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Bernard S, Maurer MS. Heart Failure With a Normal Ejection Fraction: Treatments for a Complex Syndrome? CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2012; 14:305-18. [DOI: 10.1007/s11936-012-0187-4] [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: 01/11/2023]
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202
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Park HW, Song JM, Choo SJ, Chung CH, Lee JW, Kim DH, Kang DH, Song JK. Effect of preoperative ejection fraction, left ventricular systolic dimension and hemoglobin level on survival after aortic valve surgery in patients with severe chronic aortic regurgitation. Am J Cardiol 2012; 109:1782-6. [PMID: 22459298 DOI: 10.1016/j.amjcard.2012.02.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2011] [Revised: 02/01/2012] [Accepted: 02/01/2012] [Indexed: 11/19/2022]
Abstract
Surgical indications in patients with severe chronic aortic regurgitation (AR) and normal left ventricular (LV) ejection fractions (EF) remain to be established. The aim of this study was to identify prognostic indicators after surgery in patients with severe AR and normal LV systolic function. Preoperative clinical and echocardiographic characteristics were evaluated in 284 consecutive patients with chronic severe AR who underwent aortic valve surgery. Of these patients, 169 had normal (≥50%) and 115 had depressed (<50%) preoperative LV EFs. All-cause mortality was observed for a median of 39.9 months. Of 284 patients, 7 (4.4%) with normal LV EFs and 15 (12.0%) with depressed LV EFs died during follow-up after aortic valve surgery (p = 0.017). In patients with normal EFs, multivariate Cox regression analysis showed that large LV end-systolic dimension and low plasma hemoglobin level were independent predictors of postsurgical mortality. Receiver-operating characteristic analysis showed that LV end-systolic dimension ≥45 mm and hemoglobin level <13.4 g/dl were the best cut-off values for postoperative mortality. In conclusion, preoperative LV end-systolic dimension and hemoglobin level are independent prognostic factors of survival after aortic valve surgery in patients with chronic severe AR and normal LV EFs.
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Affiliation(s)
- Hyun Woo Park
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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203
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Shah RM, Singh M, Bhuriya R, Molnar J, Arora RR, Khosla S. Favorable effects of vasodilators on left ventricular remodeling in asymptomatic patients with chronic moderate-severe aortic regurgitation and normal ejection fraction: a meta-analysis of clinical trials. Clin Cardiol 2012; 35:619-25. [PMID: 22707241 DOI: 10.1002/clc.22019] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2011] [Revised: 04/27/2012] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The role of vasodilator therapy in asymptomatic patients with chronic moderate to severe aortic regurgitation (AR) and normal left ventricular (LV) function is uncertain. We assessed the effects of vasodilator therapy (hydralazine, calcium channel blockers, and angiotensin-converting enzyme inhibitors) in this subgroup of patient population. HYPOTHESIS Vasodilators have favorable effects on LV remodelling in asymptomatic patients with chronic moderate to severe aortic regurgitation and normal LV function. METHODS We performed a systematic literature search for randomized clinical trials using long-term vasodilator therapy in asymptomatic patients with chronic severe AR and normal LV function. The magnitude of difference between the vasodilator and nonvasodilator groups was assessed by computing the mean difference (MD). Heterogeneity of the studies was analyzed by Cochran Q statistics. The MD for LV ejection fraction, LV end systolic volume index, and LV end diastolic volume index were computed by random effects model. The MD for LV end-systolic diameter and LV end-diastolic diameter were computed by fixed effects model. A 2-sided alpha error <0.05 was considered to be statistically significant. RESULTS Seven studies with 460 patients were included. Meta-analysis of the studies revealed a significant increase in LVEF (MD: 5.32, 95% confidence interval [CI]: 0.37 to 10.26, P = 0.035), a significant decrease in LV end diastolic volume index (MD: -16.282, 95% CI: -23.684 to -8.881, P < 0.001), and a significant decrease in LV end diastolic diameter (MD: -2.343, 95% CI: -3.397 to -1.288, P < 0.001) in the vasodilator group compared with the nonvasodilator group. However, there was no significant decrease in LV end systolic volume index (MD: -6.105, 95% CI: -12.478 to 0.267, P = 0.060) or in LV end systolic diameter (MD: 0.00, 95% CI: -0.986 to 0.986, P = 1.0) in the vasodilator group compared with the nonvasodilator group. CONCLUSIONS In asymptomatic patients with chronic severe AR and normal LV function, vasodilators have favorable effects on LV remodeling.
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Affiliation(s)
- Rachit M Shah
- Department of Cardiology/Internal Medicine, Rosalind Franklin University/Chicago Medical School, Chicago, Illinois, USA.
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204
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Iida N, Seo Y, Ishizu T, Nakajima H, Atsumi A, Yamamoto M, Machino-Ohtsuka T, Kawamura R, Enomoto M, Kawakami Y, Aonuma K. Transmural compensation of myocardial deformation to preserve left ventricular ejection performance in chronic aortic regurgitation. J Am Soc Echocardiogr 2012; 25:620-8. [PMID: 22440541 DOI: 10.1016/j.echo.2012.02.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2011] [Indexed: 12/22/2022]
Abstract
BACKGROUND In patients with chronic aortic regurgitation (AR), systolic wall stress and volume overload affects left ventricular (LV) systolic function and remodeling. The aim of this study was to assess transmural rearrangements of myocardial deformation to preserve LV ejection performances using speckle-tracking echocardiography in patients with chronic AR. METHODS Ninety patients with AR were enrolled. On LV short-axis images, total, inner, and outer radial strain and circumferential strain at the inner, mid, and outer layers were calculated. On apical four-chamber images, endocardial longitudinal strain was calculated. End-systolic wall stresses were calculated using previous methods. RESULTS AR severities were classified as moderate in 31 patients, severe and preserved LV ejection fraction (LVEF) (≥50%) in 42 patients, and severe and reduced LVEF (<50%) in 17 patients. Longitudinal strain was decreased even in the moderate AR group, despite normal end-systolic wall stress. Inner radial strain progressively decreased with increasing end-systolic wall stress, whereas outer radial strain in the moderate and severe AR and preserved LVEF groups was higher than in the control group. Consequently, total radial strain was preserved even in the severe AR and preserved LVEF groups with increased end-systolic wall stress. Similarly, despite reduced inner circumferential strain, outer circumferential strain was higher in the severe AR and preserved LVEF group than in the control group. All strain parameters were lower in the severe AR and reduced LVEF group with dramatically increased end-systolic wall stress than in other groups. CONCLUSIONS Transmural strain analysis revealed that subendocardial dysfunction accompanied by increased wall thickening at the subepicardium may be a compensatory mechanism of wall thickening to preserve LVEF in patients with chronic AR.
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Affiliation(s)
- Noriko Iida
- Department of Clinical Laboratory, Tsukuba University Hospital, Tsukuba, Japan
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205
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Olsen NT, Sogaard P, Larsson HBW, Goetze JP, Jons C, Mogelvang R, Nielsen OW, Fritz-Hansen T. Speckle-tracking echocardiography for predicting outcome in chronic aortic regurgitation during conservative management and after surgery. JACC Cardiovasc Imaging 2012; 4:223-30. [PMID: 21414568 DOI: 10.1016/j.jcmg.2010.11.016] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2010] [Revised: 11/09/2010] [Accepted: 11/15/2010] [Indexed: 12/22/2022]
Abstract
OBJECTIVES The aim of this study was to test myocardial deformation imaging using speckle-tracking echocardiography for predicting outcomes in chronic aortic regurgitation. BACKGROUND In chronic aortic regurgitation, left ventricular (LV) dysfunction must be detected early to allow timely surgery. Speckle-tracking echocardiography has been proposed for this purpose, but the clinical value of this method in aortic regurgitation has not been established. METHODS A longitudinal study was performed in 64 patients with moderate to severe aortic regurgitation. Thirty-five patients were managed conservatively with frequent clinical visits and sequential echocardiography and followed for an average of 19 ± 8 months, while 29 patients underwent surgery for the valve lesion and were followed for 6 months post-operatively. Baseline LV function by speckle-tracking and conventional echocardiography was compared with impaired outcome after surgery (defined as persisting symptoms or persisting LV dilation [LV end-diastolic volume index ≥ 87 ml/m(2)] or dysfunction [LV ejection fraction <50%]) and with disease progression during conservative management (defined as development of symptoms, increase in LV volume >15%, or decrease in LV ejection fraction >10%). RESULTS Reduced myocardial systolic strain, systolic strain rate, and early diastolic strain rate by speckle-tracking echocardiography was associated with disease progression during conservative management (-16.3% vs. -19.0%, p = 0.02; -1.04 vs. -1.19 s(-1), p = 0.02; and 1.20 vs. 1.60 s(-1), p = 0.002, respectively) and with impaired outcome after surgery (-11.5% vs. -15.6%, p = 0.01; -0.88 vs. -1.01 s(-1), p = 0.04; and 0.98 vs. 1.33 s(-1), p = 0.01, respectively). Conventional parameters of LV function and size (LV ejection fraction and LV end-diastolic volume index) were associated with outcome after surgery (p = 0.04 and p = 0.01, respectively) but not with outcome during conservative management (p = 0.57 and p = 0.39, respectively). CONCLUSIONS Speckle-tracking echocardiography is useful for the early detection of LV systolic and diastolic dysfunction in chronic aortic regurgitation.
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Affiliation(s)
- Niels Thue Olsen
- Department of Cardiology, Gentofte Hospital, University of Copenhagen, Hellerup, Denmark.
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206
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Aksoy S, Cam N, Guney MR, Gurkan U, Oz D, Poyraz E, Eksik A, Agirbasli M. Myocardial Ischemia in Severe Aortic Regurgitation Despite Angiographically Normal Coronary Arteries. TOHOKU J EXP MED 2012; 226:69-73. [DOI: 10.1620/tjem.226.69] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Sukru Aksoy
- Department of Cardiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital
| | - Nese Cam
- Department of Cardiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital
| | - Mehmet Rasit Guney
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital
| | - Ufuk Gurkan
- Department of Cardiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital
| | - Dilaver Oz
- Department of Cardiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital
| | - Esra Poyraz
- Department of Cardiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital
| | - Abdurrahman Eksik
- Department of Cardiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital
| | - Mehmet Agirbasli
- Department of Cardiology, Marmara University, Faculty of Medicine
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Abstract
The evaluation of left ventricular systolic function is one of the most common reasons for referral for a non-invasive cardiac imaging study. In addition to its diagnostic and prognostic value, an assessment of ejection fraction can also be used to guide medical and device therapy. Thus, obtaining an accurate and reproducible assessment of LVEF is essential for patient management. This review will focus on novel multi-modality techniques used for the quantification of left ventricular systolic function. Emerging echocardiography techniques such as three-dimensional echocardiography and strain imaging and their incremental role over traditional 2D imaging will be discussed. In addition, new developments expanding nuclear imaging techniques' evaluation of left ventricular systolic function will be reviewed. Finally, an overview of advances in imaging techniques such as cardiac magnetic resonance and cardiac computed tomography, which now allow for an accurate and highly reproducible assessment of LVEF, will be presented.
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Affiliation(s)
- Sonal Chandra
- Non-invasive Cardiac Imaging Center, Section of Cardiology, University of Chicago Medical Center, 5841 S. Maryland Ave, MC 5084, Chicago, IL 60637, USA
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209
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Strain Value in the Assessment of Left Ventricular Function and Prediction of Heart Failure Markers in Aortic Regurgitation. Echocardiography 2011; 28:983-92. [DOI: 10.1111/j.1540-8175.2011.01483.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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210
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Feuchtner GM, Spoeck A, Lessick J, Dichtl W, Plass A, Leschka S, Mueller S, Klauser A, Scheffel H, Wolf F, Jaschke W, Alkadhi H. Quantification of aortic regurgitant fraction and volume with multi-detector computed tomography comparison with echocardiography. Acad Radiol 2011; 18:334-42. [PMID: 21295735 DOI: 10.1016/j.acra.2010.11.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2010] [Revised: 11/02/2010] [Accepted: 11/03/2010] [Indexed: 11/25/2022]
Abstract
RATIONALE AND OBJECTIVES Evaluate quantification of the aortic regurgitant fraction and volume with computed tomography (CT). MATERIALS AND METHODS Fifty-three patients with aortic regurgitation (AR) and 29 controls were examined with 64-multi-detector CT coronary angiography and transthoracic echocardiography (TTE). A dedicated software algorithm employing three-dimensional segmentation of left ventricle (LV) and right ventricle (RV) volumes and LV mass was applied. AR volume and fraction was calculated based on RV and LV stroke volumes (SV) and compared with echocardiography. The aortic regurgitant orifice area (ROA) was measured by CT. RESULTS A good correlation of the AR fraction and AR volume determined by CT compared to echocardiography was found for mild, moderate, and severe AR with 14.2% ± 9, 28.8% ± 8, and 57.9% ± 9 (r = 0.95, P < .001) for AR fraction, and 15.7 mL ± 11.33 mL ± 14, and 98.9 mL ± 36 for AR volume (r = 0.92, P < .0001), respectively. CT correctly classified severity of AR in 93% of patients based of AR-fraction, and in 89% based on AR volume. The sensitivity and specificity of CT were 98% and specificity 90.3%. The specificity improved to 97%, if the ROA by CT was added as diagnostic criterion. CONCLUSION Aortic regurgitation fraction and volume can be accurately quantified from CT coronary angiography datasets. These parameters can assist clinical management, e.g. in case of pending cardiac surgery decision.
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211
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Enache R, Antonini-Canterin F, Piazza R, Popescu BA, Leiballi E, Marinigh R, Andriani C, Pecoraro R, Ginghina C, Nicolosi GL. CME: long-term outcome in asymptomatic patients with severe aortic regurgitation, normal left ventricular ejection fraction, and severe left ventricular dilatation. Echocardiography 2011; 27:915-22. [PMID: 20572853 DOI: 10.1111/j.1540-8175.2010.01193.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Although the guidelines consider severe left ventricular (LV) dilatation a class IIaC indication for surgery in asymptomatic patients with severe aortic regurgitation (AR) and normal LV function, the optimal management remains controversial. We aimed to assess the LV enlargement, hypertrophy and function, and the outcomes in these patients by the presence of severe LV dilatation at baseline. METHODS From our 20-year database, we identified all asymptomatic patients with severe AR and LV ejection fraction (EF) >50% and ≥2 echocardiograms ≥1 year apart. LV end-diastolic diameter >70 mm or LV end-systolic diameter >50 mm or LV end-systolic diameter index >25 mm/m(2) defined severe LV dilatation. A composite end point included onset of symptoms or LV dysfunction. RESULTS Eighty-four patients (52 ± 18 years, 61 men) were enrolled and followed-up for 7.1 ± 5.1 years. Two groups were defined: 22 patients with and 62 patients without severe LV dilatation at baseline. The progression of LV dilatation and hypertrophy, and the LVEF at last exam were similar in both groups. Twelve of 22 and 34 of 62 patients (P = 0.59) reached the end point. Vasodilators did not modify the progression of LV enlargement/hypertrophy. Ten of 22 and 25 of 62 patients (P = 0.45) underwent surgery and had similar postoperative LV diameters, mass, EF. CONCLUSIONS The progression of LV enlargement/hypertrophy and outcomes in asymptomatic patients with severe AR, normal LV function, and severe LV dilatation or the postoperative LV parameters were not influenced by the severe LV dilatation, suggesting that a close follow-up could delay surgery in this population.
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Affiliation(s)
- Roxana Enache
- Cardiology ARC, S. Maria degli Angeli Hospital, Via Montereale 24, Pordenone, Italy
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212
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Roşca M, Lancellotti P, Magne J, Piérard LA. Stress testing in valvular heart disease: clinical benefit of echocardiographic imaging. Expert Rev Cardiovasc Ther 2010; 9:81-92. [PMID: 21166530 DOI: 10.1586/erc.10.173] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Symptom development represents one of the most important indications for surgical intervention in patients with significant valvular heart disease. Exercise testing has an established role in the assessment of exercise capacity and symptomatic status in patients with severe valvular heart disease who claim to be asymptomatic. In these patients, clinical decision can be influenced by the results of exercise testing. In addition to the assessment of symptomatic response to exercise, stress echocardiography can provide valuable information on exercise-induced changes in valve hemodynamics, ventricular function and pulmonary artery pressure. Abnormal left ventricular response to exercise, increase in pulmonary pressure or change in the hemodynamic severity of the valvular disease adds to the prognostic value of elicited symptoms. In this article we discuss the validated indications, proven prognostic values and potential influence on clinical decisions of stress echocardiography in left valvular heart diseases.
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Affiliation(s)
- Monica Roşca
- Department of Cardiology, University Hospital, CHU Sart Tilman, University of Liège, Liège, Belgium
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213
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Mizariene V, Bucyte S, Zaliaduonyte-Peksiene D, Jonkaitiene R, Vaskelyte J, Jurkevicius R. Left ventricular mechanics in asymptomatic normotensive and hypertensive patients with aortic regurgitation. J Am Soc Echocardiogr 2010; 24:385-91. [PMID: 21168306 DOI: 10.1016/j.echo.2010.11.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2010] [Indexed: 12/22/2022]
Abstract
BACKGROUND The aims of this study were to detect subclinical left ventricular (LV) dysfunction and to determine the impact of arterial hypertension on LV systolic function using speckle-tracking echocardiography in patients with chronic aortic regurgitation (AR). METHODS Sixty-eight patients with AR and 47 healthy controls were included in the study. LV rotation and longitudinal, radial, and circumferential strain were measured using speckle-tracking imaging. RESULTS Longitudinal axis dysfunction was found in patients with moderate AR with hypertension but was not present in patients with moderate AR without hypertension. Radial strain in patients with moderate AR was unchanged, but reduced levels were noted at the apical level in patients with severe AR without hypertension and preserved in those with severe hypertensive AR. LV basal rotation was reduced in patients with severe AR, whereas apical rotation was increased in those with moderate AR. LV torsion was reduced in patients with severe AR. CONCLUSIONS Patients with asymptomatic AR show subclinical LV longitudinal axis dysfunction, with more attenuation demonstrated in hypertensive than in normotensive patients.
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214
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Pulmonary hypertension and long-term mortality in aortic and mitral regurgitation. Am J Med 2010; 123:1043-8. [PMID: 21035592 DOI: 10.1016/j.amjmed.2010.06.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2010] [Revised: 06/04/2010] [Accepted: 06/13/2010] [Indexed: 11/21/2022]
Abstract
BACKGROUND Outcomes data in patients with aortic regurgitation or mitral regurgitation have been limited to small series with generally <10 years of follow-up. The quantitative impact of pulmonary artery hypertension has not been well described. The purpose of this study was to describe the 15-year mortality of aortic regurgitation and mitral regurgitation. METHODS Our institution's electronic echocardiography database was queried to identify those patients examined in 1992 and reported to have at least mild aortic regurgitation or mitral regurgitation. Patients were classified by semi-quantitative degree of regurgitation. Pulmonary artery systolic pressure was categorized as normal, borderline, mild, or moderate or greater hypertension (pulmonary artery systolic pressure >40 mm Hg). Age-stratified Cox proportional hazards models compared survival among groups and adjusted for sex, depressed left ventricular ejection fraction, and pulmonary artery systolic pressure. Mortality data were obtained from the 2008 Social Security Death Index. RESULTS Of 4984 echocardiograms performed in 4050 patients, 1156 patients (28%; aged 72±14 years) had at least mild aortic regurgitation and 1971 patients (49%; aged 69±16 years) had at least mild mitral regurgitation. Overall 15-year mortality in patients with aortic regurgitation was 74% and similar for all grades of aortic regurgitation. Overall 15-year mortality in patients with mitral regurgitation was 71% and got progressively worse with increasing severity grade of mitral regurgitation (63% for mild to 81% for at least moderate-to-severe). For both aortic and mitral regurgitation, moderate or greater pulmonary artery systolic hypertension was associated with increased mortality (in patients with aortic regurgitation, hazard ratio [HR], 1.94; 95% confidence interval [CI], 1.58-2.41, and in mitral regurgitation patients, HR, 1.48; 95% CI, 1.26-1.75). CONCLUSION Long-term (15-year) survival of patients with aortic regurgitation is poor and is independent of regurgitation severity. In contrast, long-term survival of patients with mitral regurgitation correlates with regurgitation severity. For both groups, moderate or greater pulmonary artery systolic hypertension identified those at highest risk.
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215
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[Evaluation of the left ventricle with three-dimensional echocardiography: comparison with cardiac magnetic resonance]. RADIOLOGIA 2010; 52:534-40. [PMID: 20846703 DOI: 10.1016/j.rx.2010.06.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2009] [Revised: 05/28/2010] [Accepted: 06/04/2010] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Three-dimensional echocardiography (3DE) is becoming increasingly common in clinical environments. However, the quality of the images depends on the acoustic window, and it can be difficult to identify the endocardial borders. The objective of this study was to evaluate the performance of 3DE in determining the volumes and left ventricular ejection fraction in unselected patients against the gold standard, cardiac magnetic resonance (CMR). MATERIAL AND METHODS In 47 unselected patients who underwent CMR, we performed 3DE using a real-time acquisition technique and semiautomatic border detection. RESULTS We excluded 4 patients (8.5%) because they had an extremely deficient acoustic window. In the remaining 43 patients, including those with a suboptimal acoustic window, we obtained the following correlations between 3DE and CMR: end-diastolic volume, 0.71; end-systolic volume, 0.77; ejection fraction, 0.74. Although the end-diastolic volume was systematically underestimated, no significant differences were observed in the ejection fraction. When the 11 patients with suboptimal acoustic windows were excluded, we observed a systematic underestimation of the end-diastolic and end-systolic volumes, which paradoxically gave rise to improved correlation coefficients (0.79, 0.92, and 0.84, respectively) and a more accurate ejection fraction. CONCLUSIONS Compared to CMR, 3DE systematically underestimates the ventricular volumes but enables adequate determination of the left ventricular ejection fraction regardless of the quality of the acoustic window.
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216
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Abstract
Valvular heart disease (VHD) encompasses a number of common cardiovascular conditions that account for 10% to 20% of all cardiac surgical procedures in the United States. A better understanding of the natural history coupled with the major advances in diagnostic imaging, interventional cardiology, and surgical approaches have resulted in accurate diagnosis and appropriate selection of patients for therapeutic interventions. A thorough understanding of the various valvular disorders is important to aid in the management of patients with VHD. Appropriate work-up for patients with VHD includes a thorough history for evaluation of causes and symptoms, accurate assessment of the severity of the valvular abnormality by examination, appropriate diagnostic testing, and accurate quantification of the severity of valve dysfunction and therapeutic interventions, if necessary. It is also important to understand the role of the therapeutic interventions vs the natural history of the disease in the assessment of outcomes. Prophylaxis for infective endocarditis is no longer recommended unless the patient has a history of endocarditis or a prosthetic valve.
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Affiliation(s)
- Kameswari Maganti
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, 201 E Huron St, Ste 11-240, Chicago, IL 60611, USA.
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217
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Lai HC, Lai HC, Lee WL, Wang KY, Ting CT, Hung CJ, Liu TJ. Impact of chronic advanced aortic regurgitation on the perioperative outcome of noncardiac surgery. Acta Anaesthesiol Scand 2010; 54:580-8. [PMID: 19930243 DOI: 10.1111/j.1399-6576.2009.02171.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Whether and how chronic advanced aortic regurgitation (AR) impacts the perioperative outcome of noncardiac surgery remains unclear. METHODS From November 1999 to December 2006, all patients undergoing noncardiac operations and ever examined by echocardiography within the last 6 months were screened. Those with chronic moderate-severe or severe AR were enrolled, provided they were not already trachea-intubated or aortic valve operated, and the surgery was not performed under local anesthesia. Case-matched subjects without significant AR served as controls. The perioperative outcomes of these patients were analyzed, and independent prognostic correlates were investigated by multivariate logistic regression analysis. RESULTS A total of 167 patients (male 131, mean age of 75 years) complying with the enrollment criteria were studied. Compared with the other 167 case-matched control peers, patients with advanced AR risked potential hazards of serious hemodynamic instability (0.6%) and circulatory collapse (1.2%) during surgery despite the similar incidence of overall cardiac adverse events, and were further distressed with more cardiopulmonary complications (16.2% vs. 5.4%, P=0.003) and in-hospital deaths (9% vs. 1.8%, P=0.008) post-operatively. Multivariate regression analysis confirmed the correlation of advanced AR with perioperative mortality, and identified depressed left ventricular function, renal dysfunction, high surgical risk, and lack of cardiac medication as predictors of in-hospital death. CONCLUSION Chronic advanced AR complicates the perioperative outcome of noncardiac surgery as reflected by frequent cardiopulmonary morbidities and in-hospital deaths, especially when coexisting with specified high-risk clinical and surgical characteristics.
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Affiliation(s)
- H-C Lai
- Department of Anesthesiology and Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
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Sionis A, García-Alvarez A, Castel MÁ, Cordero M, Josa M, Pérez-Villa F, Roig E. Severe aortic regurgitation and reduced left ventricular ejection fraction: Outcomes after isolated aortic valve replacement and combined surgery. J Heart Lung Transplant 2010; 29:445-8. [DOI: 10.1016/j.healun.2009.09.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2009] [Revised: 09/03/2009] [Accepted: 09/03/2009] [Indexed: 11/26/2022] Open
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Survival Benefit of Aortic Valve Replacement in Older Patients With Asymptomatic Chronic Severe Aortic Regurgitation. Ann Thorac Surg 2010; 89:731-7. [DOI: 10.1016/j.athoracsur.2009.12.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2009] [Revised: 12/02/2009] [Accepted: 12/03/2009] [Indexed: 11/22/2022]
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Schäfers HJ, Langer F, Glombitza P, Kunihara T, Fries R, Aicher D. Aortic valve reconstruction in myxomatous degeneration of aortic valves: Are fenestrations a risk factor for repair failure? J Thorac Cardiovasc Surg 2010; 139:660-4. [DOI: 10.1016/j.jtcvs.2009.06.025] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2008] [Revised: 03/26/2009] [Accepted: 06/23/2009] [Indexed: 12/01/2022]
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Picano E, Pibarot P, Lancellotti P, Monin JL, Bonow RO. The emerging role of exercise testing and stress echocardiography in valvular heart disease. J Am Coll Cardiol 2010; 54:2251-60. [PMID: 19958961 DOI: 10.1016/j.jacc.2009.07.046] [Citation(s) in RCA: 144] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2008] [Revised: 07/08/2009] [Accepted: 07/28/2009] [Indexed: 02/07/2023]
Abstract
Exercise testing has an established role in the evaluation of patients with valvular heart disease and can aid clinical decision making. Because symptoms may develop slowly and indolently in chronic valve diseases and are often not recognized by patients and their physicians, the symptomatic, blood pressure, and electrocardiographic responses to exercise can help identify patients who would benefit from early valve repair or replacement. In addition, stress echocardiography has emerged as an important component of stress testing in patients with valvular heart disease, with relevant established and potential applications. Stress echocardiography has the advantages of its wide availability, low cost, and versatility for the assessment of disease severity. The versatile applications of stress echocardiography can be tailored to the individual patient with aortic or mitral valve disease, both before and after valve replacement or repair. Hence, exercise-induced changes in valve hemodynamics, ventricular function, and pulmonary artery pressure, together with exercise capacity and symptomatic responses to exercise, provide the clinician with diagnostic and prognostic information that can contribute to subsequent clinical decisions. Nevertheless, there is a lack of convincing evidence that the results of stress echocardiography lead to clinical decisions that result in better outcomes, and therefore large-scale prospective randomized studies focusing on patient outcomes are needed in the future.
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Affiliation(s)
- Eugenio Picano
- CNR, Institute of Clinical Physiology, Fondazione G. Monasterio, Pisa, Italy
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222
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Claver E, Leta R, Pujadas S, Hidalgo A, Carreras F, Pons-Lladó G. Evaluation of the left ventricle with three-dimensional echocardiography: Comparison with cardiac magnetic resonance. RADIOLOGIA 2010. [DOI: 10.1016/s2173-5107(10)70027-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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223
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Vivancos R, Aranda P. Aportación de la ecocardiografía en la valoración de la enfermedad aórtica. CIRUGIA CARDIOVASCULAR 2009. [DOI: 10.1016/s1134-0096(09)70129-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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224
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Detaint D, Messika-Zeitoun D, Maalouf J, Tribouilloy C, Mahoney DW, Tajik AJ, Enriquez-Sarano M. Quantitative echocardiographic determinants of clinical outcome in asymptomatic patients with aortic regurgitation: a prospective study. JACC Cardiovasc Imaging 2009; 1:1-11. [PMID: 19356398 DOI: 10.1016/j.jcmg.2007.10.008] [Citation(s) in RCA: 106] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2007] [Revised: 10/11/2007] [Accepted: 10/18/2007] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The purpose of this study was to define the link between aortic regurgitation (AR) quantitation and clinical outcome in asymptomatic patients with AR. BACKGROUND Quantitative American Society of Echocardiography (QASE) thresholds are recommended for AR assessment, but impact on clinical outcome is unknown. METHODS We prospectively enrolled (1991 to 2003) 251 asymptomatic patients (age 60 +/- 17 years) with isolated AR and ejection fraction > or =50% with quantified AR and left ventricular (LV) volumes using Doppler-echocardiography. RESULTS Survival under medical management was independently determined by baseline regurgitant volume (RVol) (adjusted hazard ratio [HR] 1.22 [95% confidence interval (CI) 1.08 to 1.35] per 10 ml/beat, p = 0.002) and effective regurgitant orifice (ERO) (adjusted HR 1.52 [95% CI 1.19 to 1.91] per 10 mm(2), p = 0.002), which superseded traditional AR grading. Patients with QASE-severe AR (RVol > or =60 ml/beat or ERO > or =30 mm(2)) versus QASE-mild AR (RVol <30 ml and ERO <10 mm(2)) had lower survival (10 years: 69 +/- 9% vs. 92 +/- 4%, p = 0.05) independently of all clinical characteristics (adjusted HR 4.1 [95% CI 1.4 to 14.1], p = 0.01) and lower survival free of surgery for AR (10 years: 20 +/- 5% vs. 92 +/- 4%, p < 0.001, adjusted HR 12.9 [95% CI 5.4 to 38.5]). Cardiac events were considerably more frequent with QASE-severe versus -moderate or -mild AR (10 years: 63 +/- 8% vs. 34 +/- 6% and 21 +/- 8%, p < 0.0001). Independent determinants of cardiac events were quantitative AR grading (QASE-severe adjusted HR 5.2 [95% CI 2.2 to 14.8], p < 0.001; QASE-moderate adjusted HR 2.4 [95% CI 1.06 to 6.6], p = 0.035), which superseded traditional AR assessment (p < 0.001) and LV end-systolic volume index (ESVI) (adjusted HR 1.09 [95% CI 1.03 to 1.14 per 10 ml/m(2)], p = 0.002), which superseded LV M-mode diameters. In QASE-severe AR, patients with ESVI > or =45 versus <45 ml/m(2) had higher cardiac event rates (10 years: 87 +/- 8% vs. 40 +/- 10%, p < 0.001). Cardiac surgery for AR reduced cardiac events in patients with QASE-severe AR (adjusted HR 0.23 [95% CI 0.09 to 0.57], p = 0.002). CONCLUSIONS Echocardiographic quantitation of AR severity and ESVI provides independent and superior predictors of clinical outcome in asymptomatic patients with AR and ejection fraction > or =50% and should be widely clinically applied. Patients with QASE-severe AR and ESVI > or =45 ml/m(2) should be carefully considered for cardiac surgery, which reduces cardiac events risk.
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Affiliation(s)
- Delphine Detaint
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA
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Hess PJ, Harman PK, Klodell CT, Beaver TM, Bologna MT, Mikhail P, Tribble CG, Martin TD. Early outcomes using the Florida sleeve repair for correction of aortic insufficiency due to root aneurysms. Ann Thorac Surg 2009; 87:1161-8; discussion 1168-9. [PMID: 19324144 DOI: 10.1016/j.athoracsur.2009.01.016] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2008] [Revised: 01/04/2009] [Accepted: 01/07/2009] [Indexed: 11/28/2022]
Abstract
BACKGROUND The Florida sleeve procedure is a simplified valve-sparing technique for repair of functional type I aortic insufficiency associated with root aneurysms. Midterm outcomes are reported, including standard echocardiographic measurements. METHODS The study included all patients undergoing the Florida sleeve procedure who had at least 2 years of postoperative echocardiographic follow-up. Data were acquired preoperatively and postoperatively at 1 week and 1, 2, and 3 years. Measurements analyzed included left ventricular end-diastolic diameter (LVEDD), left ventricular end-systolic diameter (LVESD), and degree of aortic insufficiency. RESULTS Complete echocardiographic data for a mean 32 +/- 6.3 months after repair were available for 18 patients. Mean LVEDD decreased from 51.6 +/- 7.4 to 49.7 +/- 6.3 mm at 1 week (p = 0.05) and 47.1 +/- 6.3 mm at 1 year (p = 0.008), and remained unchanged at 47.2 +/- 6.6 and 47.1 +/- 5.0 mm at 2 and 3 years. Mean LVESD decreased from 35.2 +/- 7.6 to 32.9 +/- 7.0 mm at 1 week (p = 0.002) and 30.7 +/- 5.6 mm at 1 year (p < 0.001), and remained unchanged at 30.9 +/- 6.2 and 31.7 +/- 4.9 mm after 2 and 3 years. The mean grade of aortic insufficiency decreased from 2.61 +/- 0.78 to 1.39 +/- 0.85 mm at 1 week (p < 0.001) and remained 1.39 +/- 0.84 mm at 1 year. Aortic insufficiency increased to 1.72 +/- 0.89 (p = 0.03) at 2 years and decreased to 1.67 +/- 0.50 (p = 0.59, from 1 week postoperatively) at 3 years. CONCLUSIONS The sustained reduction of left ventricular dimensions 3 years after operation suggests the Florida sleeve procedure is a durable valve repair. A minor increase in the degree of aortic insufficiency warrants close follow-up, but the absence of an increase of LVEDD supports continued use of the procedure in closely studied series.
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Affiliation(s)
- Philip J Hess
- Division of Thoracic and Cardiovascular Surgery, University of Florida, College of Medicine, Gainesville, Florida 32610, USA.
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Indexed Left Ventricular Dimensions Best Predict Survival After Aortic Valve Replacement in Patients With Aortic Valve Regurgitation. Ann Thorac Surg 2009; 87:1170-5; discussion 1175-6. [DOI: 10.1016/j.athoracsur.2008.12.086] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2008] [Revised: 12/22/2008] [Accepted: 12/26/2008] [Indexed: 11/21/2022]
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227
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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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Detaint D, Maalouf J, Tribouilloy C, Mahoney DW, Schaff HV, Tajik AJ, Enriquez-Sarano M. Congestive heart failure complicating aortic regurgitation with medical and surgical management: A prospective study of traditional and quantitative echocardiographic markers. J Thorac Cardiovasc Surg 2008; 136:1549-57. [DOI: 10.1016/j.jtcvs.2008.07.036] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2008] [Revised: 06/10/2008] [Accepted: 07/22/2008] [Indexed: 01/09/2023]
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229
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Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O'Gara PT, O'Rourke RA, Otto CM, Shah PM, Shanewise JS, Nishimura RA, Carabello BA, Faxon DP, Freed MD, Lytle BW, O'Gara PT, O'Rourke RA, Shah PM. 2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1998 guidelines for the management of patients with valvular heart disease). Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 2008; 52:e1-142. [PMID: 18848134 DOI: 10.1016/j.jacc.2008.05.007] [Citation(s) in RCA: 1058] [Impact Index Per Article: 66.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Pouleur AC, de Waroux JBLP, Goffinet C, Vancraeynest D, Pasquet A, Gerber BL, Vanoverschelde JL. Accuracy of the flow convergence method for quantification of aortic regurgitation in patients with central versus eccentric jets. Am J Cardiol 2008; 102:475-80. [PMID: 18678309 DOI: 10.1016/j.amjcard.2008.04.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2007] [Revised: 04/02/2008] [Accepted: 04/02/2008] [Indexed: 10/22/2022]
Abstract
Proximal isovelocity surface area (PISA) has been proposed as a quantitative method to assess the severity of aortic regurgitation (AR). Yet the accuracy of this method in patients with eccentric AR jets is unknown. The aims of this study were to compare the accuracy of the PISA method for the quantification of AR severity in patients with central versus eccentric AR jets and to verify whether imaging from the left parasternal instead of the apical window improves the accuracy of the PISA method in patients with eccentric jets. Fifty patients with AR (21 with central jets and 29 with eccentric jets) underwent PISA and phase-contrast cardiac magnetic resonance (CMR) measurements of AR volume. In patients with eccentric AR jets, PISA measurements obtained from the left parasternal and apical windows were compared. In patients with central AR jets, CMR- and PISA-derived AR volumes were similar (28 +/- 19 vs 30 +/- 20 ml, p = 0.34), were strongly correlated (r = 0.92, p <0.0001), and differed minimally from each other (by 2 +/- 8 ml). In patients with eccentric AR jets, PISA-derived AR volumes underestimated those measured by CMR (38 +/- 22 vs 51 +/- 27 ml, bias -13 +/- 20 ml) and were correlated only fairly (r = 0.69, p <0.001). Imaging from the left parasternal window eliminated the differences between CMR- and PISA-derived AR volumes (51 +/- 27 vs 53 +/- 26 ml, p = 0.24) and improved the correlation between the 2 measures (r = 0.95). In conclusion, in patients with eccentric AR jets imaged from the apical window, the PISA method significantly underestimated AR severity. This was no longer the case when imaging was performed from the left parasternal instead of the apical window.
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232
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The Diagnosis and Management of Chronic Rheumatic Heart Disease—An Australian Guideline. Heart Lung Circ 2008; 17:271-89. [DOI: 10.1016/j.hlc.2007.12.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2007] [Revised: 11/30/2007] [Accepted: 12/03/2007] [Indexed: 11/22/2022]
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233
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Shaw S, Lewis N, Williams S, Tan L. A role for BNP assays in monitoring aortic valve disease for optimal timing of surgery. Int J Cardiol 2008; 127:328-30. [DOI: 10.1016/j.ijcard.2007.12.035] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2007] [Accepted: 12/11/2007] [Indexed: 11/27/2022]
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234
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Marciniak A, Sutherland GR, Marciniak M, Claus P, Bijnens B, Jahangiri M. Myocardial deformation abnormalities in patients with aortic regurgitation: a strain rate imaging study. EUROPEAN JOURNAL OF ECHOCARDIOGRAPHY 2008; 10:112-9. [PMID: 18579501 DOI: 10.1093/ejechocard/jen185] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
AIMS Early left ventricular (LV) dysfunction in asymptomatic patients with severe aortic regurgitation (AR) may go undetected due to the lack of a sufficiently sensitive diagnostic tool. Ultrasonic strain/strain rate (S/SR) imaging should now provide such sensitivity in detecting early dysfunction in regional LV systolic deformation. The aim of this study was to understand and define the changes in LV regional systolic deformation based on S/SR imaging in patients with asymptomatic or minimally symptomatic AR. METHODS AND RESULTS Eighty-one individuals were studied: 59 asymptomatic patients with isolated non-ischaemic AR who were divided into three sub-groups such as mild, moderate, and severe AR and 22 age-matched healthy subjects. All patients underwent standard echocardiographic examinations including a tissue Doppler imaging study. For LV radial deformation, the posterior wall (LVPW) was examined. To assess LV longitudinal deformation, S and SR data were acquired from the LV lateral wall and septum. Radial as well as longitudinal peak systolic SRs were significantly decreased in patients with both moderate AR (LVPW, P=0.0009; septum, P=0.03; LV lateral wall, P=0.0009) and severe AR (P<0.0001) compared with healthy subjects. Changes in regional LV deformation correlated inversely both with LV end-diastolic volume and with end-systolic volume. CONCLUSIONS Strain rate imaging is a sensitive tool in detecting the spectrum of changes in radial and longitudinal deformation in asymptomatic or minimally symptomatic patients with AR. The index where volume was corrected by deformation should form the basis for predicting subclinical LV dysfunction in patients with increasing LV dilatation.
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Affiliation(s)
- Anna Marciniak
- Department of Cardiology and Cardiothoracic Surgery, St. George's Hospital, Blackshaw Road, London SW17 0QT, UK
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235
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Koskenvuo JW, Hartiala JJ, Nuutila P, Kalliokoski R, Viikari JS, Engblom E, Penttinen M, Knuuti J, Mononen I, Kantola IM. Twenty-four-month alpha-galactosidase A replacement therapy in Fabry disease has only minimal effects on symptoms and cardiovascular parameters. J Inherit Metab Dis 2008; 31:432-41. [PMID: 18509742 DOI: 10.1007/s10545-008-0848-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2007] [Revised: 02/21/2008] [Accepted: 02/27/2008] [Indexed: 12/18/2022]
Abstract
Fabry disease is an X-linked lysosomal storage disease caused by deficiency of alpha-galactosidase A enzyme activity. Decreased enzyme activity leads to accumulation of glycosphingolipids in different tissues including endothelial cells and smooth-muscle cells and cardiomyocytes, and cardiovascular complications are common in the disease. Since 2001, specific enzyme replacement therapy (ERT) with alpha-galactosidase A has been available. It has been reported to improve clinical symptoms and quality of life. However, limited and controversial data on its efficacy to cardiac involvement have been published. Nine patients (5 male) with Fabry disease were included in an open-label prospective follow-up study of 24-month ERT. Comprehensive cardiovascular evaluation was performed by MRI, stress echocardiography and quality of life assessment. Plasma globotriaosylceramide decreased from 6.2 to 1.4 microg/ml during ERT (p<0.05). The only other measured parameters that changed significantly were resting heart rate that decreased from 79 to 67 bpm (p<0.01) and end-systolic volume that decreased by 12.4 ml (p<0.05). The other parameters consisting of quality of life, self-estimated cardiovascular condition, diastolic function, exercise capacity, ECG parameters, ejection fraction and ventricular mass did not change. ERT has only minimal effect on symptoms and cardiovascular morphology and function in Fabry disease. Therefore, effective conventional medical therapy is still of major importance in Fabry disease. Larger ERT studies are warranted, especially in women, to solve current open questions, such as the age at which ERT should be started, optimal dosage and intervals between infusions. Furthermore, longer follow-up studies are needed to assess the effects of ERT on prognosis.
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Affiliation(s)
- J W Koskenvuo
- Department of Clinical Physiology and Nuclear Medicine, Turku University Hospital, Kiinamyllynkatu 4-8, FIN-20520, Turku, Finland.
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Sambola A, Tornos P, Ferreira-Gonzalez I, Evangelista A. Prognostic value of preoperative indexed end-systolic left ventricle diameter in the outcome after surgery in patients with chronic aortic regurgitation. Am Heart J 2008; 155:1114-20. [PMID: 18513527 DOI: 10.1016/j.ahj.2007.12.025] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2007] [Accepted: 12/26/2007] [Indexed: 11/26/2022]
Abstract
BACKGROUND End-systolic diameter (ESD) is an important parameter in the prognosis and indication for surgery in chronic aortic regurgitation (AR). It has been suggested that ESD values noncorrected for body surface area (BSA) could be inappropriate in the management of patients with extreme BSA. The aim of the study was to assess the usefulness of indexed ESD (IESD) of the left ventricle in the management of patients with severe isolated chronic AR. METHODS One hundred forty-seven patients underwent surgery for chronic AR and were followed up for a mean of 8 +/- 6 years (1-22 years). A post hoc assessment was made of the prognostic value of preoperative ESD and IESD in different BSA percentiles: group 1, <or= 25th percentile (BSA 1.43-1.68 m(2), n = 40); group 2, >25th percentile and <or=75th percentile (BSA 1.69-1.91 m(2), n = 68); and group 3, >75th percentile (BSA 1.92-2.24 m(2), n = 39). RESULTS Age-adjusted preoperative ESD and IESD were independent predictors of mortality or heart failure in the entire population. Magnitude of the relative risk was slightly greater using preoperative IESD than ESD (HR 1.07, 95% CI 1.01-1.29, P = .017; HR 1.04, 95% CI 1.01-1.08, P = .016). In group 1, the age-adjusted expected mortality rate would drop if IESD of 25 mm/m(2) was used as a surgical criterion instead of ESD 50 mm, from 37.94% to 24.27% at 10 years (P = .002). CONCLUSIONS The use of IESD improves the prediction of unfavorable outcomes after surgery in patients with low BSA but not in those with high BSA. In patients with low BSA, IESD >or=25 mm/m(2) should be used as a cutoff point for surgery rather than ESD >50 mm.
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237
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Abergel E, Bernard Y, Brochet E, Chauvel C, Cohen A, Cormier B, Forissier JF, Gallet B, Habib G, Malergue MC, Tribouilloy C. Organic valve diseases. Arch Cardiovasc Dis 2008. [DOI: 10.1016/s1875-2136(08)73702-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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238
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Aortic regurgitation: disease progression and management. ACTA ACUST UNITED AC 2008; 5:269-79. [DOI: 10.1038/ncpcardio1179] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2007] [Accepted: 01/18/2008] [Indexed: 11/08/2022]
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Mittnacht AJC, Fanshawe M, Konstadt S. Anesthetic Considerations in the Patient With Valvular Heart Disease Undergoing Noncardiac Surgery. Semin Cardiothorac Vasc Anesth 2008; 12:33-59. [DOI: 10.1177/1089253208316442] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Valvular heart disease can be an important finding in patients presenting for noncardiac surgery. Valvular heart disease and resulting comorbidity, such as heart failure or atrial fibrillation, significantly increase the risk for perioperative adverse events. Appropriate preoperative assessment, adequate perioperative monitoring, and early intervention, should hemodynamic disturbances occur, may help prevent adverse events and improve patient outcome. This review article aims to guide the practitioner in the various aspects of anesthetic management in the perioperative care of patients with valvular heart disease. The pharmacological approach to optimization of patient outcome with drugs, such as βblockers and lipid-lowering medications (statins), is an evolving field, and recent developments are discussed in this article.
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Affiliation(s)
| | | | - Steven Konstadt
- Department of Anesthesiology, Maimonides Medical Center, Brooklyn New York
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240
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Obase K, Watanabe N, Yamaura Y, Tsukiji M, Neishi Y, Kawamoto T, Toyota E, Okura H, Yoshida K. Dynamic Change in the Mitral Valve Tenting as a Predictor of the Long-Term Prognosis in Patients With Decompensated Heart Failure. J Echocardiogr 2008. [DOI: 10.2303/jecho.6.15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Bunch TJ, Connolly HM, Asirvatham SJ, Brady PA, Gersh BJ, Munger TM, Shen WK, Monahan KH, Packer DL. Catheter ablation for atrial fibrillation in patients with the Marfan and Marfan-like syndromes. J Interv Card Electrophysiol 2007; 20:15-20. [PMID: 17952580 DOI: 10.1007/s10840-007-9162-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2007] [Accepted: 09/11/2007] [Indexed: 10/22/2022]
Abstract
Patients with the Marfan syndrome may pose a difficult challenge for catheter-based interventions due to frequent coexisting valve disease, potential delay in vascular healing and repair, and intra-atrial scar from prior cardiac surgery. We report a case series of four patients with Marfan or Marfan-like syndromes who underwent ablation for drug-refractory atrial fibrillation. Ultimately three of four patients remained in sinus rhythm, however most patients required multiple ablative attempts and long-term atrial flutter was common. Nonetheless, peri-procedural complications were minimal despite the connective tissue disorder and prosthetic valves in three of four patients. In conclusion, catheter ablation of AF in patients with Marfan syndrome is a viable option in those individuals refractory to conventional therapy.
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Affiliation(s)
- T Jared Bunch
- Department of Internal Medicine, Mayo Clinic, Rochester, MN 55902, USA.
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243
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Mehrotra R, Mittal S, Kasliwal R. Aortic Regurgitation: Current Perspective. APOLLO MEDICINE 2007. [DOI: 10.1016/s0976-0016(11)60449-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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244
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Bredin F, Olsson A, Franco-Cereceda A. No Additive Effect of Passive Containment Surgery in Patients With Aortic Regurgitation and Left Ventricular Dilation. Ann Thorac Surg 2007; 84:510-3. [PMID: 17643625 DOI: 10.1016/j.athoracsur.2007.04.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2007] [Revised: 03/30/2007] [Accepted: 04/02/2007] [Indexed: 11/19/2022]
Abstract
BACKGROUND After valve replacement in patients with aortic regurgitation short-term and long-term improvement of left ventricular function are related to early reduction of left ventricular dilatation. This case-control study was conducted to investigate the potential beneficial effects by concomitant application of the Acorn Cor Cap Cardiac Support Device (Acorn Cardiovascular Inc, St. Paul, MN) on reduction of ventricular dilatation in patients with aortic regurgitation and advanced ventricular dilatation undergoing aortic valve replacement. METHODS Of ten patients with longstanding aortic regurgitation and ventricular dilatation subjected to aortic valve replacement using mechanical valve prostheses, five were in addition subjected to application of the Cardiac Support Device (Acorn). Cardiac function and dimensions were measured by echocardiography preoperatively and 3 and 12 months postoperatively. RESULTS After aortic valve replacement, there was a rapid and sustained decrease in end-diastolic and end-systolic diameters (before operation 72 +/- 4 and 54 +/- 8 mm, to 54 +/- 10 and 40 + 11 mm at 3 months; and 53 +/- 9 and 35 +/- 6 mm, 12 months after operation). This did not differ after Cardiac Support Device (Acorn) application (before operation 74 +/- 1 and 56 +/- 5 mm; 52 +/- 8 and 39 +/- 9 mm, 3 months after operation; and 54 +/- 6 and 39 +/- 8 mm, at 12 months). The left ventricular ejection fraction remained unchanged in both groups. CONCLUSIONS Application of the Acorn Cor Cap Cardiac Support Device in patients with aortic regurgitation and severe ventricular dilatation does not influence reverse remodeling or cardiac function compared with aortic valve replacement alone.
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Affiliation(s)
- Fredrik Bredin
- Section of Cardiothoracic Surgery and Anaesthesiology, Institution of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
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245
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Rahmouni H, St John Sutton M. Expectations of surgeons from an imager. Heart Fail Clin 2007; 3:121-37. [PMID: 17643918 DOI: 10.1016/j.hfc.2007.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
In the last decade, we have witnessed an extraordinary development of new cardiac imaging techniques. Some are already in routine use while other promising techniques, such as 3D and intracardiac echocardiography, are still taking their first steps in clinical applications and have not yet revealed all their potential. Heart failure surgery is also evolving rapidly toward less-invasive procedures with the introduction of video-assisted robotic valve repair/replacement surgery, percutaneous delivery of epicardial restraint devices, mitral edge-to-edge clips, coronary sinus mitral annuloplasty rings, and stem cell therapy. These rapid developments are challenging for the imager and the surgeon and mandate a close collaboration between the two disciplines to minimize surgical risk and improve the outcome of patients who have heart failure.
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MESH Headings
- Diagnostic Techniques, Cardiovascular
- Echocardiography/methods
- Heart Failure/diagnosis
- Heart Failure/etiology
- Heart Failure/surgery
- Heart Septal Defects, Ventricular/complications
- Heart Septal Defects, Ventricular/diagnosis
- Heart Septal Defects, Ventricular/surgery
- Heart Valve Diseases/complications
- Heart Valve Diseases/diagnosis
- Heart Valve Diseases/surgery
- Humans
- Hypertension, Pulmonary/complications
- Hypertension, Pulmonary/diagnosis
- Magnetic Resonance Imaging/methods
- Perioperative Care/methods
- Preoperative Care/methods
- Shock, Cardiogenic/complications
- Shock, Cardiogenic/diagnosis
- Shock, Cardiogenic/therapy
- Thoracic Surgery/methods
- Thrombosis/complications
- Thrombosis/diagnosis
- Ventricular Dysfunction, Left/complications
- Ventricular Dysfunction, Left/diagnosis
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Affiliation(s)
- Hind Rahmouni
- University of Pennsylvania Medical Center, Philadelphia, PA 19104, USA
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Ley S, Eichhorn J, Ley-Zaporozhan J, Ulmer H, Schenk JP, Kauczor HU, Arnold R. Evaluation of aortic regurgitation in congenital heart disease: value of MR imaging in comparison to echocardiography. Pediatr Radiol 2007; 37:426-36. [PMID: 17387466 DOI: 10.1007/s00247-007-0414-4] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2006] [Revised: 12/15/2006] [Accepted: 01/01/2007] [Indexed: 01/20/2023]
Abstract
BACKGROUND Evaluation of the severity and the follow-up of aortic insufficiency (AI) are important tasks in paediatric cardiology. Assessment is based on clinical and echocardiographic (ECHO) findings such as the configuration of the valve and the regurgitation fraction (RF). OBJECTIVE The goal of this study was to evaluate MRI compared to ECHO for determination of clinical severity, valve morphology and RF. MATERIALS AND METHODS Thirty patients (age 3-27 years) with mild-to-severe AI were evaluated by clinical examination, ECHO (2-D and Doppler), and MRI at 1.5 T (2-D true-FISP cine short axis, phase-contrast flow in the ascending aorta). RESULTS Both methods identified 13 bicuspid and 17 tricuspid valves. Good correlations between ECHO and cine MRI were found for ventricular mass, stroke volume, and ejection fraction. A good linear correlation was found for the RF determined by ECHO and phase-contrast MRI (r = 0.7). The RF was 6% in mild AI, 17% in moderate AI, and 30% in severe AI. The different severity groups showed significantly different RF and it was possible to discriminate between clinical severity grades (P = 0.01). CONCLUSION ECHO and MRI showed good agreement in evaluating morphology and function of the left ventricle. The clinical severity of the disease can be evaluated correctly using MRI.
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Affiliation(s)
- Sebastian Ley
- Department of Radiology (E010), German Cancer Research Centre (DKFZ), Im Neuenheimer Feld 280, Heidelberg, Germany.
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Grayburn PA. Improved surgical outcome for chronic severe aortic regurgitation with severely depressed left ventricular systolic function. J Am Coll Cardiol 2007; 49:1472-3. [PMID: 17397677 DOI: 10.1016/j.jacc.2007.01.033] [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: 11/28/2022]
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249
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Iung B, Messika-Zeitoun D, Cachier A, Delahaye F, Baron G, Tornos P, Gohlke-Bärwolf C, Boersma E, Ravaud P, Vahanian A. Actual management of patients with asymptomatic aortic valve disease: how practice fits with guidelines. Am Heart J 2007; 153:696-703. [PMID: 17383314 DOI: 10.1016/j.ahj.2005.12.031] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2005] [Accepted: 12/24/2005] [Indexed: 10/23/2022]
Abstract
BACKGROUND Intervention is advised in selected asymptomatic patients with aortic valve disease. However, little is known regarding their actual management. METHODS The Euro Heart Survey was designed to evaluate practices. Severe isolated aortic stenosis (AS) was defined by a valve area < or = 0.6 cm2/m2 body surface area or mean gradient > or = 50 mm Hg. Severe aortic regurgitation (AR) was defined by a grade > or = 3/4. Patients were classified as asymptomatic when they were in New York Heart Association class I and were without angina. Decision to operate was analyzed by comparing patient characteristics with the American College of Cardiology/American Heart Association recommendations. RESULTS Of the 5001 patients, 136 had severe, isolated, and asymptomatic aortic valve disease (84 with AS and 52 with AR). Stress testing was performed in only 6 patients (4%). A decision to operate was taken in 45 patients (54%) with AS and 21 (40%) with AR. Indications for surgery were in accordance with the American College of Cardiology/American Heart Association guidelines in 57 patients (68%) with AS and in 41 (83%) with AR. However, the decision to operate was frequently based on class IIb recommendations in patients with AS. Intervention was "overused" in 18 patients with AS (21%) and in 5 (9%) with AR. Intervention was "underused" in 9 patients (11%) with AS and in 4 (8%) with AR. CONCLUSIONS In asymptomatic patients with severe aortic valve disease, a decision to operate is frequently taken; and it is most often in agreement with guidelines, although often based on low-level recommendations.
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Affiliation(s)
- Bernard Iung
- Cardiology Department, Bichat Hospital, AP-HP, Paris, France.
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Bhudia SK, McCarthy PM, Kumpati GS, Helou J, Hoercher KJ, Rajeswaran J, Blackstone EH. Improved Outcomes After Aortic Valve Surgery for Chronic Aortic Regurgitation With Severe Left Ventricular Dysfunction. J Am Coll Cardiol 2007; 49:1465-71. [PMID: 17397676 DOI: 10.1016/j.jacc.2007.01.026] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2006] [Revised: 10/25/2006] [Accepted: 11/01/2006] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Among patients undergoing aortic valve surgery for chronic aortic regurgitation (AR), we sought to: 1) compare survival among those with and without severe left ventricular dysfunction (LVD); 2) identify risk factors for death, including LVD and date of operation; and 3) estimate contemporary risk for cardiomyopathic patients. BACKGROUND Patients with chronic AR and severe LVD have been considered high risk for aortic valve surgery, with limited prognosis. Transplantation is considered for some. METHODS From 1972 to 1999, 724 patients underwent surgery for chronic AR; 88 (12%) had severe LVD. They were propensity matched to patients with nonsevere LVD to compare hospital mortality, interaction of operative date with severity of LVD, and late survival. Propensity score-adjusted multivariable analysis was performed for all 724 patients to identify risk factors for death. RESULTS Survival was lower (p = 0.04) among patients with severe LVD than among matched patients with nonsevere LVD (30-day, 1-, 5-, and 25-year survival estimates were 91% vs. 96%, 81% vs. 92%, 68% vs. 81%, and 5% vs. 12%, respectively). However, survival of patients with severe LVD improved dramatically across the study time frame (p = 0.0004): hospital mortality decreased from 50% in 1975 to 0% after 1985, and time-related survival in patients with severe LVD operated on since 1985 became equivalent to that of matched patients with nonsevere LVD (p = 0.96). CONCLUSIONS Neutralizing risk of severe LVD has improved early and late survival such that aortic valve surgery for chronic AR and cardiomyopathy is no longer a high-risk procedure for which transplantation is the best option.
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Affiliation(s)
- Sunil K Bhudia
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio, USA
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