil
| | - José Kawazoe Lazzoli
- Sociedade Brasileira de Medicina do Esporte e do Exercício (SBMEE), São Paulo, SP - Brazil
- Federação Internacional de Medicina do Esporte (FIMS), Lausanne - Switzerland
| | | | - Marcelo Bichels Leitão
- Sociedade Brasileira de Medicina do Esporte e do Exercício (SBMEE), São Paulo, SP - Brazil
| | - Ricardo Contesini Francisco
- Instituto Dante Pazzanese de Cardiologia, São Paulo, SP - Brazil
- Hospital do Coração (HCor), Associação do Sanatório Sírio, São Paulo, SP - Brazil
| | - Rodrigo Otávio Bougleux Alô
- Instituto Dante Pazzanese de Cardiologia, São Paulo, SP - Brazil
- Hospital Geral de São Mateus, São Paulo, SP - Brazil
| | - Sérgio Timerman
- Instituto do Coração da Faculdade de Medicina da Universidade de São Paulo (InCor-FMUSP), São Paulo, SP - Brazil
- Universidade Anhembi Morumbi, Laureate International Universities, São Paulo, SP - Brazil
| | - Tales de Carvalho
- Clínica Cardiosport de Prevenção e Reabilitação, Florianópolis, SC - Brazil
- Departamento de Ergometria e Reabilitação Cardiovascular da Sociedade Brasileira de Cardiologia (DERC/SBC), Rio de Janeiro, RJ - Brazil
- Universidade do Estado de Santa Catarina (UDESC), Florianópolis, SC - Brazil
| | - Thiago Ghorayeb Garcia
- Instituto Dante Pazzanese de Cardiologia, São Paulo, SP - Brazil
- Hospital do Coração (HCor), Associação do Sanatório Sírio, São Paulo, SP - Brazil
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100
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Doukky R, Golzar Y. Straining for New Prognostic Predictors in Asymptomatic Severe Aortic Regurgitation. JACC Cardiovasc Imaging 2019; 13:22-24. [PMID: 30772225 DOI: 10.1016/j.jcmg.2019.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 01/03/2019] [Accepted: 01/03/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Rami Doukky
- Division of Cardiology, Cook County Health and Hospitals System, Chicago, Illinois; Division of Cardiology, Rush University Medical Center, Chicago, Illinois.
| | - Yasmeen Golzar
- Division of Cardiology, Cook County Health and Hospitals System, Chicago, Illinois
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