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Updates to a Modern Dilemma: a Practical Approach to the Workup and Management of Low-Gradient Severe Aortic Stenosis Using Transvalvular Flow Rate. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2020. [DOI: 10.1007/s11936-020-00865-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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52
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Barbieri A, Antonini-Canterin F, Pepi M, Monte IP, Trocino G, Barchitta A, Ciampi Q, Cresti A, Miceli S, Petrella L, Benedetto F, Zito C, Benfari G, Bursi F, Malagoli A, Bartolacelli Y, Mantovani F, Clavel MA. Discordant Echocardiographic Grading in Low Gradient Aortic Stenosis (DEGAS Study) From the Italian Society of Echocardiography and Cardiovascular Imaging Research Network: Rationale and Study Design. J Cardiovasc Echogr 2020; 30:52-61. [PMID: 33282641 PMCID: PMC7706377 DOI: 10.4103/jcecho.jcecho_68_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 07/13/2020] [Indexed: 11/04/2022] Open
Abstract
Background Low-gradient aortic stenosis (LG-AS) is characterized by the combination of an aortic valve area compatible with severe stenosis and a low transvalvular mean gradient with low-flow state (i.e., indexed stroke volume <35 mL/m2) in the presence of reduced (classical low-flow AS) or preserved (paradoxical low-flow AS) ejection fraction. Furthermore, the occurrence of a normal-flow LG-AS is still advocated by many authors. Within this diagnostic complexity, the diagnosis of severe AS remains challenging. Objective The general objective of the Discordant Echocardiographic Grading in Low-gradient AS (DEGAS Study) study will be to assess the prevalence of true severe AS in this population and validate new parameters to improve the assessment and the clinical decision-making in patients with LG-AS. Methods and Analyses The DEGAS Study of the Italian Society of Echocardiography and Cardiovascular Imaging is a prospective, multicenter, observational diagnostic study that will enroll consecutively adult patients with LG-AS over 2 years. AS severity will be ideally confirmed by a multimodality approach, but only the quantification of calcium score by multidetector computed tomography will be mandatory. The primary clinical outcome variable will be 12-month all-cause mortality. The secondary outcome variables will be (i) 30-day mortality (for patients treated by Surgical aortic valve replacement or TAVR); (ii) 12-month cardiovascular mortality; (iii) 12-month new major cardiovascular events such as myocardial infarction, stroke, vascular complications, and rehospitalization for heart failure; and (iv) composite endpoint of cardiovascular mortality and hospitalization for heart failure. Data collection will take place through a web platform (REDCap), absolutely secure based on current standards concerning the ethical requirements and data integrity.
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Affiliation(s)
- Andrea Barbieri
- Division of Cardiology, Department of Diagnostics, Clinical and Public Health Medicine, Policlinico University Hospital of Modena, Milano, Italy
| | - Francesco Antonini-Canterin
- Rehabilitative Cardiology, Ospedale Riabilitativo di Alta Specializzazione di Motta di Livenza (TV), Milano, Italy
| | - Mauro Pepi
- Monzino Cardiology Center, IRCCS, Milano, Italy
| | | | - Giuseppe Trocino
- Cardiology, Hospital of Desio, S. Antonio Hospital, AO Padova, Italy
| | | | | | - Alberto Cresti
- Cardiology, Dip. Cardio Neuro Vascolare Asl sudest Toscana, Hospital of Grosseto, Italy
| | | | | | - Frank Benedetto
- Cardiology, G.O.M. "Bianchi Melacrino Morelli", Reggio Calabria, Italy
| | - Concetta Zito
- Department of Clinical and Experimental Medicine - Section of Cardiology, G. Martino General Hospital, University of Messina, Italy
| | - Giovanni Benfari
- Section of Cardiology, Department of Medicine, University of Verona, Italy
| | - Francesca Bursi
- Division of Cardiology, Heart and Lung Department, San Paolo Hospital, ASST Santi Paolo and Carlo, University of Milan, Italy
| | | | - Ylenia Bartolacelli
- Pediatric and Adult Congenital Heart Cardiac Surgery, S.Orsola Malpighi Hospital, University of Bologna, Italy
| | | | - Marie-Annick Clavel
- Institut universitaire de cardiologie et de pneumologie de Québec, Université Laval, Quebec City, Quebec, Canada
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53
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Using Discrete Multiphysics Modelling to Assess the Effect of Calcification on Hemodynamic and Mechanical Deformation of Aortic Valve. CHEMENGINEERING 2020. [DOI: 10.3390/chemengineering4030048] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study proposes a 3D particle-based (discrete) multiphysics approach for modelling calcification in the aortic valve. Different stages of calcification (from mild to severe) were simulated, and their effects on the cardiac output were assessed. The cardiac flow rate decreases with the level of calcification. In particular, there is a critical level of calcification below which the flow rate decreases dramatically. Mechanical stress on the membrane is also calculated. The results show that, as calcification progresses, spots of high mechanical stress appear. Firstly, they concentrate in the regions connecting two leaflets; when severe calcification is reached, then they extend to the area at the basis of the valve.
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Sato K, Sankaramangalam K, Kandregula K, Bullen JA, Kapadia SR, Krishnaswamy A, Mick S, Rodriguez LL, Grimm RA, Menon V, Desai MY, Svensson LG, Griffin BP, Popović ZB. Contemporary Outcomes in Low-Gradient Aortic Stenosis Patients Who Underwent Dobutamine Stress Echocardiography. J Am Heart Assoc 2020; 8:e011168. [PMID: 30879370 PMCID: PMC6475055 DOI: 10.1161/jaha.118.011168] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Detection of flow reserve (FR) by dobutamine stress echocardiography is used for risk stratification in low‐gradient aortic stenosis (AS). Prognostic significance of dobutamine stress echocardiography in the transcatheter aortic valve replacement era is unclear. We aimed to assess the current relevance of FR. Methods and Results We studied 235 patients with low‐gradient severe AS (rest aortic valve area ≤1.0 cm2 or indexed aortic valve area ≤0.60 cm2/m2; mean aortic valve gradient <40 mm Hg) and left ventricular ejection fraction <50%) with dobutamine stress echocardiography done September 2010 through July 2016. FR was defined by ≥20% stroke volume increase. We diagnosed “true‐severe AS” if peak aortic valve velocity ≥4 m/s occurred with aortic valve area ≤1.0 cm2 (or indexed aortic valve area ≤0.6 cm2/m2). At a median time of 51 days, 128 patients underwent aortic valve replacement,either surgical aortic valve replacement (n=42) or transcatheter aortic valve replacement (n=86). FR was observed in 138 patients, while 86 patients had true‐severe AS. During median follow‐up of 2.3 years, 138 patients died. In a multivariable model, aortic valve replacement (hazard ratio 0.41, 95% CI: 0.29–0.58, P <0.001) and lower Society of Thoracic Surgeons score (hazard ratio 1.06, 95% CI: 1.04–1.09, P<0.001) were associated with better survival, while FR was not predictive. aortic valve replacement was associated with survival regardless of the presence or absence of FR or AS severity stratification. Conclusions In low‐gradient AS with reduced ejection fraction, FR or AS severity stratification by dobutamine stress echocardiography was not associated with survival. Aortic valve replacement was associated with better survival in low‐gradient AS independent of FR. See Editorial by Annabi et al
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Affiliation(s)
- Kimi Sato
- Heart and Vascular InstituteCleveland ClinicClevelandOH
| | | | | | | | | | | | | | | | | | - Venu Menon
- Heart and Vascular InstituteCleveland ClinicClevelandOH
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Anand V, Mankad SV, Eleid M. What Is New in Low Gradient Aortic Stenosis: Surgery, TAVR, or Medical Therapy? Curr Cardiol Rep 2020; 22:78. [DOI: 10.1007/s11886-020-01341-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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56
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"Pure" severe aortic stenosis without concomitant valvular heart diseases: echocardiographic and pathophysiological features. Int J Cardiovasc Imaging 2020; 36:1917-1929. [PMID: 32500398 PMCID: PMC7497506 DOI: 10.1007/s10554-020-01907-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 06/01/2020] [Indexed: 02/06/2023]
Abstract
Purpose In echocardiography the severity of aortic stenosis (AS) is defined by effective orifice area (EOA), mean pressure gradient (mPGAV) and transvalvular flow velocity (maxVAV). The hypothesis of the present study was to confirm the pathophysiological presence of combined left ventricular hypertrophy (LVH), diastolic dysfunction (DD) and pulmonary artery hypertension (PAH) in patients with “pure” severe AS. Methods and Results Patients (n = 306) with asymptomatic (n = 133) and symptomatic (n = 173) “pure” severe AS (mean age 78 ± 9.5 years) defined by indexed EOA < 0.6 cm2 were enrolled between 2014 and 2016. AS patients were divided into 4 subgroups according to mPGAV and indexed left ventricular stroke volume: low flow (LF) low gradient (LG)-AS (n = 133), normal flow (NF) LG-AS (n = 91), LF high gradient (HG)-AS (n = 21) and NFHG-AS (n = 61). Patients with “pure” severe AS showed mean mPGAV of 31.7 ± 9.1 mmHg and mean maxVAV of 3.8 ± 0.6 m/s. Only 131 of 306 patients (43%) exhibited mPGAV > 40 mmHg and maxVAV > 4 m/s documenting incongruencies of the AS severity assessment by Doppler echocardiography. LVH was documented in 81%, DD in 76% and PAH in 80% of AS patients. 54% of “pure” AS patients exhibited all three alterations. Ranges of mPGAV and maxVAV were higher in patients with all three alterations compared to patients with less than three. 224 (73%) patients presented LG-conditions and 82 (27%) HG-conditions. LVH was predominant in NF-AS (p = 0.014) and PAH in LFHG-AS (p = 0.014). Patients’ treatment was retrospectively assessed (surgery: n = 100, TAVI: n = 48, optimal medical treatment: n = 156). Conclusion In patients with “pure” AS according to current guidelines the presence of combined LVH, DD and PAH as accepted pathophysiological sequelae of severe AS cannot be confirmed. Probably, the detection of these secondary cardiac alterations might improve the diagnostic algorithm to avoid overestimation of AS severity.
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Namasivayam M, Picard MH. Flow Rate in Aortic Stenosis: Clinical Tool, Hemodynamic Insight, or Both? J Am Soc Echocardiogr 2020; 33:449-451. [DOI: 10.1016/j.echo.2020.01.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 01/28/2020] [Indexed: 12/11/2022]
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58
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Hirasawa K, Izumo M, Suzuki K, Suzuki T, Ohara H, Watanabe M, Sato Y, Kamijima R, Nobuoka S, Akashi YJ. Value of Transvalvular Flow Rate during Exercise in Asymptomatic Patients with Aortic Stenosis. J Am Soc Echocardiogr 2020; 33:438-448. [DOI: 10.1016/j.echo.2019.11.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 11/13/2019] [Accepted: 11/17/2019] [Indexed: 12/14/2022]
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Clinical Usefulness of Pressure Recovery Adjustment in Patients with Predominantly Severe Aortic Stenosis: Asian Valve Registry Data. J Am Soc Echocardiogr 2020; 33:332-341.e2. [DOI: 10.1016/j.echo.2019.10.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 10/16/2019] [Accepted: 10/17/2019] [Indexed: 01/11/2023]
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61
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Johnson NP, Zelis JM, Tonino PAL, Houthuizen P, Bouwman RA, Brueren GRG, Johnson DT, Koolen JJ, Korsten HHM, Wijnbergen IF, Zimmermann FM, Kirkeeide RL, Pijls NHJ, Gould KL. Pressure gradient vs. flow relationships to characterize the physiology of a severely stenotic aortic valve before and after transcatheter valve implantation. Eur Heart J 2019; 39:2646-2655. [PMID: 29617762 PMCID: PMC6055586 DOI: 10.1093/eurheartj/ehy126] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 02/23/2018] [Indexed: 11/14/2022] Open
Abstract
Aims Echocardiography and tomographic imaging have documented dynamic changes in aortic stenosis (AS) geometry and severity during both the cardiac cycle and stress-induced increases in cardiac output. However, corresponding pressure gradient vs. flow relationships have not been described. Methods and results We recruited 16 routine transcatheter aortic valve implantations (TAVI’s) for graded dobutamine infusions both before and after implantation; 0.014″ pressure wires in the aorta and left ventricle (LV) continuously measured the transvalvular pressure gradient (ΔP) while a pulmonary artery catheter regularly assessed cardiac output by thermodilution. Before TAVI, ΔP did not display a consistent relationship with transvalvular flow (Q). Neither linear resistor (median R2 0.16) nor quadratic orifice (median R2 < 0.01) models at rest predicted stress observations; the severely stenotic valve behaved like a combination. The unitless ratio of aortic to left ventricular pressures during systolic ejection under stress conditions correlated best with post-TAVI flow improvement. After TAVI, a highly linear relationship (median R2 0.96) indicated a valid valve resistance. Conclusion Pressure loss vs. flow curves offer a fundamental fluid dynamic synthesis for describing aortic valve pathophysiology. Severe AS does not consistently behave like an orifice (as suggested by Gorlin) or a resistor, whereas TAVI devices behave like a pure resistor. During peak dobutamine, the ratio of aortic to left ventricular pressures during systolic ejection provides a ‘fractional flow reserve’ of the aortic valve that closely approximates the complex, changing fluid dynamics. Because resting assessment cannot reliably predict stress haemodynamics, ‘valvular fractional flow’ warrants study to explain exertional symptoms in patients with only moderate AS at rest. ![]()
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Affiliation(s)
- Nils P Johnson
- Weatherhead PET Center, Division of Cardiology, Department of Medicine, McGovern Medical School at UTHealth and Memorial Hermann Hospital, Houston, TX, USA.,Department of Cardiology, Catharina Hospital, Eindhoven, Netherlands
| | - Jo M Zelis
- Department of Cardiology, Catharina Hospital, Eindhoven, Netherlands
| | - Pim A L Tonino
- Department of Cardiology, Catharina Hospital, Eindhoven, Netherlands
| | | | - R Arthur Bouwman
- Department of Anesthesiology, Catharina Hospital, Eindhoven, Netherlands.,Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
| | - Guus R G Brueren
- Department of Cardiology, Catharina Hospital, Eindhoven, Netherlands
| | - Daniel T Johnson
- Weatherhead PET Center, Division of Cardiology, Department of Medicine, McGovern Medical School at UTHealth and Memorial Hermann Hospital, Houston, TX, USA
| | - Jacques J Koolen
- Department of Cardiology, Catharina Hospital, Eindhoven, Netherlands
| | - Hendrikus H M Korsten
- Department of Anesthesiology, Catharina Hospital, Eindhoven, Netherlands.,Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
| | - Inge F Wijnbergen
- Department of Cardiology, Catharina Hospital, Eindhoven, Netherlands
| | | | - Richard L Kirkeeide
- Weatherhead PET Center, Division of Cardiology, Department of Medicine, McGovern Medical School at UTHealth and Memorial Hermann Hospital, Houston, TX, USA
| | - Nico H J Pijls
- Department of Cardiology, Catharina Hospital, Eindhoven, Netherlands.,Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
| | - K Lance Gould
- Weatherhead PET Center, Division of Cardiology, Department of Medicine, McGovern Medical School at UTHealth and Memorial Hermann Hospital, Houston, TX, USA
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Kitai T, Tsutsui RS. The contemporary role of echocardiography in the assessment and management of aortic stenosis. J Med Ultrason (2001) 2019; 47:71-80. [PMID: 31792637 DOI: 10.1007/s10396-019-00991-x] [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: 09/14/2019] [Accepted: 11/11/2019] [Indexed: 10/25/2022]
Abstract
Aortic stenosis (AS) represents a major healthcare issue because of its ever-increasing prevalence, poor prognosis, and complex pathophysiology. Echocardiography plays a central role in providing a comprehensive morphological and hemodynamic evaluation of AS. The diagnosis of severe AS is currently based on three hemodynamic parameters including maximal jet velocity, mean pressure gradient (mPG) across the aortic valve, and aortic valve area (AVA). However, inconsistent grading of AS severity is common when the AVA is < 1.0 cm2 but the mPG is < 40 mmHg, also known as low-gradient AS (LGAS). Special attention should be paid to patients with symptomatic LGAS with low stroke volume and/or low ejection fraction because this entity is more difficult to diagnose and has a worse prognosis. Stress echocardiography testing plays an important role in this disease entity. Elderly patients with prohibitive comorbidities for surgical aortic valve replacement (AVR) were without procedural options until the advent of transcatheter AVR (TAVR), which has dramatically changed these circumstances. Along with computed tomography, echocardiography plays a vital role in the periprocedural assessment of the aortic valve and surrounding apparatus. This review describes the evolution of the role of echocardiography in the diagnosis and management of AS, the complexity of the aortic apparatus, and the increased need for expert use of three-dimensional echocardiography.
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Affiliation(s)
- Takeshi Kitai
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-minamimachi, Chuo-ku, Kobe, 650-0047, Japan. .,Center for Clinical Research, Kobe City Medical Center General Hospital, Kobe, Japan.
| | - Rayji S Tsutsui
- Heart and Vascular Institute, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
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Zelis JM, Tonino PAL, Johnson DT, Balan P, Brueren GRG, Wijnbergen I, Kirkeeide RL, Pijls NHJ, Gould KL, Johnson NP. Stress Aortic Valve Index (SAVI) with Dobutamine for Low-Gradient Aortic Stenosis: A Pilot Study. STRUCTURAL HEART 2019. [DOI: 10.1080/24748706.2019.1690180] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Jo M. Zelis
- Department of Cardiology, Catharina Hospital, Eindhoven, Netherlands
| | - Pim A. L. Tonino
- Department of Cardiology, Catharina Hospital, Eindhoven, Netherlands
| | - Daniel T. Johnson
- Weatherhead PET Center, Division of Cardiology, Department of Medicine, McGovern Medical School at UTHealth and Memorial Hermann Hospital, Houston, Texas, USA
| | - Prakash Balan
- Weatherhead PET Center, Division of Cardiology, Department of Medicine, McGovern Medical School at UTHealth and Memorial Hermann Hospital, Houston, Texas, USA
| | | | - Inge Wijnbergen
- Department of Cardiology, Catharina Hospital, Eindhoven, Netherlands
| | - Richard L. Kirkeeide
- Weatherhead PET Center, Division of Cardiology, Department of Medicine, McGovern Medical School at UTHealth and Memorial Hermann Hospital, Houston, Texas, USA
| | - Nico H. J. Pijls
- Department of Cardiology, Catharina Hospital, Eindhoven, Netherlands
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
| | - K. Lance Gould
- Weatherhead PET Center, Division of Cardiology, Department of Medicine, McGovern Medical School at UTHealth and Memorial Hermann Hospital, Houston, Texas, USA
| | - Nils P. Johnson
- Weatherhead PET Center, Division of Cardiology, Department of Medicine, McGovern Medical School at UTHealth and Memorial Hermann Hospital, Houston, Texas, USA
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Bridonneau V, Galli E, Auffret V, Lederlin M, Campion M, Le Breton H, Boulmier D, Hubert A, Lenz PA, Leclercq C, Oger E, Donal E. Management of aortic valve replacement according to the gradient across symptomatic aortic valve stenosis and its prognostic impact. Echocardiography 2019; 36:2136-2144. [PMID: 31705575 DOI: 10.1111/echo.14531] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Revised: 10/14/2019] [Accepted: 10/15/2019] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Treatment strategy for low-gradient (LG) aortic stenosis (AS) remains an unresolved issue. The presence of a low aortic gradient and preserved left ventricular ejection fraction (LVEF) might lead toward the underestimation of aortic stenosis severity and a more conservative management. We sought (a) to describe the nature and timing of intervention according to flow/gradient subgroups in patibents with LG-AS, (2) to determine the factors associated with the decision to intervene, and (c) to describe prognosis. METHODS AND RESULTS One hundred and ten patients prospectively included in this study underwent a standardized clinical and imaging evaluation at inclusion and at 1-year follow-up. According to aortic flow, gradient and LVEF, patients were divided into 4 groups: LG-normal flow [n = 27], LG-low flow-low LVEF [n = 27], LG-low flow-normal LVEF [n = 16], and high gradient (HG) [n = 40]). 73% of patients underwent AVR 86 ± 59 days after the initial assessment. The HG subgroup had significantly higher intervention rates (P < .001). In multivariable analysis, four parameters were associated with the AVR: aortic gradient (HR 1.52 [1.10-2.11], P = .012), LVEF (HR 0.58 [0.40-0.85], P = .006), atrial fibrillation (HR 0.43 [0.021-0.87], P = .019), and NT-proBNP (HR 0.92[0.86-0.98), P = .008]. Patients operated earlier had better outcomes than those having a delayed AVR (P = .042). LG-AS patients had worse outcomes than HG-AS patients (P < .001). CONCLUSION Compared to HG-AS, LG-AS is less likely to benefit from an AVR and had a significantly worse outcome. Further interventional studies are needed to investigate the timing of AVR in these patients.
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Affiliation(s)
- Valentin Bridonneau
- Service de Cardiologie, Inserm LTSI-UMR1099, CHU Rennes, Université Rennes 1, Rennes, France.,Imagerie médicale, CHU Rennes, Rennes, France.,Pharmacologie Clinique et CIC-IP 1414, CHU Rennes et Université Rennes-1, Rennes, France
| | - Elena Galli
- Service de Cardiologie, Inserm LTSI-UMR1099, CHU Rennes, Université Rennes 1, Rennes, France.,Imagerie médicale, CHU Rennes, Rennes, France.,Pharmacologie Clinique et CIC-IP 1414, CHU Rennes et Université Rennes-1, Rennes, France
| | - Vincent Auffret
- Service de Cardiologie, Inserm LTSI-UMR1099, CHU Rennes, Université Rennes 1, Rennes, France.,Imagerie médicale, CHU Rennes, Rennes, France.,Pharmacologie Clinique et CIC-IP 1414, CHU Rennes et Université Rennes-1, Rennes, France
| | - Mathieu Lederlin
- Service de Cardiologie, Inserm LTSI-UMR1099, CHU Rennes, Université Rennes 1, Rennes, France.,Imagerie médicale, CHU Rennes, Rennes, France.,Pharmacologie Clinique et CIC-IP 1414, CHU Rennes et Université Rennes-1, Rennes, France
| | - Marine Campion
- Service de Cardiologie, Inserm LTSI-UMR1099, CHU Rennes, Université Rennes 1, Rennes, France.,Imagerie médicale, CHU Rennes, Rennes, France.,Pharmacologie Clinique et CIC-IP 1414, CHU Rennes et Université Rennes-1, Rennes, France
| | - Herve Le Breton
- Service de Cardiologie, Inserm LTSI-UMR1099, CHU Rennes, Université Rennes 1, Rennes, France.,Imagerie médicale, CHU Rennes, Rennes, France.,Pharmacologie Clinique et CIC-IP 1414, CHU Rennes et Université Rennes-1, Rennes, France
| | - Dominique Boulmier
- Service de Cardiologie, Inserm LTSI-UMR1099, CHU Rennes, Université Rennes 1, Rennes, France.,Imagerie médicale, CHU Rennes, Rennes, France.,Pharmacologie Clinique et CIC-IP 1414, CHU Rennes et Université Rennes-1, Rennes, France
| | - Arnaud Hubert
- Service de Cardiologie, Inserm LTSI-UMR1099, CHU Rennes, Université Rennes 1, Rennes, France.,Imagerie médicale, CHU Rennes, Rennes, France.,Pharmacologie Clinique et CIC-IP 1414, CHU Rennes et Université Rennes-1, Rennes, France
| | - Pierre-Axel Lenz
- Service de Cardiologie, Inserm LTSI-UMR1099, CHU Rennes, Université Rennes 1, Rennes, France.,Imagerie médicale, CHU Rennes, Rennes, France.,Pharmacologie Clinique et CIC-IP 1414, CHU Rennes et Université Rennes-1, Rennes, France
| | - Christophe Leclercq
- Service de Cardiologie, Inserm LTSI-UMR1099, CHU Rennes, Université Rennes 1, Rennes, France.,Imagerie médicale, CHU Rennes, Rennes, France.,Pharmacologie Clinique et CIC-IP 1414, CHU Rennes et Université Rennes-1, Rennes, France
| | - Emmanuel Oger
- Service de Cardiologie, Inserm LTSI-UMR1099, CHU Rennes, Université Rennes 1, Rennes, France.,Imagerie médicale, CHU Rennes, Rennes, France.,Pharmacologie Clinique et CIC-IP 1414, CHU Rennes et Université Rennes-1, Rennes, France
| | - Erwan Donal
- Service de Cardiologie, Inserm LTSI-UMR1099, CHU Rennes, Université Rennes 1, Rennes, France.,Imagerie médicale, CHU Rennes, Rennes, France.,Pharmacologie Clinique et CIC-IP 1414, CHU Rennes et Université Rennes-1, Rennes, France
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Low Gradient Aortic Stenosis: Role of Echocardiography. CURRENT CARDIOVASCULAR IMAGING REPORTS 2019. [DOI: 10.1007/s12410-019-9518-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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67
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Marullo AG, Biondi-Zoccai G, Giordano A, Frati G. Transcatheter aortic valve implantation for low-flow/low-gradient aortic stenosis. J Cardiovasc Med (Hagerstown) 2019; 20:699-700. [PMID: 31469714 DOI: 10.2459/jcm.0000000000000854] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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68
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Vamvakidou A, Jin W, Danylenko O, Chahal N, Khattar R, Senior R. Low Transvalvular Flow Rate Predicts Mortality in Patients With Low-Gradient Aortic Stenosis Following Aortic Valve Intervention. JACC Cardiovasc Imaging 2019; 12:1715-1724. [DOI: 10.1016/j.jcmg.2018.01.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 01/16/2018] [Accepted: 01/17/2018] [Indexed: 10/17/2022]
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The impact of aortic valve replacement on survival in patients with normal flow low gradient severe aortic stenosis: a propensity-matched comparison. Eur Heart J Cardiovasc Imaging 2019; 20:1094-1101. [DOI: 10.1093/ehjci/jez191] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 07/03/2019] [Indexed: 12/23/2022] Open
Abstract
Abstract
Aims
To assess the survival benefit of aortic valve replacement (AVR) in patients with normal flow low gradient severe aortic stenosis (AS).
Methods and results
A retrospective study of prospectively collected data of 276 patients (mean age 75 ± 15 years, 51% male) with normal transaortic flow [flow rate (FR) ≥200 mL/s or stroke volume index (SVi) ≥35 mL/m2] and severe AS (aortic valve area <1.0 cm2). The outcome measure was all-cause mortality. Of the 276 patients, 151 (55%) were medically treated, while 125 (45%) underwent an AVR. Over a mean follow-up of 3.2 ± 1.8 years (range 0–6.9 years), a total of 96 (34.8%) deaths occurred: 17 (13.6%) in AVR group vs. 79 (52.3%) in those medically treated, when transaortic flow was defined by FR (P < 0.001). When transaortic flow was defined by SVi, a total of 79 (31.3%) deaths occurred: 18 (15.1%) in AVR group vs. 61 (45.9%) in medically treated (P < 0.001). In a propensity-matched multivariable Cox regression analysis adjusting for age, gender, body surface area, smoking, hypertension, diabetes mellitus, atrial fibrillation, peripheral vascular disease, chronic kidney disease, left ventricular ejection fraction, left ventricular mass, and mean aortic gradient, not having AVR was associated with a 6.3-fold higher hazard ratio (HR) of all-cause mortality [HR 6.28, 95% confidence interval (CI) 3.34–13.16; P < 0.001] when flow was defined by FR. In the SVi-guided model, it was 3.83-fold (HR 3.83, 95% CI 2.30–6.37; P < 0.001).
Conclusion
In patients with normal flow low gradient severe AS, AVR was associated with a significantly improved survival compared with those who received standard medical treatment.
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71
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Vriz O, Pirisi M, Habib E, Galzerano D, Fadel B, Antonini-Canterin F, Veldtman G, Bossone E. Age related structural and functional changes in left ventricular performance in healthy subjects: a 2D echocardiographic study. Int J Cardiovasc Imaging 2019; 35:2037-2047. [PMID: 31297672 DOI: 10.1007/s10554-019-01665-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Accepted: 07/03/2019] [Indexed: 12/19/2022]
Abstract
Left ventricular (LV) adaptation to aging is currently poorly understood. We aimed to characterize age related changes in LV structure and function by studying a large group of healthy subjects across a wide age range. Prospectively enrolled healthy volunteers (n = 778, 327 females; age 18 to 100 years, mean age 49.8 ± 18.1 years), were divided into 4 age groups: 18 to 34 years (n = 165); 35 to 49 years (n = 242), 50 to 79 years (n = 334) and ≥ 80 years (n = 40). All subjects underwent clinical examination, as well as comprehensive transthoracic echocardiogram [TTE]. Body mass index, systolic blood pressure (BP), and left atrial volume (p < 0.0001) increased with age while diastolic BP (p < 0.0001) decreased over time. LV mass/body surface area (BSA) and relative wall thickness increased with age (p < 0.0001) coincident with worsening parameters of diastolic function (E/A and E/Em, p < 0.0001). The ejection fraction and Sm did not change significantly. Stroke volume, ejection time index, flow rate and stroke work significantly increased with age (p < 0.01). The arterial elastance (Ea), a measure of ventricular afterload, and ventricular elastance (Ees), an index of LV systolic stiffness did not change with age nor did their ratio (Ees/Ea) the latter being an expression of ventricular-arterial coupling. Age, gender and LVM were the main independent variables associated with LV systolic function. In conclusion, LV adaptation to aging in a healthy cohort is characterized by concentric LV remodeling, increased contractility and preserved ventricular-arterial coupling.
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Affiliation(s)
- Olga Vriz
- Heart Centre Department, King Faisal Specialist Hospital & Research Center, Riyadh, Kingdom of Saudi Arabia. .,Cardiology and Emergency San Antonio Hospital, San Daniele del Friuli, Italy.
| | - Mario Pirisi
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Eiad Habib
- Alfaisal University, Riyadh, Kingdom of Saudi Arabia
| | - Domenico Galzerano
- Heart Centre Department, King Faisal Specialist Hospital & Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Bahaa Fadel
- Heart Centre Department, King Faisal Specialist Hospital & Research Center, Riyadh, Kingdom of Saudi Arabia
| | | | - Gruschen Veldtman
- Heart Centre Department, King Faisal Specialist Hospital & Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Eduardo Bossone
- U.O.C Riabilitazione Cardiovascolare, A Cardarelli, Naples, Italy
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72
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Contemporary Imaging of Aortic Stenosis. Heart Lung Circ 2019; 28:1310-1319. [PMID: 31266725 DOI: 10.1016/j.hlc.2019.05.177] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 04/29/2019] [Accepted: 05/17/2019] [Indexed: 12/26/2022]
Abstract
Degenerative or fibrocalcific aortic stenosis (AS) is now the most common native valvular heart disease assessed and managed by cardiologists in developed countries. Transthoracic echocardiography remains the quintessential imaging modality for the non-invasive characterisation of AS due to its widespread availability, superior assessment of flow haemodynamics, and a wealth of prognostic data accumulated over decades of clinical utility and research applications. With expanding technologies and increasing availability of treatment options such as transcatheter aortic valve replacements, in addition to conventional surgical approaches, accurate and precise assessment of AS severity is critical to guide decisions for and timing of interventions. Despite clear guideline echocardiographic parameters demarcating severe AS, discrepancies between transvalvular velocities, gradients, and calculated valve areas are commonly encountered in clinical practice. This often results in diagnostically challenging cases with significant implications. Greater emphasis must be placed on the quality of performance of basic two dimensional (2D) and Doppler measurements (attention to detail ensuring accuracy and precision), incorporating ancillary haemodynamic surrogates, understanding study- or patient-specific confounders, and recognising the role and limitations of stress echocardiography in the subgroups of low-flow low-gradient AS. A multiparametric approach, along with the incorporation of multimodality imaging (cardiac computed tomography or magnetic resonance imaging) in certain scenarios, is now mandatory to avoid incorrect misclassification of severe AS. This is essential to ensure appropriate selection of patients who would most benefit from interventions on the aortic valve to relieve the afterload mismatch resulting from truly severe valvular stenosis.
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Lynch C, O'Connor JA, O'Brien D, Vaughan C, Bolton D, Coffey A, Lucey B. First reported detection of biofilm formation by Campylobacter fetus during investigation of a case of prosthetic valve endocarditis. J Clin Pathol 2019; 72:554-557. [PMID: 31055471 DOI: 10.1136/jclinpath-2018-205677] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 03/13/2019] [Accepted: 04/15/2019] [Indexed: 02/03/2023]
Abstract
AIMS Campylobacter fetus subsp fetus (CFF) can cause intestinal illness, particularly in immunocompromised humans, with the potential to cause severe systemic infections. CFF is a zoonotic pathogen with a broad host range among farm animals and humans, inducing abortion in sheep and cows. The current paper describes a strain of CFF isolated from a patient with prosthetic valve endocarditis in Mercy University Hospital, Cork, Ireland, during 2017. Only five cases of C. fetus as a cause of prosthetic valve endocarditis have been reported in the literature, with no reports of biofilm formation within the species. METHODS The aetiological strain was speciated and subspeciated by the VITEK 2 NH card and matrix-assisted laser desorption ionisation time-of-flight mass spectrometry. CFF biofilm formation was analysed using a crystal violet staining method. C. jejuni National Collection of Type Cultures (NCTC) 11168 was used as a positive control organism. Strains were incubated statically in Mueller-Hinton broth and Mueller-Hinton broth supplemented with 0.025% sodium deoxycholate for 3 and 7 days at 37°C, microaerobically. RESULTS The CFF strain formed stronger attached biofilms on polystyrene plates on day 3 (72 hours) than the C. jejuni NCTC 11168 control strain, but were weaker than the control strain on day 7 in Mueller-Hinton broth. Monoculture of this C. fetus isolate was found to exist in three defined forms of biofilms (attached, air-liquid interface and floccules). CONCLUSIONS This clinically significant C. fetus isolate showed considerable biofilm-forming capability, which we suggest conferred a survivalist advantage, contributing to the genesis of infective prosthetic valve endocarditis.
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Affiliation(s)
- Caoimhe Lynch
- Biological Sciences, Cork Institute of Technology, Cork, Cork, Ireland
| | | | | | - Carl Vaughan
- Cardiology, Mercy University Hospital, Cork, Ireland
| | | | - Aidan Coffey
- Biological Sciences, Cork Institute of Technology, Cork, Cork, Ireland
| | - Brigid Lucey
- Biological Sciences, Cork Institute of Technology, Cork, Cork, Ireland
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Enhancing ventricular contractility by post-extra-systolic potentiation is useful for predicting projected aortic valve area in low-flow low-gradient aortic stenosis: a case report. J Echocardiogr 2019; 18:132-133. [PMID: 30788726 DOI: 10.1007/s12574-019-00422-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 02/01/2019] [Accepted: 02/12/2019] [Indexed: 10/27/2022]
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Abbas AE, Pibarot P. Hemodynamic characterization of aortic stenosis states. Catheter Cardiovasc Interv 2019; 93:1002-1023. [PMID: 30790429 DOI: 10.1002/ccd.28146] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 01/29/2019] [Indexed: 11/12/2022]
Abstract
Aortic stenosis (AS) has become an increasingly prevalent clinical condition, as a result of the "greying of the population", the widespread application of sophisticated diagnostic tools including non-invasive imaging and invasive techniques, and the advent of minimally invasive surgical and percutaneous valve therapies. The diagnosis of severe AS traditionally has relied on the assessment of the mean transvalvular gradient (ΔPmean ) and aortic valve area (AVA) by either echocardiography or catheterization. However, other hemodynamic variables as flow, pressure recovery, and jet eccentricity also play a major role in determining the final hemodynamic state of AS. Moreover, mismatch between ΔPmean and AVA as in low flow low gradient AS and discordance between catheterization and echocardiographic studies in grading severity of AS have increased the complexity of AS diagnosis. The present case-based treatise emphasizes a multi-modality approach to delineation of the hemodynamic pathophysiology of different AS states. KEY POINTS: Reduction in the aortic valve area, flow across the aortic valve, and direction of the aortic stenosis jet determine the pressure gradient generated across the aortic valve in patients with aortic stenosis. Discordance between echo and catheterization maximum gradients is related to the inherent temporal differences between the times of their acquisition. Discordance between echo and catheterization mean gradients is related to pressure recovery and assumptions in the application of Bernoulli equation to estimate the aortic valve gradient. Pressure recovery relates to the ratio of the aortic valve area and ascending aortic diameter as well as the jet direction. Mismatch between area and gradient criteria for aortic stenosis severity may occur with or without concordance between echocardiographic and catheterization data. Errors of measurement should be excluded prior to assuming any mismatch or discordance between the data. Area gradient mismatch occurs when the aortic valve area is in the severe range, while the gradient is in the non-severe range as in low flow low gradient aortic stenosis. Reverse area gradient mismatch occurs when the gradient is in the severe range, while the aortic valve area is in the non-severe range as in congenital aortic stenosis with an eccentric jet.
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Affiliation(s)
- Amr E Abbas
- Department of Cardiovascular Medicine, Beaumont Health, Royal Oak, Michigan.,Department of Internal Medicine, Oakland University William Beaumont School of Medicine, Auburn Hills, Michigan
| | - Philippe Pibarot
- Department of Medicine, Laval University, Quebec City, QC, Canada
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Low-Gradient Aortic Stenosis: Solving the Conundrum Using Multi-Modality Imaging. Prog Cardiovasc Dis 2018; 61:416-422. [DOI: 10.1016/j.pcad.2018.11.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 11/12/2018] [Indexed: 10/27/2022]
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Alexandru D, Pollack S, Petillo F, Cao JJ, Barasch E. The Utility of Flow Rate Compared with Left Ventricular Stroke Volume Index in the Hemodynamic Classification of Severe Aortic Stenosis with Preserved Ejection Fraction. Cardiology 2018; 141:37-45. [PMID: 30304720 DOI: 10.1159/000493165] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 08/20/2018] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To substitute the stroke volume index (SVi) with flow rate (FR) in the hemodynamic classification of severe aortic stenosis (AS) with preserved ejection fraction (EF), in order to evaluate its prognostic value. METHODS A total of 529 patients (78.8 ± 9.8 years old, 44.1% males) with isolated severe AS (aortic valve area, AVA < 1 cm2), EF ≥50%, in sinus rhythm, who underwent transthoracic echocardiography, were stratified by FR (≥/< 200 mL/s) and mean pressure gradient (MG) (≥/< 40 mm Hg): FRnormal/MGhigh, FRlow/MGhigh, FRnormal/MGlow, and FRlow/MGlow. RESULTS Aortic valve replacement was more frequently performed in the FRnormal/MGhigh than in the FRlow/MGlow group (69.3 vs. 47%, respectively, p < 0.0001), yielding a similar survival benefit across all four groups. Over a median follow-up of 51 ± 29 months, there were 249 deaths. In highly adjusted models, the FRlow/MGlow group had a higher all-cause mortality (HR = 1.7, 95% CI: 1.1-2.6, p = 0.02) than patients with FRnormal/MGhigh. FR had a stronger association with AVA than SVi (r = 0.51 vs. 0.41, respectively, p = 0.0002), and a similar predictive value for death (AUC = 0.57 and 0.58, respectively, p = 0.88). CONCLUSIONS The FRlow/MGlow subset of AS is associated with the worst prognosis, and FR is not superior to SVi in the hemodynamic classification of severe AS.
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Badiani S, Waddingham P, Lloyd G, Bhattacharyya S. Stress echocardiography in valvular heart disease. Expert Rev Cardiovasc Ther 2018; 16:795-804. [PMID: 30286667 DOI: 10.1080/14779072.2018.1532791] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION The management of patients with heart valve disease can be complex. Patients may have symptoms disproportionate to the severity or the severity may be unclear. In addition, the optimal timing of intervention in patients with severe disease may be controversial. Areas covered: This article examines the role of stress echocardiography for assessment of patients with low-flow, low-gradient aortic stenosis, asymptomatic severe valve disease and patients where symptoms are discordant to the resting severity of valve disease. Expert commentary: Stress echocardiography helps clinicians determine the true severity of valve disease and may identify the cause of symptoms in patients with only mild/moderate disease. The data provided by stress echocardiography will help determine the appropriate management strategy and the correct timing of intervention.
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Affiliation(s)
- Sveeta Badiani
- a Echocardiography Laboratory , Barts Heart Centre, St Bartholomew's Hospital , London , UK.,b Heart Valve Clinic, Barts Heart Centre , St Bartholomew's Hospital , London , UK
| | - Peter Waddingham
- a Echocardiography Laboratory , Barts Heart Centre, St Bartholomew's Hospital , London , UK.,b Heart Valve Clinic, Barts Heart Centre , St Bartholomew's Hospital , London , UK
| | - Guy Lloyd
- a Echocardiography Laboratory , Barts Heart Centre, St Bartholomew's Hospital , London , UK.,b Heart Valve Clinic, Barts Heart Centre , St Bartholomew's Hospital , London , UK.,c William Harvey Research Institute, Queen Mary & Westfield , University of London , London , UK.,d Institute of Cardiovascular Sciences, UCL , London , UK
| | - Sanjeev Bhattacharyya
- a Echocardiography Laboratory , Barts Heart Centre, St Bartholomew's Hospital , London , UK.,b Heart Valve Clinic, Barts Heart Centre , St Bartholomew's Hospital , London , UK.,c William Harvey Research Institute, Queen Mary & Westfield , University of London , London , UK.,d Institute of Cardiovascular Sciences, UCL , London , UK
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Dahou A, Clavel MA, Capoulade R, O’Connor K, Ribeiro HB, Côté N, Le Ven F, Rodés-Cabau J, Dumesnil JG, Mathieu P, Pibarot P. B-Type Natriuretic Peptide and High-Sensitivity Cardiac Troponin for Risk Stratification in Low-Flow, Low-Gradient Aortic Stenosis. JACC Cardiovasc Imaging 2018; 11:939-947. [DOI: 10.1016/j.jcmg.2017.06.018] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 06/09/2017] [Accepted: 06/21/2017] [Indexed: 10/18/2022]
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Abstract
PURPOSE OF REVIEW Grading of aortic stenosis is essential in aortic stenosis management patients. However, despite clear thresholds provided in the guidelines, up to 30% of patients have discordant grading of aortic stenosis. The management of patients with low gradients/velocity despite tight aortic valve area is challenging. RECENT FINDINGS Recent studies demonstrated that patients with or without low flow may have a severe aortic stenosis despite a low gradient. Moreover, aortic valve replacement has been shown to improve outcome in low-gradient aortic stenosis patients with or without low flow. Finally, measurement of aortic valve calcification by multidetector computed tomography is an important tool to assess aortic stenosis severity in these patients. SUMMARY The presence of a low gradient/velocity despite a tight aortic valve area could be linked to low ejection fraction or low flow with preserved ejection fraction but also with normal flow and normal ejection fraction. In each situation, aortic stenosis could be truly severe or pseudosevere, and the severity of aortic stenosis has to be accurately evaluated for clinical decision-making. Nowadays, two types of interventions are available: surgical and transcatheter aortic valve replacement, whereas conservative management should be considered as a palliative treatment in patients with proven severe aortic stenosis and symptoms or left ventricle dysfunction.
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Fanari Z, Gunasekaran PC, Shaukat A, Hammami S, Dawn B, Wiley M, Tadros P. Safety and utility of dobutamine and pressure wire use in the hemodynamic assessment of low-flow, low-gradient aortic stenosis with reduced left ventricular ejection fraction. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2018; 19:438-443. [DOI: 10.1016/j.carrev.2017.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2017] [Revised: 10/02/2017] [Accepted: 10/02/2017] [Indexed: 10/18/2022]
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Workup and Management of Patients With Paradoxical Low-Flow, Low-Gradient Aortic Stenosis. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2018; 20:49. [DOI: 10.1007/s11936-018-0642-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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83
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Yousef A, Hibbert B, Feder J, Bernick J, Russo J, MacDonald Z, Glover C, Dick A, Boodhwani M, Lam BK, Ruel M, Labinaz M, Burwash IG. A novel echocardiographic hemodynamic index for predicting outcome of aortic stenosis patients following transcatheter aortic valve replacement. PLoS One 2018; 13:e0195641. [PMID: 29698407 PMCID: PMC5919479 DOI: 10.1371/journal.pone.0195641] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 03/26/2018] [Indexed: 11/29/2022] Open
Abstract
Objective Transcatheter aortic valve replacement (TAVR) reduces left ventricular (LV) afterload and improves prognosis in aortic stenosis (AS) patients. However, LV afterload consists of both valvular and arterial loads, and the benefits of TAVR may be attenuated if the arterial load dominates. We proposed a new hemodynamic index, the Relative Valve Load (RVL), a ratio of mean gradient (MG) and valvuloarterial impedance (Zva), to describe the relative contribution of the valvular load to the global LV load, and examined whether RVL predicted patient outcome following TAVR. Methods A total of 258 patients with symptomatic severe AS (indexed aortic valve area (AVA)<0.6cm2/m2, AR≤2+) underwent successful TAVR at the University of Ottawa Heart Institute and had clinical follow-up to 1-year post-TAVR. Pre-TAVR MG, AVA, percent stroke work loss (%SWL), Zva and RVL were measured by echocardiography. The primary endpoint was all cause mortality at 1-year post TAVR. Results There were 53 deaths (20.5%) at 1-year. RVL≤7.95ml/m2 had a sensitivity of 60.4% and specificity of 75.1% for identifying all cause mortality at 1-year post-TAVR and provided better specificity than MG<40 mmHg, AVA>0.75cm2, %SWL≤25% and Zva>5mmHg/ml/m2 despite equivalent or better sensitivity. In multivariable Cox analysis, RVL≤7.95ml/m2 was an independent predictor of all cause mortality (HR 3.2, CI 1.8–5.9; p<0.0001). RVL≤7.95ml/m2 was predictive of all cause mortality in both low flow and normal flow severe AS. Conclusions RVL is a strong predictor of all-cause mortality in severe AS patients undergoing TAVR. A pre-procedural RVL≤7.95ml/m2 identifies AS patients at increased risk of death despite TAVR and may assist with decision making on the benefits of TAVR.
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Affiliation(s)
- Altayyeb Yousef
- Division of Cardiology, University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Benjamin Hibbert
- Division of Cardiology, University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Joshua Feder
- Division of Cardiology, University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Jordan Bernick
- Division of Cardiology, University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Juan Russo
- Division of Cardiology, University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Zachary MacDonald
- Division of Cardiology, University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Christopher Glover
- Division of Cardiology, University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Alexander Dick
- Division of Cardiology, University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Munir Boodhwani
- Division of Cardiac Surgery, University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Buu-Khanh Lam
- Division of Cardiac Surgery, University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Marc Ruel
- Division of Cardiac Surgery, University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Marino Labinaz
- Division of Cardiology, University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Ian G. Burwash
- Division of Cardiology, University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
- * E-mail:
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Raissi SR, Thomas JD, Bonow RO. Transcatheter Aortic Valve Replacement in Low-Flow Aortic Stenosis: Treat the Flow or Treat the Patient? J Am Heart Assoc 2018; 7:JAHA.118.008932. [PMID: 29654200 PMCID: PMC6015401 DOI: 10.1161/jaha.118.008932] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Sasan Ryan Raissi
- Bluhm Cardiovascular Institute Northwestern University Feinberg School of Medicine Northwestern Memorial Hospital, Chicago, IL
| | - James D Thomas
- Bluhm Cardiovascular Institute Northwestern University Feinberg School of Medicine Northwestern Memorial Hospital, Chicago, IL
| | - Robert O Bonow
- Bluhm Cardiovascular Institute Northwestern University Feinberg School of Medicine Northwestern Memorial Hospital, Chicago, IL
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Kanwar A, Thaden JJ, Nkomo VT. Management of Patients With Aortic Valve Stenosis. Mayo Clin Proc 2018; 93:488-508. [PMID: 29622096 DOI: 10.1016/j.mayocp.2018.01.020] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Revised: 12/26/2017] [Accepted: 01/08/2018] [Indexed: 12/15/2022]
Abstract
With increased life expectancy and aging of the population, aortic stenosis is now one of the most common valvular heart diseases. Early recognition and management of aortic stenosis are of paramount importance because untreated symptomatic severe disease is universally fatal. The advent of transcather aortic valve replacement technologies provides exciting avenues of care to patients with this disease in whom traditional surgical procedures could not be performed or were associated with high risk. This review for clinicians offers an overview of aortic stenosis and updated information on the current status of various treatment strategies. An electronic literature search of PubMed, MEDLINE, EMBASE, and Scopus was performed from conception July 1, 2016, through November 30, 2017, using the terms aortic stenosis, aortic valve replacement, transcatheter aortic valve replacement (TAVR), transcatheter aortic valve insertion (TAVI), surgical aortic valve replacement, aortic stenosis flow-gradient patterns, low-flow aortic valve stenosis, natural history, stress testing, pathophysiology, bicuspid aortic valve, and congenital aortic valve disease.
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Affiliation(s)
- Amrit Kanwar
- Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA; Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Jeremy J Thaden
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Vuyisile T Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN.
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Mathias Junior W. Low-Flow Low-Gradient and Low-Ejection Fraction Aortic Stenosis and Projected Aortic Valve Area Calculation: So Important but so Complicated. Let us Just Keep it Simple! Arq Bras Cardiol 2018; 110:109-110. [PMID: 29561987 PMCID: PMC5855901 DOI: 10.5935/abc.20180030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Ferreira JSSM, Moreira N, Ferreira R, Mendes S, Martins R, Ferreira MJ, Pego M. An Alternative Method to Calculate Simplified Projected Aortic Valve Area at Normal Flow Rate. Arq Bras Cardiol 2018; 110:132-139. [PMID: 29561991 PMCID: PMC5855906 DOI: 10.5935/abc.20180018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 07/21/2017] [Indexed: 11/30/2022] Open
Abstract
Background Simplified projected aortic valve area (EOAproj) is a valuable
echocardiographic parameter in the evaluation of low flow low gradient
aortic stenosis (LFLG AS). Its widespread use in clinical practice is
hampered by the laborious process of flow rate (Q) calculation. Objetive This study proposes a less burdensome, alternative method of Q calculation to
be incorporated in the original formula of EOAproj and measures
the agreement between the new proposed method of EOAproj
calculation and the original one. Methods Retrospective observational single-institution study that included all
consecutive patients with classic LFLG AS that showed a Q variation with
dobutamine infusion ≥ |15|% by both calculation methods. Results Twenty-two consecutive patients with classical LFLG AS who underwent
dobutamine stress echocardiography were included. Nine patients showed a Q
variation with dobutamine infusion calculated by both classical and
alternative methods ≥ |15|% and were selected for further statistical
analysis. Using the Bland-Altman method to assess agreement we found a
systematic bias of 0,037 cm2 (95% CI 0,004 - 0,066), meaning that
on average the new method overestimates the EOAproj in 0,037
cm2 compared to the original method. The 95% limits of
agreement are narrow (from -0,04 cm2 to 0,12 cm2),
meaning that for 95% of individuals, EOAproj calculated by the
new method would be between 0,04 cm2 less to 0,12 cm2
more than the EOAproj calculated by the original equation. Conclusion The bias and 95% limits of agreement of the new method are narrow and not
clinically relevant, supporting the potential interchangeability of the two
methods of EOAproj calculation. As the new method requires less
additional measurements, it would be easier to implement in clinical
practice, promoting an increase in the use of EOAproj.
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Affiliation(s)
| | - Nádia Moreira
- Centro Hospitalar e Universitário de Coimbra, Serviço de Cardiologia, Coimbra - Portugal
| | - Rita Ferreira
- Centro Hospitalar e Universitário de Coimbra, Serviço de Cardiologia, Coimbra - Portugal
| | - Sofia Mendes
- Centro Hospitalar e Universitário de Coimbra, Serviço de Cardiologia, Coimbra - Portugal
| | - Rui Martins
- Centro Hospitalar e Universitário de Coimbra, Serviço de Cardiologia, Coimbra - Portugal
| | - Maria João Ferreira
- Centro Hospitalar e Universitário de Coimbra, Serviço de Cardiologia, Coimbra - Portugal
| | - Mariano Pego
- Centro Hospitalar e Universitário de Coimbra, Serviço de Cardiologia, Coimbra - Portugal
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88
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Onishi T, Sengoku K, Ichibori Y, Mizote I, Maeda K, Kuratani T, Sawa Y, Sakata Y. The role of echocardiography in transcatheter aortic valve implantation. Cardiovasc Diagn Ther 2018. [PMID: 29541607 DOI: 10.21037/cdt.2018.01.06] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Transcatheter aortic valve implantation (TAVI) is an effective and less invasive treatment for the increasing population of individuals with severe aortic stenosis (AS). Echocardiography is crucial in the assessment of AS patients from pre- to post-procedure. Transthoracic echocardiography (TTE) may be used to assess patient suitability for TAVI, as well as evaluate the severity of AS, the aortic valve complex, aortic valve morphology, mitral regurgitation (MR), and left ventricular function. Transesophageal echocardiography (TEE) is usually used as an intra-procedural monitoring tool to provide feedback during the procedure, to assess prosthetic valve function, and to detect complications rapidly before and after balloon aortic valvuloplasty (BAV) or transcatheter heart valve (THV) deployment. In this review, the role of echocardiography in the pre-, intra-, and post-TAVI procedure periods is described in detail.
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Affiliation(s)
- Toshinari Onishi
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Kaoruko Sengoku
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yasuhiro Ichibori
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Isamu Mizote
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Koichi Maeda
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Japan
| | - Toru Kuratani
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yasushi Sakata
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
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89
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Dobutamine Stress Echocardiography for Management of Low-Flow, Low-Gradient Aortic Stenosis. J Am Coll Cardiol 2018; 71:475-485. [DOI: 10.1016/j.jacc.2017.11.052] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Revised: 11/02/2017] [Accepted: 11/20/2017] [Indexed: 01/08/2023]
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90
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Grayburn PA. Evaluating Patients With Low-Flow, Low-Gradient Aortic Stenosis by Dobutamine Echocardiography. J Am Coll Cardiol 2018; 71:486-488. [DOI: 10.1016/j.jacc.2017.12.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 12/12/2017] [Indexed: 10/18/2022]
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91
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Baumgartner H, Hung J, Bermejo J, Chambers JB, Edvardsen T, Goldstein S, Lancellotti P, LeFevre M, Miller F, Otto CM. Recommendations on the echocardiographic assessment of aortic valve stenosis: a focused update from the European Association of Cardiovascular Imaging and the American Society of Echocardiography. Eur Heart J Cardiovasc Imaging 2018; 18:254-275. [PMID: 28363204 DOI: 10.1093/ehjci/jew335] [Citation(s) in RCA: 442] [Impact Index Per Article: 73.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 12/23/2016] [Indexed: 02/07/2023] Open
Abstract
Echocardiography is the key tool for the diagnosis and evaluation of aortic stenosis. Because clinical decision-making is based on the echocardiographic assessment of its severity, it is essential that standards are adopted to maintain accuracy and consistency across echocardiographic laboratories. Detailed recommendations for the echocardiographic assessment of valve stenosis were published by the European Association of Echocardiography and the American Society of Echocardiography in 2009. In the meantime, numerous new studies on aortic stenosis have been published with particular new insights into the difficult subgroup of low gradient aortic stenosis making an update of recommendations necessary. The document focuses in particular on the optimization of left ventricular outflow tract assessment, low flow, low gradient aortic stenosis with preserved ejection fraction, a new classification of aortic stenosis by gradient, flow and ejection fraction, and a grading algorithm for an integrated and stepwise approach of artic stenosis assessment in clinical practice.
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Affiliation(s)
- Helmut Baumgartner
- Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster, Muenster, Germany
| | - Judy Hung
- Division of Cardiology, Massachusetts General Hospital, Boston, MA, USA
| | - Javier Bermejo
- Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense de Madrid and CIBERCV, Madrid, Spain
| | | | - Thor Edvardsen
- Department of Cardiology and Center for Cardiological Innovation, Oslo University Hospital, Oslo and University of Oslo, Oslo, Norway
| | | | - Patrizio Lancellotti
- Universtiy of Liège Hospital, GIGA Cardiovascular Science, Heart Valve Clinic, Imaging Cardiology, Liège, Belgium and Gruppo Villa Maria Care and Research, Anthea Hospital, Bari, Italy
| | | | | | - Catherine M Otto
- Division of Cardiology, University of Washington School of Medicine, Seattle, WA, USA
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92
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Lancellotti P, Dulgheru R, Go YY, Sugimoto T, Marchetta S, Oury C, Garbi M. Stress echocardiography in patients with native valvular heart disease. Heart 2017; 104:807-813. [DOI: 10.1136/heartjnl-2017-311682] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 10/30/2017] [Accepted: 11/15/2017] [Indexed: 12/20/2022] Open
Abstract
Valve stress echocardiography (VSE) can be performed as exercise stress echocardiography (ESE) or dobutamine stress echocardiography (DSE) depending on the patient’s clinical status, severity and type of valve disease. ESE combines exercise testing with two-dimensional grey scale and Doppler echocardiography during exercise. Thus, it provides objective assessment of symptomatic status (exercise test), as well as exercise-induced changes of a series of echocardiographic parameters (different depending on the valve disease type), which yield prognostic information in individual patients and help in a better treatment planning. DSE is useful in symptomatic patients with low-gradient aortic stenosis. It clarifies its severity and helps in assessing surgical risk in patients with severe disease and systolic dysfunction. It can be also used to test valve haemodynamics in asymptomatic patients with significant mitral stenosis unable to perform an exercise test or to test the left ventricle response, namely to test viability, in patients with ischaemic secondary mitral regurgitation. VSE has taught us that history taking, clinical examination and resting echocardiography give an ‘incomplete picture’ of the disease in patients presenting with a severe valve disease. Therefore, its use should be encouraged in such patients.
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93
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Abstract
Aortic stenosis (AS) is the most common primary valve disorder in the elderly with an increasing prevalence. It is increasingly clear that it is also a disease of the left ventricle (LV) rather than purely the aortic valve. The transition from left ventricular hypertrophy to fibrosis results in the eventual adverse effects on systolic and diastolic function. Appropriate selection of patients for aortic valve intervention is crucial, and current guidelines recommend aortic valve replacement in severe AS with symptoms or in asymptomatic patients with left ventricular ejection fraction (LVEF) <50 %. LVEF is not a sensitive marker and there are other parameters used in multimodality imaging techniques, including longitudinal strain, exercise stress echo and cardiac MRI that may assist in detecting subclinical and subtle LV dysfunction. These findings offer potentially better ways to evaluate patients, time surgery, predict recovery and potentially offer targets for specific therapies. This article outlines the pathophysiology behind the LV response to aortic stenosis and the role of advanced multimodality imaging in describing it.
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94
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Safi LM, Passeri JJ, Picard MH. New considerations in the assessment of aortic stenosis. Future Cardiol 2017; 13:433-441. [PMID: 28828892 DOI: 10.2217/fca-2017-0031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Calcific aortic stenosis (AS) is one of the most common acquired valvular heart diseases in industrialized nations. It is a slowly progressive disease and with the aging population, the prevalence of AS is expected to increase. Doppler echocardiography is used to classify patients based on severity of stenosis. Research efforts on how to better identify and risk-assess these patients are currently underway using advanced imaging modalities and serum biomarkers. Thus far, medications for AS prevention have been unsuccessful. As technology progresses, the assessment of AS will transition from one heavily weighed on echocardiographic gradients to one of active surveillances with multimodality imaging, serum biomarkers and genetic assessment.
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Affiliation(s)
- Lucy M Safi
- Director of Interventional Echocardiography, Hackensack University Medical Center, Hackensack, NJ 07601, USA
| | - Jonathan J Passeri
- Co-Director Heart Valve Program, Director of Interventional Echocardiography, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Michael H Picard
- Cardiology Division, Massachusetts General Hospital, Professor of Medicine, Harvard Medical School, Boston, MA 02114, USA
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95
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Saeed S, Senior R, Chahal NS, Lønnebakken MT, Chambers JB, Bahlmann E, Gerdts E. Lower Transaortic Flow Rate Is Associated With Increased Mortality in Aortic Valve Stenosis. JACC Cardiovasc Imaging 2017; 10:912-920. [DOI: 10.1016/j.jcmg.2017.05.008] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 05/15/2017] [Accepted: 05/19/2017] [Indexed: 10/19/2022]
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96
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Saybolt MD, Fiorilli PN, Gertz ZM, Herrmann HC. Low-Flow Severe Aortic Stenosis. Circ Cardiovasc Interv 2017; 10:CIRCINTERVENTIONS.117.004838. [DOI: 10.1161/circinterventions.117.004838] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2017] [Accepted: 07/03/2017] [Indexed: 12/14/2022]
Affiliation(s)
- Matthew D. Saybolt
- From the Departments of Medicine of the University of Pennsylvania, Philadelphia (M.D.S., P.N.F., H.C.H.) and Virginia Commonwealth University, Richmond (Z.M.G.)
| | - Paul N. Fiorilli
- From the Departments of Medicine of the University of Pennsylvania, Philadelphia (M.D.S., P.N.F., H.C.H.) and Virginia Commonwealth University, Richmond (Z.M.G.)
| | - Zachary M. Gertz
- From the Departments of Medicine of the University of Pennsylvania, Philadelphia (M.D.S., P.N.F., H.C.H.) and Virginia Commonwealth University, Richmond (Z.M.G.)
| | - Howard C. Herrmann
- From the Departments of Medicine of the University of Pennsylvania, Philadelphia (M.D.S., P.N.F., H.C.H.) and Virginia Commonwealth University, Richmond (Z.M.G.)
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97
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Grayburn PA. Low Transvalvular Flow and Prognosis in the SEAS Trial. JACC Cardiovasc Imaging 2017; 10:921-922. [DOI: 10.1016/j.jcmg.2017.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 06/15/2017] [Accepted: 06/15/2017] [Indexed: 11/24/2022]
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98
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Abstract
Many patients with severe aortic stenosis have a "low-flow, low-gradient" aortic stenosis. The management of these patients can be quite difficult, as these patients often show impairment of the left ventricle, which can lead to false measurements of the severity of stenosis and also leads to a higher risk during aortic valve replacement. More diagnostic tools than only standard echocardiography are needed to correctly differentiate true severe aortic stenosis from pseudo severe aortic stenosis.
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99
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Aortic Stenosis Is Still Very Tricky, Especially When it Is Moderate. J Am Coll Cardiol 2017; 69:2393-2396. [PMID: 28494977 DOI: 10.1016/j.jacc.2017.03.569] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 03/27/2017] [Indexed: 12/21/2022]
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100
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Multimodality Imaging for Planning and Follow-up of Transcatheter Aortic Valve Replacement. Can J Cardiol 2017; 33:1110-1123. [PMID: 28666614 DOI: 10.1016/j.cjca.2017.03.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 03/21/2017] [Accepted: 03/21/2017] [Indexed: 01/23/2023] Open
Abstract
The complementary modalities of Doppler echocardiography and multidetector computed tomography are most frequently used for the planning and follow-up of transcatheter aortic valve replacement (TAVR). TAVR is now a well-established modality in the treatment of high-risk and inoperable patients with symptomatic severe aortic stenosis. Furthermore, recent studies have shown that TAVR is equivalent or superior to surgical aortic valve replacement in patients at intermediate surgical risk. We review the most commonly used imaging modalities and discuss their respective strengths and contributions to optimal patient selection, procedure planning, implementation, and follow-up in TAVR.
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