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Denault AY, Deschamps A, Couture P. Intraoperative Hemodynamic Instability During and After Separation From Cardiopulmonary Bypass. Semin Cardiothorac Vasc Anesth 2010; 14:165-82. [DOI: 10.1177/1089253210376673] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Every year, more than 1 million patients worldwide undergo cardiac surgery. Because of the aging of the population, cardiac surgery will increasingly be offered to patients at a higher risk of complications. The consequence is a reduced physiological reserve and hence an increased risk of mortality. These issues will have a significant impact on future health care costs because the population undergoing cardiac surgery will be older and more likely to develop postoperative complications. One of the most dreaded complications in cardiac surgery is difficult separation from cardiopulmonary bypass (CPB). When separation from CPB is associated with right-ventricular failure, the mortality rate will range from 44% to 86%. Therefore, the diagnosis and the preoperative prediction of difficult separation from CPB will be crucial to improve the selection and care of patients and to prevent complications for this high-risk patient population.
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Affiliation(s)
- André Y. Denault
- Department of Anesthesiology, Montréal Heart Institute and Université de Montréal, Montréal, Quebec, Canada,
| | - Alain Deschamps
- Department of Anesthesiology, Montréal Heart Institute and Université de Montréal, Montréal, Quebec, Canada
| | - Pierre Couture
- Department of Anesthesiology, Montréal Heart Institute and Université de Montréal, Montréal, Quebec, Canada
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102
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Pellikka PA. Predicting outcome in asymptomatic aortic stenosis: should we measure the severity of obstruction or its physiological consequences? Eur Heart J 2010; 31:2191-3. [DOI: 10.1093/eurheartj/ehq182] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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103
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Chang SA, Park PW, Sung K, Lee SC, Park SW, Lee YT, Oh JK. Noninvasive estimate of left ventricular filling pressure correlated with early and midterm postoperative cardiovascular events after isolated aortic valve replacement in patients with severe aortic stenosis. J Thorac Cardiovasc Surg 2010; 140:1361-6. [PMID: 20381086 DOI: 10.1016/j.jtcvs.2010.02.022] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2009] [Revised: 01/12/2010] [Accepted: 02/08/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVES The aim of this study was to investigate whether preoperative estimated left ventricular filling pressure predicts the postoperative outcome in patients with severe aortic stenosis. METHODS Two hundred ten patients who underwent isolated aortic valve replacement because of severe aortic stenosis were analyzed. Left ventricular filling pressure was noninvasively assessed based on the ratio between early diastolic mitral inflow and mitral annular velocity (E/E'), which was calculated based on results of mitral inflow and mitral annular tissue Doppler scanning. Early postoperative hospital events were reviewed. Postoperative mortality and morbidity were searched and compared according to left ventricular filling pressure. RESULTS Preoperative functional class was associated with increased E/E' values. Postoperative hospital events were higher in patients with increased preoperative E/E' values. Midterm mortality of the overall population was very low after aortic valve replacement (2%). Cardiovascular event-free survival, including hospital visits caused by heart failure symptoms, embolic cerebral infarction, and sudden cardiac death, was significantly lower in the patients with increased left ventricular filling pressure and E/E' values of greater than 12 (P = .03). Multivariable analysis showed a high hazard ratio of increased E/E' values of greater than 12 (hazard ratio, 41; P < .001). CONCLUSIONS The incidence of postoperative mortality after isolated aortic valve replacement caused by severe aortic stenosis is relatively low in the current era. E/E' representing diastolic filling pressure is the most important preoperative predictor of risk of early postoperative hospital course and postoperative morbidity.
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Affiliation(s)
- Sung-A Chang
- Cardiovascular Imaging Center, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Casaclang-Verzosa G, Malouf JF, Scott CG, Juracan EM, Nishimura RA, Pellikka PA. Does Left Atrial Size Predict Mortality in Asymptomatic Patients with Severe Aortic Stenosis? Echocardiography 2010; 27:105-9. [DOI: 10.1111/j.1540-8175.2009.01002.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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105
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Rodés-Cabau J, Webb JG, Cheung A, Ye J, Dumont E, Feindel CM, Osten M, Natarajan MK, Velianou JL, Martucci G, DeVarennes B, Chisholm R, Peterson MD, Lichtenstein SV, Nietlispach F, Doyle D, DeLarochellière R, Teoh K, Chu V, Dancea A, Lachapelle K, Cheema A, Latter D, Horlick E. Transcatheter aortic valve implantation for the treatment of severe symptomatic aortic stenosis in patients at very high or prohibitive surgical risk: acute and late outcomes of the multicenter Canadian experience. J Am Coll Cardiol 2010; 55:1080-90. [PMID: 20096533 DOI: 10.1016/j.jacc.2009.12.014] [Citation(s) in RCA: 760] [Impact Index Per Article: 54.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2009] [Revised: 11/11/2009] [Accepted: 12/17/2009] [Indexed: 12/29/2022]
Abstract
OBJECTIVES The aim of this study was: 1) to evaluate the acute and late outcomes of a transcatheter aortic valve implantation (TAVI) program including both the transfemoral (TF) and transapical (TA) approaches; and 2) to determine the results of TAVI in patients deemed inoperable because of either porcelain aorta or frailty. BACKGROUND Very few data exist on the results of a comprehensive TAVI program including both TA and TF approaches for the treatment of severe aortic stenosis in patients at very high or prohibitive surgical risk. METHODS Consecutive patients who underwent TAVI with the Edwards valve (Edwards Lifesciences, Inc., Irvine, California) between January 2005 and June 2009 in 6 Canadian centers were included. RESULTS A total of 345 procedures (TF: 168, TA: 177) were performed in 339 patients. The predicted surgical mortality (Society of Thoracic Surgeons risk score) was 9.8 +/- 6.4%. The procedural success rate was 93.3%, and 30-day mortality was 10.4% (TF: 9.5%, TA: 11.3%). After a median follow-up of 8 months (25th to 75th interquartile range: 3 to 14 months) the mortality rate was 22.1%. The predictors of cumulative late mortality were peri-procedural sepsis (hazard ratio [HR]: 3.49, 95% confidence interval [CI]: 1.48 to 8.28) or need for hemodynamic support (HR: 2.58, 95% CI: 1.11 to 6), pulmonary hypertension (PH) (HR: 1.88, 95% CI: 1.17 to 3), chronic kidney disease (CKD) (HR: 2.30, 95% CI: 1.38 to 3.84), and chronic obstructive pulmonary disease (COPD) (HR: 1.75, 95% CI: 1.09 to 2.83). Patients with either porcelain aorta (18%) or frailty (25%) exhibited acute outcomes similar to the rest of the study population, and porcelain aorta patients tended to have a better survival rate at 1-year follow-up. CONCLUSIONS A TAVI program including both TF and TA approaches was associated with comparable mortality as predicted by surgical risk calculators for the treatment of patients at very high or prohibitive surgical risk, including porcelain aorta and frail patients. Baseline (PH, COPD, CKD) and peri-procedural (hemodynamic support, sepsis) factors but not the approach determined worse outcomes.
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Affiliation(s)
- Josep Rodés-Cabau
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada.
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106
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Apostolakis EE, Baikoussis NG, Parissis H, Siminelakis SN, Papadopoulos GS. Left ventricular diastolic dysfunction of the cardiac surgery patient; a point of view for the cardiac surgeon and cardio-anesthesiologist. J Cardiothorac Surg 2009; 4:67. [PMID: 19930694 PMCID: PMC2788544 DOI: 10.1186/1749-8090-4-67] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2009] [Accepted: 11/24/2009] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Left ventricular diastolic dysfunction (DD) is defined as the inability of the ventricle to fill to a normal end-diastolic volume, both during exercise as well as at rest, while left atrial pressure does not exceed 12 mm Hg. We examined the concept of left ventricular diastolic dysfunction in a cardiac surgery setting. MATERIALS AND METHODS Literature review was carried out in order to identify the overall experience of an important and highly underestimated issue: the unexpected adverse outcome due to ventricular stiffness, following cardiac surgery. RESULTS Although diverse group of patients for cardiac surgery could potentially affected from diastolic dysfunction, there are only few studies looking in to the impact of DD on the postoperative outcome; Trans-thoracic echo-cardiography (TTE) is the main stay for the diagnosis of DD. Intraoperative trans-oesophageal (TOE) adds to the management. Subgroups of DD can be defined with prognostic significance. CONCLUSION DD with elevated left ventricular end-diastolic pressure can predispose to increased perioperative mortality and morbidity. Furthermore, DD is often associated with systolic dysfunction, left ventricular hypertrophy or indeed pulmonary hypertension. When the diagnosis of DD is made, peri-operative attention to this group of patients becomes mandatory.
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Affiliation(s)
| | - Nikolaos G Baikoussis
- Cardiothoracic Surgery Department, University of Patras, School of Medicine, Patras, Greece
- Cardiac Surgery Department, University of Ioannina, School of Medicine, Ioannina, Greece
| | | | - Stavros N Siminelakis
- Cardiac Surgery Department, University of Ioannina, School of Medicine, Ioannina, Greece
| | - Georgios S Papadopoulos
- Department of Clinical Anesthesiology and Intensive Postoperative Care Unit, University of Ioannina, School of Medicine, Ioannina, Greece
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Ding WH, Lam YY, Duncan A, Li W, Lim E, Kaya MG, Chung R, Pepper JR, Henein MY. Predictors of survival after aortic valve replacement in patients with low-flow and high-gradient aortic stenosis. Eur J Heart Fail 2009; 11:897-902. [PMID: 19596667 DOI: 10.1093/eurjhf/hfp096] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Wen-Hong Ding
- Department of Paediatric Cardiology; Beijing Anzhen Hospital, Capital University of Medical Sciences; Beijing China
| | - Yat-Yin Lam
- Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital, Li Ka Shing Institute of Health and Sciences, Institute of Vascular Medicine; The Chinese University of Hong Kong; Hong Kong SAR China
| | | | - Wei Li
- Royal Brompton Hospital; London UK
| | - Eric Lim
- Royal Brompton Hospital; London UK
| | - Mehmet G. Kaya
- Department of Cardiology; Erciyes University; Erciyes Turkey
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108
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109
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McLaughlin VV, Archer SL, Badesch DB, Barst RJ, Farber HW, Lindner JR, Mathier MA, McGoon MD, Park MH, Rosenson RS, Rubin LJ, Tapson VF, Varga J. ACCF/AHA 2009 expert consensus document on pulmonary hypertension a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents and the American Heart Association developed in collaboration with the American College of Chest Physicians; American Thoracic Society, Inc.; and the Pulmonary Hypertension Association. J Am Coll Cardiol 2009; 53:1573-619. [PMID: 19389575 DOI: 10.1016/j.jacc.2009.01.004] [Citation(s) in RCA: 1134] [Impact Index Per Article: 75.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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110
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McLaughlin VV, Archer SL, Badesch DB, Barst RJ, Farber HW, Lindner JR, Mathier MA, McGoon MD, Park MH, Rosenson RS, Rubin LJ, Tapson VF, Varga J, Harrington RA, Anderson JL, Bates ER, Bridges CR, Eisenberg MJ, Ferrari VA, Grines CL, Hlatky MA, Jacobs AK, Kaul S, Lichtenberg RC, Lindner JR, Moliterno DJ, Mukherjee D, Pohost GM, Rosenson RS, Schofield RS, Shubrooks SJ, Stein JH, Tracy CM, Weitz HH, Wesley DJ. ACCF/AHA 2009 expert consensus document on pulmonary hypertension: a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents and the American Heart Association: developed in collaboration with the American College of Chest Physicians, American Thoracic Society, Inc., and the Pulmonary Hypertension Association. Circulation 2009; 119:2250-94. [PMID: 19332472 DOI: 10.1161/circulationaha.109.192230] [Citation(s) in RCA: 745] [Impact Index Per Article: 49.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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111
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Goel R, Sengupta PP, Mookadam F, Chaliki HP, Khandheria BK, Tajik AJ. Valvular regurgitation and stenosis: when is surgery required? HEART ASIA 2009; 1:20-5. [PMID: 27325921 DOI: 10.1136/ha.2008.000315] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Accepted: 01/20/2009] [Indexed: 11/04/2022]
Abstract
Valvular heart disease is a growing public health problem, with an increasing prevalence due to an ageing population. Despite advances, the medical management of symptomatic valvular heart diseases remains suboptimal, necessitating surgical correction. The challenge remains in identifying an asymptomatic or mildly symptomatic patient who will benefit from timely surgery before irreversible changes in cardiac function have occurred. The potential risks of surgery versus watchful expectancy require careful decision-making. This review is a focused update on the existing guidelines and identifies the knowledge gaps and avenues of future research in the management of patients with valvular heart diseases.
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Affiliation(s)
- R Goel
- Division of Cardiovascular Diseases, Mayo Clinic, Scottsdale, Arizona, USA
| | - P P Sengupta
- Division of Cardiovascular Diseases, Mayo Clinic, Scottsdale, Arizona, USA
| | - F Mookadam
- Division of Cardiovascular Diseases, Mayo Clinic, Scottsdale, Arizona, USA
| | - H P Chaliki
- Division of Cardiovascular Diseases, Mayo Clinic, Scottsdale, Arizona, USA
| | - B K Khandheria
- Division of Cardiovascular Diseases, Mayo Clinic, Scottsdale, Arizona, USA
| | - A J Tajik
- Division of Cardiovascular Diseases, Mayo Clinic, Scottsdale, Arizona, USA
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112
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Affiliation(s)
- Stuart Rich
- Section of Cardiology, University of Chicago, 5841 S Maryland Ave, MC 2016, Chicago, IL 60637, USA.
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113
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Higgins JR, Arimie R, Currier J. Low gradient aortic stenosis: Assessment, treatment, and outcome. Catheter Cardiovasc Interv 2008; 72:731-8. [DOI: 10.1002/ccd.21610] [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] [Indexed: 11/06/2022]
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114
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Tanné D, Kadem L, Rieu R, Pibarot P. Hemodynamic impact of mitral prosthesis-patient mismatch on pulmonary hypertension: an in silico study. J Appl Physiol (1985) 2008; 105:1916-26. [PMID: 18719235 DOI: 10.1152/japplphysiol.90572.2008] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Recent clinical studies reported that prosthesis-patient mismatch (PPM) becomes clinically relevant when the effective orifice area (EOA) indexed by the body surface area (iEOA) is <1.2-1.25 cm(2)/m(2). To examine the effect of PPM on transmitral pressure gradient and left atrial (LA) and pulmonary arterial (PA) pressures and to validate the PPM cutoff values, we used a lumped model to compute instantaneous pressures, volumes, and flows into the left-sided heart and the pulmonary and systemic circulations. We simulated hemodynamic conditions at low cardiac output, at rest, and at three levels of exercise. The iEOA was varied from 0.44 to 1.67 cm(2)/m(2). We normalized the mean pressure gradient by the square of mean mitral flow indexed by the body surface area to determine at which cutoff values of iEOA the impact of PPM becomes hemodynamically significant. In vivo data were used to validate the numerical study, which shows that small values of iEOA (severe PPM) induce high PA pressure (residual PA hypertension) and contribute to its nonnormalization following a valve replacement, providing a justification for implementation of operative strategies to prevent PPM. Furthermore, we emphasize the major impact of pulmonary resistance and compliance on PA pressure. The model suggests also that the cutoff iEOA that should be used to define PPM at rest in the mitral position is approximately 1.16 cm(2)/m(2). At higher levels of exercise, the threshold for iEOA is rather close to 1.5 cm(2)/m(2). Severe PPM should be considered when iEOA is <0.94 cm(2)/m(2) at rest.
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Affiliation(s)
- David Tanné
- Quebec Heart Institute, Laval Hospital, 2725 Chemin Sainte-Foy, Sainte-Foy, PQ, Canada G1V 4G5
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115
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E/Ea is the Major Determinant of Pulmonary Artery Pressure in Moderate to Severe Aortic Stenosis. J Am Soc Echocardiogr 2008; 21:824-7. [DOI: 10.1016/j.echo.2007.12.002] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2007] [Indexed: 11/23/2022]
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116
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Nistri S, Galderisi M, Faggiano P, Antonini-Canterin F, Ansalone G, Dini FL, Di Salvo G, Gallina S, Mele D, Montisci R, Sciomer S, Di Bello V, Mondillo S, Marino PN. Practical echocardiography in aortic valve stenosis. J Cardiovasc Med (Hagerstown) 2008; 9:653-65. [DOI: 10.2459/jcm.0b013e3282f27d49] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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117
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Rahimtoola SH. Valvular heart disease: a perspective on the asymptomatic patient with severe valvular aortic stenosis. Eur Heart J 2008; 29:1783-90. [DOI: 10.1093/eurheartj/ehn272] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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118
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Aortic stenosis. ACTA ACUST UNITED AC 2008; 33:174-83. [PMID: 18025609 DOI: 10.1007/s12019-007-8021-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2007] [Revised: 11/30/1999] [Accepted: 07/16/2007] [Indexed: 10/22/2022]
Abstract
Patients with aortic stenosis (AS) have an increased prevalence of coronary risk factors, coronary artery disease, and other atherosclerotic vascular disease and an increased incidence of coronary events and death. Statins may reduce the progression of AS. Angina pectoris, syncope or near syncope, and heart failure are the three classic manifestations of severe AS. Prolonged duration and late peaking of an aortic systolic ejection murmur best differentiate severe AS from mild AS on physical examination. Doppler echocardiography is used to diagnose the presence and severity of AS. Once symptoms develop, aortic valve replacement (AVR) should be performed in patients with severe or moderate AS. Warfarin should be administered indefinitely after AVR in patients with a mechanical aortic valve and in patients with a bioprosthetic aortic valve who have either atrial fibrillation, prior thromboembolism, left ventricular systolic dysfunction, or a hypercoagulable condition. Patients with a bioprosthetic aortic valve without any of these four risk factors should be treated with aspirin 75-100 mg daily.
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119
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Abstract
Pulmonary hypertension is a frequently encountered problem in older patients. True idiopathic pulmonary arterial hypertension can also be seen and requires careful exclusion in older patients. Institution of therapies must be tempered with an appreciation of individual comorbidities and functional limitations that may affect patients' ability to comply and benefit from the complex treatments available for pulmonary arterial hypertension. This article reviews the existing data on the various forms of pulmonary hypertension presenting in older patients and on appropriate therapy in this challenging population.
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Affiliation(s)
- John R McArdle
- Division of Internal Medicine, Section of Pulmonary and Critical Care Medicine, Pulmonary Hypertension Center, Yale University School of Medicine, 333 Cedar Street, LCI 105D, P.O. Box 208057, New Haven, CT 06520-8057, USA.
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120
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Qizilbash B, Couture P, Denault A. Impact of Perioperative Transesophageal Echocardiography in Aortic Valve Replacement. Semin Cardiothorac Vasc Anesth 2008; 11:288-300. [DOI: 10.1177/1089253207311789] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Intraoperative transesophageal echocardiography (TEE) is currently being used routinely during aortic valve replacement (AVR). TEE provides information that can lead to modifications of anesthetic and surgical care that leads to improved outcome. Numerous studies have shown that modifications in therapy occur from 10% to more than 40% of cases. The impact of TEE can be divided among modifications of therapy before, during, and after cardiopulmonary bypass. Before cardiopulmonary bypass, TEE can provide prognostic information, optimize hemodynamics, and diagnose conditions that were not appreciated before surgery, including patient—prosthesis mismatch. TEE can guide and modify the placement of various bypass cannulae. After bypass, TEE verifies the surgical result, rules out left and right ventricular outflow tract obstruction, and assures stable hemodynamics. Although current guidelines state that aortic valve surgery is a class IIa indication for TEE use, the authors' experience suggests that TEE should be routinely used in AVR.
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Affiliation(s)
- Baqir Qizilbash
- Department of Anesthesiology, Montreal Heart Institute/ Université de Montréal, Montreal, Quebec, Canada,
| | - Pierre Couture
- Department of Anesthesiology, Montreal Heart Institute/ Université de Montréal, Montreal, Quebec, Canada
| | - André Denault
- Department of Anesthesiology, Montreal Heart Institute/ Université de Montréal, Montreal, Quebec, Canada
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121
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Chaliki HP, Brown ML, Sundt TM, Tajik AJ. Timing of operation in asymptomatic severe aortic stenosis. Expert Rev Cardiovasc Ther 2008; 5:1065-71. [PMID: 18035922 DOI: 10.1586/14779072.5.6.1065] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Calcific aortic stenosis is now the main cause of aortic stenosis in the majority of patients, due to declining incidence of rheumatic fever. Risk factors such as hyperlipidemia play an important role in the progression of aortic stenosis. According to the most recent American College of Cardiology/American Heart Association guidelines, peak velocity greater than 4 m/sec, a mean gradient of more than 40 mmHg and a valve area of less than 1.0 cm(2) is considered hemodynamically severe aortic stenosis. Aortic valve surgery promptly should be done in symptomatic patients due to dismal prognosis without operation. Features such as high aortic valve calcium and positive exercise test identify asymptomatic patients who would benefit from early aortic valve surgery. Due to improvement in surgical techniques and better prosthesis, aortic valve surgery can now be offered at low risk to a selected group of asymptomatic patients with severe aortic stenosis. Currently percutaneous aortic valves are used in very high-risk patients with severe symptomatic aortic stenosis. Their role may expand in the future, depending on the improvements in design and operator experience. Whether advances in molecular cardiology lead to novel therapies in preventing calcific aortic stenosis in the future remains to be seen.
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Affiliation(s)
- Hari P Chaliki
- Mayo Clinic Arizona, Division of Cardiovascular Diseases, 13400 E. Shea Boulevard, Scottsdale, AZ 85255, USA.
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122
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Abstract
Elderly patients with valvular aortic stenosis have an increased prevalence of coronary risk factors, of coronary artery disease, and evidence of other atherosclerotic vascular diseases. Statins may reduce the progression of aortic stenosis (AS). Angina pectoris, syncope or near syncope, and congestive heart failure are the 3 classic manifestations of severe AS. Prolonged duration and late peaking of an aortic systolic ejection murmur best differentiate severe AS from mild AS on physical examination. Doppler echocardiography is used to diagnose the prevalence and severity of AS. The indications for cardiac catheterization and the medical management of AS are discussed. Once symptoms develop, aortic valve replacement (AVR) should be performed in patients with severe or moderate AS. Other indications for AVR are discussed. Warfarin should be administered indefinitely after AVR in patients with a mechanical aortic valve and in patients with a bioprosthetic aortic valve who have either atrial fibrillation, prior thromboembolism, left ventricular systolic dysfunction, or a hypercoagulable condition. Patients with a bioprosthetic aortic valve without any of these 4 risk factors should be treated with aspirin 75-100 mg daily.
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Affiliation(s)
- Wilbert S Aronow
- Cardiology Division, Department of Medicine, New York Medical College, Valhalla, New York 10595, USA.
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123
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Pai RG, Varadarajan P, Kapoor N, Bansal RC. Aortic Valve Replacement Improves Survival in Severe Aortic Stenosis Associated With Severe Pulmonary Hypertension. Ann Thorac Surg 2007; 84:80-5. [PMID: 17588389 DOI: 10.1016/j.athoracsur.2007.02.094] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2006] [Revised: 02/27/2007] [Accepted: 02/28/2007] [Indexed: 11/27/2022]
Abstract
BACKGROUND Severe pulmonary arterial hypertension in patients with severe aortic stenosis (AS) carries a poor prognosis. There are limited data on the effect of aortic valve replacement (AVR) in these patients. METHODS Our echocardiographic database between 1993 and 2003 was searched for patients with severe AS defined as a Doppler estimated aortic valve area of 0.8 cm2 or less and severe pulmonary hypertension defined as a pulmonary arterial systolic pressure 60 mm Hg or greater. Of the 740 patients with severe AS, 119 (16%) had severe pulmonary hypertension forming the study cohort. The AVR was performed in 36 (30%) of these patients. Survival of patients with and without AVR were compared and adjusted for comorbidities and group differences using the Cox regression model. RESULTS Characteristics of patients with severe pulmonary hypertension; age 75 +/- 13 years, 39% women, left ventricular ejection fraction 41 +/- 20%. Patients who underwent AVR had a significantly higher five-year survival of 65% compared with 20% for those treated medically (p < 0.0001). The relative mortality risk associated with AVR was 0.28 (95% confidence interval 0.22 to 0.36) and was independent of age, gender, ejection fraction, diabetes, coronary disease, serum creatinine level, and concomitant medical therapy such as beta blockers, angiotensin converting inhibitors, and statins. The benefit of AVR was further supported by sensitivity and propensity score analyses. Patients on conservative therapy had a 30-day mortality of 30% and a one-year mortality of 70%. CONCLUSIONS Aortic valve replacement in patients with severe pulmonary hypertension secondary to severe AS is associated with a huge survival benefit. Medical therapy alone carries a dismal prognosis and AVR should be considered urgently in severe AS patients with severe pulmonary hypertension.
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Affiliation(s)
- Ramdas G Pai
- Loma Linda University Medical Center, Loma Linda, California, USA.
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124
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Denault AY, Lamarche Y, Couture P, Haddad F, Lambert J, Tardif JC, Perrault LP. Inhaled milrinone: a new alternative in cardiac surgery? Semin Cardiothorac Vasc Anesth 2007; 10:346-60. [PMID: 17200091 DOI: 10.1177/1089253206294400] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The administration of milrinone through inhalation has been studied in only a few animal and human studies. Compared to the intravenous administration, inhaled milrinone has been shown to reduce pulmonary artery pressure without systemic hypotension. Therefore, this approach could represent an alternative to nitric oxide. This current state of knowledge of intravenous and inhaled milrinone is presented and summarized.
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Affiliation(s)
- André Y Denault
- Department of Cardiac Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.
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125
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Ristow B, Ali S, Ren X, Whooley MA, Schiller NB. Elevated pulmonary artery pressure by Doppler echocardiography predicts hospitalization for heart failure and mortality in ambulatory stable coronary artery disease: the Heart and Soul Study. J Am Coll Cardiol 2006; 49:43-9. [PMID: 17207721 PMCID: PMC2771184 DOI: 10.1016/j.jacc.2006.04.108] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2006] [Revised: 04/13/2006] [Accepted: 04/17/2006] [Indexed: 11/17/2022]
Abstract
OBJECTIVES We compared the predictive ability of tricuspid regurgitation (TR) and end-diastolic pulmonary regurgitation (EDPR) gradients in outpatients with coronary artery disease. BACKGROUND The TR and EDPR gradients, in conjunction with right atrial pressure, provide Doppler estimates of pulmonary artery systolic and diastolic pressures. We hypothesized that increases in TR or EDPR gradients in stable coronary artery disease would predict heart failure (HF) hospitalization or cardiovascular (CV) death. METHODS We measured TR and EDPR gradients in 717 adults with completed outcome adjudications who were recruited for the Heart and Soul Study. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for HF hospitalization, CV death, all-cause death, and the combined end point. Multivariate adjustments were made for age, gender, race, history of CV or pulmonary disease, functional class, and left ventricular ejection fraction. RESULTS There were 63 HF hospitalizations, 19 CV deaths, and 86 all-cause deaths at the 3-year follow-up. There were 466 measurable EDPR gradients and 573 measurable TR gradients. Age-adjusted ORs for EDPR >5 mm Hg predicted HF hospitalization (2.7, 95% CI 1.3 to 5.5, p = 0.006), all-cause death (2.5, 95% CI 1.4 to 4.4, p = 0.002), and HF hospitalization or CV death (2.7, 95% CI 1.4 to 5.2, p = 0.004). Age-adjusted OR for TR >30 mm Hg predicted HF hospitalization (3.4, 95% CI 1.9 to 6.2, p < 0.0001) and HF hospitalization or CV death (3.0, 95% CI 1.7 to 5.3, p = 0.0001). Multivariate adjusted OR per 5-mm Hg incremental increases in EDPR predicted HF hospitalization or CV death (1.9, 95% CI 1.01 to 3.6, p = 0.046) and all-cause death (1.7, 95% CI 1.05 to 2.8, p = 0.03). Multivariate adjusted OR per 10-mm Hg incremental increases in TR predicted HF hospitalization or CV death (1.6, 95% CI 1.1 to 2.4, p = 0.008). CONCLUSIONS Increases in EDPR or TR gradients predict HF hospitalization or CV death among ambulatory adults with coronary artery disease.
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Affiliation(s)
- Bryan Ristow
- Department of Medicine, Division of Cardiology, University of California, San Francisco, California, USA.
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126
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Minhaj MM, Zvara DA, Nayyar P, Maslow A. Case 1-2007 morbidly obese patient undergoing cardiac surgery. J Cardiothorac Vasc Anesth 2006; 21:133-43. [PMID: 17289497 DOI: 10.1053/j.jvca.2006.04.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2006] [Indexed: 12/20/2022]
Affiliation(s)
- Mohammed M Minhaj
- Department of Anesthesia and Critical Care, University of Chicago Hospitals, University of Chicago, Chicago, IL 60637, USA.
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127
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Salem R, Denault AY, Couture P, Bélisle S, Fortier A, Guertin MC, Carrier M, Martineau R. Left ventricular end-diastolic pressure is a predictor of mortality in cardiac surgery independently of left ventricular ejection fraction. Br J Anaesth 2006; 97:292-7. [PMID: 16835254 DOI: 10.1093/bja/ael140] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Several risk factors have been shown to increase mortality in cardiac surgery. However, the importance of left ventricular end-diastolic pressure (LVEDP) as an independent risk factor before cardiac surgery is unclear. Method. This observational study investigated 3024 consecutive adult patients who underwent cardiac surgical procedures at the Montreal Heart Institute from 1996 to 2000. The primary outcome was in-hospital mortality with 99 deaths (3.3%) among these patients. RESULTS Of the 35 variables subjected to univariate analysis, 23 demonstrated a significant association with mortality. Stepwise multivariate logistic regression identified LVEDP as an independent predictor of mortality after cardiac surgery. The area under the receiver operating characteristic curve of the model predicting mortality was 0.85. CONCLUSIONS Elevated LVEDP is an independent predictor of mortality in cardiac surgery. This variable is independent of left ventricular ejection fraction.
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Affiliation(s)
- R Salem
- Department of Anesthesiology, Montreal Heart Institute Montreal, Quebec, H1T 1C8, Canada
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128
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Affiliation(s)
- John Chambers
- Cardiothoracic Centre, St Thomas Hospital, London SE1 7EH, UK.
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129
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Benza RL, Tallaj JA. Pulmonary Hypertension Out of Proportion to Left Heart Disease. ACTA ACUST UNITED AC 2006. [DOI: 10.21693/1933-088x-5.1.21] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Raymond L. Benza
- Division of Cardiology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - José A. Tallaj
- Department of Medicine, Birmingham VA Medical Center, Division of Cardiology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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130
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Hu WTL, Malouf JF. 75-year-old man with progressive shortness of breath on exertion. Mayo Clin Proc 2005; 80:1651-4. [PMID: 16342659 DOI: 10.4065/80.12.1651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- William T L Hu
- Internal Medicine and Neurology, Mayo School of Graduate Medical Education, Mayo Clinic College of Medicine, Rochester, Minn 55905, USA
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131
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Pellikka PA, Sarano ME, Nishimura RA, Malouf JF, Bailey KR, Scott CG, Barnes ME, Tajik AJ. Outcome of 622 adults with asymptomatic, hemodynamically significant aortic stenosis during prolonged follow-up. Circulation 2005; 111:3290-5. [PMID: 15956131 DOI: 10.1161/circulationaha.104.495903] [Citation(s) in RCA: 539] [Impact Index Per Article: 28.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND This study assessed the long-term outcome of a large, asymptomatic population with hemodynamically significant aortic stenosis (AS). METHODS AND RESULTS We identified 622 patients with isolated, asymptomatic AS and peak systolic velocity > or =4 m/s by Doppler echocardiography who did not undergo surgery at the initial evaluation and obtained follow-up (5.4+/-4.0 years) in all. Mean age (+/-SD) was 72+/-11 years; there were 384 (62%) men. The probability of remaining free of cardiac symptoms while unoperated was 82%, 67%, and 33% at 1, 2, and 5 years, respectively. Aortic valve area and left ventricular hypertrophy predicted symptom development. During follow-up, 352 (57%) patients were referred for aortic valve surgery and 265 (43%) patients died, including cardiac death in 117 (19%). The 1-, 2-, and 5-year probabilities of remaining free of surgery or cardiac death were 80%, 63%, and 25%, respectively. Multivariate predictors of all-cause mortality were age (hazard ratio [HR], 1.05; P<0.0001), chronic renal failure (HR, 2.41; P=0.004), inactivity (HR, 2.00; P=0.001), and aortic valve velocity (HR, 1.46; P=0.03). Sudden death without preceding symptoms occurred in 11 (4.1%) of 270 unoperated patients. Patients with peak velocity > or =4.5 m/s had a higher likelihood of developing symptoms (relative risk, 1.34) or having surgery or cardiac death (relative risk, 1.48). CONCLUSIONS Most patients with asymptomatic, hemodynamically significant AS will develop symptoms within 5 years. Sudden death occurs in approximately 1%/y. Age, chronic renal failure, inactivity, and aortic valve velocity are independently predictive of all-cause mortality.
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Affiliation(s)
- Patricia A Pellikka
- Division of Cardiovascular Diseases, Mayo Clinic and Mayo Foundation, Rochester, Minn 55905, USA.
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132
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Anesthesia for non-cardiac surgery in the patient with cardiac disease. Can J Anaesth 2005. [DOI: 10.1007/bf03023082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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133
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Li M, Dumesnil JG, Mathieu P, Pibarot P. Impact of valve prosthesis-patient mismatch on pulmonary arterial pressure after mitral valve replacement. J Am Coll Cardiol 2005; 45:1034-40. [PMID: 15808760 DOI: 10.1016/j.jacc.2004.10.073] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2004] [Accepted: 10/14/2004] [Indexed: 10/25/2022]
Abstract
OBJECTIVES We sought to determine the impact of valve prosthesis-patient mismatch (PPM) on pulmonary arterial (PA) pressure after mitral valve replacement (MVR). BACKGROUND Pulmonary arterial hypertension is a serious complication of mitral valve disease, and it is a major risk factor for poor outcome after MVR. We hypothesized that valve PPM might be a determinant of PA hypertension after MVR. METHODS Systolic PA pressure was measured by Doppler echocardiography in 56 patients with normally functioning mitral prosthetic valves. Mitral valve effective orifice area (EOA) was determined by the continuity equation and indexed for body surface area. RESULTS Thirty patients (54%) had PA hypertension defined as systolic PA pressure >40 mm Hg, whereas 40 patients (71%) had PPM defined as an indexed EOA < or =1.2 cm(2)/m(2). There was a significant correlation (r = 0.64) between systolic PA pressure and indexed EOA. The average systolic PA pressure and prevalence of PA hypertension were 34 +/- 8 mm Hg and 19% in patients with no PPM versus 46 +/- 8 mm Hg and 68% in patients with PPM (p < 0.001). In multivariate analysis, the indexed EOA was by far the strongest predictor of systolic PA pressure. CONCLUSIONS Persistent PA hypertension is frequent after MVR and strongly associated with the presence of PPM. The clinical implications of these findings are important given that PPM can largely be avoided by using a simple prospective strategy at the time of operation.
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Affiliation(s)
- Mingzhou Li
- Research Group in Valvular Heart Diseases, Research Center of Laval Hospital/Quebec Heart Institute, Laval University, 2725 Chemin Saint-Foy, Sainte-Foy, Quebec, Canada G1V 4G5
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134
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Affiliation(s)
- Shahbudin H Rahimtoola
- Division of Cardiovascular Medicine, Department of Medicine, LAC + USC Medical Center, Keck School of Medicine, University of Southern California, 2025 Zonal Avenue, Los Angeles, CA 90033, USA
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135
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Chambers J. Low gradient, low ejection fraction aortic stenosis. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2003; 5:469-474. [PMID: 14575624 DOI: 10.1007/s11936-003-0036-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Low gradient aortic stenosis can be caused by critical aortic stenosis causing left ventricular impairment or by more moderate aortic stenosis coexisting with another cause of left ventricular impairment. The main challenges are to differentiate these two states and then to determine whether the left ventricle is likely to recover after aortic valve surgery. Exhaustive echocardiography is necessary, including the use of dobutamine stress. Guideline criteria for severe aortic stenosis are given in this article. The most secure criteria are mean transaortic pressure difference greater than 30 mm Hg and effective orifice area less than 1.2 cm(2) during dobutamine stress. However, the presence of left ventricular contractile reserve more closely determines outcome after surgery than do markers of stenosis. Surgery is most clearly indicated if there is severe aortic stenosis and an increase in the systolic velocity integral by greater than 20% during dobutamine infusion. Preoperative catheterization is necessary to determine coronary anatomy, but the aortic valve should not be crossed because of the relatively high risk of death, stroke, pulmonary edema, and cardiogenic shock. In patients judged too ill for immediate surgery, a period of medical resuscitation with diuretics and dobutamine should be considered. Balloon valvotomy is not indicated.
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Affiliation(s)
- John Chambers
- Cardiothoracic Centre, St. Thomas' Hospital, Lambeth Palace Road, London SE1 7EH, UK.
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Rahimtoola SH. Questions remain regarding patients with aortic stenosis and severe pulmonary hypertension. J Am Coll Cardiol 2003; 41:1847-8; author reply 1848. [PMID: 12767677 DOI: 10.1016/s0735-1097(03)00323-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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137
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Malouf JF, Enrique-Sarano M, Pellika PA, Oh JK, Bailey KR, Chandrasekaran K, Mullany CJ, Tajik A. Questions remain regarding patients with aortic stenosis and severe pulmonary hypertension: Reply. J Am Coll Cardiol 2003. [DOI: 10.1016/s0735-1097(03)00324-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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