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Çelikbudak Orhon C, Stergiopulos N, Noble S, Giannakopoulos G, Müller H, Adamopoulos D. The Impact of Left Ventricular Performance and Afterload on the Evaluation of Aortic Valve Stenosis: A 1D Mathematical Modeling Approach. Bioengineering (Basel) 2023; 10:bioengineering10040425. [PMID: 37106613 PMCID: PMC10136235 DOI: 10.3390/bioengineering10040425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 03/22/2023] [Accepted: 03/24/2023] [Indexed: 03/30/2023] Open
Abstract
The transaortic valvular pressure gradient (TPG) plays a central role in decision-making for patients suffering from severe aortic stenosis. However, the flow-dependence nature of the TPG makes the diagnosis of aortic stenosis challenging since the markers of cardiac performance and afterload present high physiological interdependence and thus, isolated effects cannot be measured directly in vivo. We used a validated 1D mathematical model of the cardiovascular system, coupled with a model of aortic stenosis, to assess and quantify the independent effect of the main left ventricular performance parameters (end-systolic (Ees) and end-diastolic (Eed) elastance) and principal afterload indices (total vascular resistance (TVR) and total arterial compliance (TAC)) on the TPG for different levels of aortic stenosis. In patients with critical aortic stenosis (aortic valve area (AVA) ≤ 0.6 cm2), a 10% increase of Eed from the baseline value was associated with the most important effect on the TPG (−5.6 ± 0.5 mmHg, p < 0.001), followed by a similar increase of Ees (3.4 ± 0.1 mmHg, p < 0.001), in TAC (1.3 ±0.2 mmHg, p < 0.001) and TVR (−0.7 ± 0.04 mmHg, p < 0.001). The interdependence of the TPG left ventricular performance and afterload indices become stronger with increased aortic stenosis severity. Disregarding their effects may lead to an underestimation of stenosis severity and a potential delay in therapeutic intervention. Therefore, a comprehensive evaluation of left ventricular function and afterload should be performed, especially in cases of diagnostic challenge, since it may offer the pathophysiological mechanism that explains the mismatch between aortic severity and the TPG.
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Rosalia L, Ozturk C, Goswami D, Bonnemain J, Wang SX, Bonner B, Weaver JC, Puri R, Kapadia S, Nguyen CT, Roche ET. Soft robotic patient-specific hydrodynamic model of aortic stenosis and ventricular remodeling. Sci Robot 2023; 8:eade2184. [PMID: 36812335 PMCID: PMC10280738 DOI: 10.1126/scirobotics.ade2184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 01/30/2023] [Indexed: 02/24/2023]
Abstract
Aortic stenosis (AS) affects about 1.5 million people in the United States and is associated with a 5-year survival rate of 20% if untreated. In these patients, aortic valve replacement is performed to restore adequate hemodynamics and alleviate symptoms. The development of next-generation prosthetic aortic valves seeks to provide enhanced hemodynamic performance, durability, and long-term safety, emphasizing the need for high-fidelity testing platforms for these devices. We propose a soft robotic model that recapitulates patient-specific hemodynamics of AS and secondary ventricular remodeling which we validated against clinical data. The model leverages 3D-printed replicas of each patient's cardiac anatomy and patient-specific soft robotic sleeves to recreate the patients' hemodynamics. An aortic sleeve allows mimicry of AS lesions due to degenerative or congenital disease, whereas a left ventricular sleeve recapitulates loss of ventricular compliance and diastolic dysfunction (DD) associated with AS. Through a combination of echocardiographic and catheterization techniques, this system is shown to recreate clinical metrics of AS with greater controllability compared with methods based on image-guided aortic root reconstruction and parameters of cardiac function that rigid systems fail to mimic physiologically. Last, we leverage this model to evaluate the hemodynamic benefit of transcatheter aortic valves in a subset of patients with diverse anatomies, etiologies, and disease states. Through the development of a high-fidelity model of AS and DD, this work demonstrates the use of soft robotics to recreate cardiovascular disease, with potential applications in device development, procedural planning, and outcome prediction in industrial and clinical settings.
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Affiliation(s)
- Luca Rosalia
- Health Sciences and Technology Program, Harvard–Massachusetts Institute of Technology, Cambridge, MA, USA
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
- Cardiovascular Research Center, Massachusetts General Hospital, Charlestown, MA, USA
- A.A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA
| | - Caglar Ozturk
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Debkalpa Goswami
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
- Department of Health Sciences and Technology, ETH-Zürich, Zürich, Switzerland
- Institute of Robotics and Intelligent Systems, ETH-Zürich, Zürich, Switzerland
| | - Jean Bonnemain
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
- Department of Adult Intensive Care Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Sophie X. Wang
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Benjamin Bonner
- Cardiovascular Research Center, Massachusetts General Hospital, Charlestown, MA, USA
- A.A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA
| | - James C. Weaver
- Wyss Institute for Biologically Inspired Engineering, Harvard University, Boston, MA, USA
| | - Rishi Puri
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Samir Kapadia
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Christopher T. Nguyen
- Cardiovascular Research Center, Massachusetts General Hospital, Charlestown, MA, USA
- A.A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
- Cardiovascular Innovation Research Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ellen T. Roche
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
- Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, MA, USA
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Albu A, Para I, Bidian C. Arterial stiffness in aortic stenosis - complex clinical and prognostic implications. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2022; 166:369-379. [PMID: 36128849 DOI: 10.5507/bp.2022.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 08/31/2022] [Indexed: 12/15/2022] Open
Abstract
Arterial stiffness and degenerative aortic stenosis (AoS) are frequently associated leading to a combined valvular and vascular load imposed on the left ventricle (LV). Vascular load consists of a pulsatile load represented by arterial stiffness and a steady load corresponding to vascular resistance. Increased vascular load in AoS has been associated with LV dysfunction and poor prognosis in pre-intervention state, as well as after aortic valve replacement (AVR), suggesting that the evaluation of arterial load in AoS may have clinical benefits. Nevertheless, studies that investigated arterial stiffness in AoS either before or after AVR used various methods of measurement and their results are conflicting. The aim of the present review was to summarize the main pathophysiological mechanisms which may explain the complex valvulo-arterial interplay in AoS and their consequences on LV structure and function on the patients' outcome. Future larger studies are needed to clarify the complex hemodynamic modifications produced by increased vascular load in AoS and its changes after AVR. Prospective evaluation is needed to confirm the prognostic value of arterial stiffness in patients with AoS. Simple, non-invasive, reliable methods which must be validated in AoS still remain to be established before implementing arterial stiffness measurement in patients with AoS in clinical practice.
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Affiliation(s)
- Adriana Albu
- 2nd Department of Internal Medicine, "Iuliu Hatieganu" University of Medicine and Pharmacy, 8 Babes Street, Cluj-Napoca, 400012, Romania
| | - Ioana Para
- 4th Department of Internal Medicine, "Iuliu Hatieganu" University of Medicine and Pharmacy, 8 Babes Street, Cluj-Napoca, 400012, Romania
| | - Cristina Bidian
- Department of Physiology, "Iuliu Hatieganu" University of Medicine and Pharmacy, 8 Babes Street, Cluj-Napoca, 400012, Romania
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Długosz D, Surdacki A, Zawiślak B, Bartuś S, Chyrchel B. Impaired Left Ventricular Circumferential Midwall Systolic Performance Appears Linked to Depressed Preload, but Not Intrinsic Contractile Dysfunction or Excessive Afterload, in Paradoxical Low-Flow/Low-Gradient Severe Aortic Stenosis. J Clin Med 2022; 11:2873. [PMID: 35628998 PMCID: PMC9144151 DOI: 10.3390/jcm11102873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 04/30/2022] [Accepted: 05/09/2022] [Indexed: 11/16/2022] Open
Abstract
Paradoxical low-flow/low-gradient aortic stenosis (P-LFLG-AS) occurs in about one-third of patients with severe AS and preserved left ventricular (LV) ejection fraction (EF). Our aim was to differentiate between altered LV loading conditions and contractility as determinants of subtle LV systolic dysfunction in P-LFLG-AS. We retrospectively analyzed medical records of patients with isolated severe degenerative AS and preserved EF (30 subjects with P-LFLG-AS and 30 patients with normal-flow/high-gradient severe AS (NFHG-AS)), without relevant coexistent diseases (e.g., diabetes, coronary artery disease and chronic kidney disease) or any abnormalities which could account for a low-flow state. Patients with P-LFLG-AS and NFHG-AS did not differ in aortic valve area index and most clinical characteristics. Compared to NFHG-AS, subjects with P-LFLG-AS exhibited smaller LV end-diastolic diameter (LVd) (44 ± 5 vs. 54 ± 5 mm, p < 0.001) (consistent with lower LV preload) with pronounced concentric remodeling, higher valvulo-arterial impedance (3.8 ± 1.1 vs. 2.2 ± 0.5 mmHg per mL/m2, p < 0.001) and diminished systemic arterial compliance (0.45 ± 0.11 vs. 0.76 ± 0.23 mL/m2 per mmHg, p < 0.001), while circumferential end-systolic LV midwall stress (cESS), an estimate of afterload at the LV level, was similar in P-LFLG-AS and NFHG-AS (175 ± 83 vs. 198 ± 69 hPa, p = 0.3). LV midwall fractional shortening (mwFS) was depressed in P-LFLG-AS vs. NFHG-AS (12.3 ± 3.5 vs. 14.7 ± 2.9%, p = 0.006) despite similar EF (61 ± 6 vs. 59 ± 8%, p = 0.4). By multiple regression, the presence of P-LFLG-AS remained a significant predictor of lower mwFS compared to NFHG-AS upon adjustment for cESS (β ± SEM: −2.35 ± 0.67, p < 0.001); however, the significance was lost after further correction for LVd (β = −1.10 ± 0.85, p = 0.21). In conclusion, the association of P-LFLG-AS with a lower cESS-adjusted mwFS, an index of afterload-corrected LV circumferential systolic function at the midwall level, appears secondary to a smaller LV end-diastolic cavity size according to the Frank−Starling law. Thus, low LV preload, not intrinsic contractile dysfunction or excessive afterload, may account for impaired LV circumferential midwall systolic performance in P-LFLG-AS.
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Affiliation(s)
- Dorota Długosz
- Department of Cardiology and Cardiovascular Interventions, University Hospital, 2 Jakubowskiego Street, 30-688 Cracow, Poland; (D.D.); (A.S.); (S.B.)
| | - Andrzej Surdacki
- Department of Cardiology and Cardiovascular Interventions, University Hospital, 2 Jakubowskiego Street, 30-688 Cracow, Poland; (D.D.); (A.S.); (S.B.)
- Second Department of Cardiology, Institute of Cardiology, Jagiellonian University, 2 Jakubowskiego Street, 30-688 Cracow, Poland
| | - Barbara Zawiślak
- Intensive Care Unit, Department of Cardiology and Cardiovascular Interventions, University Hospital, 2 Jakubowskiego Street, 30-688 Cracow, Poland;
| | - Stanisław Bartuś
- Department of Cardiology and Cardiovascular Interventions, University Hospital, 2 Jakubowskiego Street, 30-688 Cracow, Poland; (D.D.); (A.S.); (S.B.)
- Second Department of Cardiology, Institute of Cardiology, Jagiellonian University, 2 Jakubowskiego Street, 30-688 Cracow, Poland
| | - Bernadeta Chyrchel
- Department of Cardiology and Cardiovascular Interventions, University Hospital, 2 Jakubowskiego Street, 30-688 Cracow, Poland; (D.D.); (A.S.); (S.B.)
- Second Department of Cardiology, Institute of Cardiology, Jagiellonian University, 2 Jakubowskiego Street, 30-688 Cracow, Poland
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Sharifi H, Mann CK, Rockward AL, Mehri M, Mojumder J, Lee LC, Campbell KS, Wenk JF. Multiscale simulations of left ventricular growth and remodeling. Biophys Rev 2021; 13:729-746. [PMID: 34777616 PMCID: PMC8555068 DOI: 10.1007/s12551-021-00826-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 08/05/2021] [Indexed: 02/07/2023] Open
Abstract
Cardiomyocytes can adapt their size, shape, and orientation in response to altered biomechanical or biochemical stimuli. The process by which the heart undergoes structural changes-affecting both geometry and material properties-in response to altered ventricular loading, altered hormonal levels, or mutant sarcomeric proteins is broadly known as cardiac growth and remodeling (G&R). Although it is likely that cardiac G&R initially occurs as an adaptive response of the heart to the underlying stimuli, prolonged pathological changes can lead to increased risk of atrial fibrillation, heart failure, and sudden death. During the past few decades, computational models have been extensively used to investigate the mechanisms of cardiac G&R, as a complement to experimental measurements. These models have provided an opportunity to quantitatively study the relationships between the underlying stimuli (primarily mechanical) and the adverse outcomes of cardiac G&R, i.e., alterations in ventricular size and function. State-of-the-art computational models have shown promise in predicting the progression of cardiac G&R. However, there are still limitations that need to be addressed in future works to advance the field. In this review, we first outline the current state of computational models of cardiac growth and myofiber remodeling. Then, we discuss the potential limitations of current models of cardiac G&R that need to be addressed before they can be utilized in clinical care. Finally, we briefly discuss the next feasible steps and future directions that could advance the field of cardiac G&R.
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Affiliation(s)
- Hossein Sharifi
- Department of Mechanical Engineering, University of Kentucky, 269 Ralph G. Anderson Building, Lexington, KY 40506-0503 USA
| | - Charles K. Mann
- Department of Mechanical Engineering, University of Kentucky, 269 Ralph G. Anderson Building, Lexington, KY 40506-0503 USA
| | - Alexus L. Rockward
- Department of Mechanical Engineering, University of Kentucky, 269 Ralph G. Anderson Building, Lexington, KY 40506-0503 USA
| | - Mohammad Mehri
- Department of Mechanical Engineering, University of Kentucky, 269 Ralph G. Anderson Building, Lexington, KY 40506-0503 USA
| | - Joy Mojumder
- Department of Mechanical Engineering, Michigan State University, East Lansing, MI USA
| | - Lik-Chuan Lee
- Department of Mechanical Engineering, Michigan State University, East Lansing, MI USA
| | - Kenneth S. Campbell
- Department of Physiology & Division of Cardiovascular Medicine, University of Kentucky, Lexington, KY USA
| | - Jonathan F. Wenk
- Department of Mechanical Engineering, University of Kentucky, 269 Ralph G. Anderson Building, Lexington, KY 40506-0503 USA
- Department of Surgery, University of Kentucky, Lexington, KY USA
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Lakatos BK, Ruppert M, Tokodi M, Oláh A, Braun S, Karime C, Ladányi Z, Sayour AA, Barta BA, Merkely B, Radovits T, Kovács A. Myocardial work index: a marker of left ventricular contractility in pressure- or volume overload-induced heart failure. ESC Heart Fail 2021; 8:2220-2231. [PMID: 33754487 PMCID: PMC8120402 DOI: 10.1002/ehf2.13314] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 02/15/2021] [Accepted: 03/02/2021] [Indexed: 12/11/2022] Open
Abstract
Aims While global longitudinal strain (GLS) is considered to be a sensitive marker of left ventricular (LV) function, it is significantly influenced by loading conditions. We hypothesized that global myocardial work index (GMWI), a novel marker of LV function, may show better correlation with load‐independent markers of LV contractility in rat models of pressure‐induced or volume overload‐induced heart failure. Methods and results Male Wistar rats underwent either transverse aortic constriction (TAC; n = 12) or aortocaval fistula creation (ACF; n = 12), inducing LV pressure or volume overload, respectively. Sham procedures were performed to establish control groups (n = 12/12). Echocardiographic loops were obtained to determine GLS and GMWI. Pressure‐volume analysis with transient occlusion of the inferior caval vein was carried out to calculate preload recruitable stroke work (PRSW), a load‐independent ‘gold‐standard’ parameter of LV contractility. Myocardial samples were collected to assess interstitial and perivascular fibrosis area and also myocardial atrial‐type natriuretic peptide (ANP) and brain‐type natriuretic peptide (BNP) relative mRNA expression. Compared with controls, GLS was substantially lower in the TAC group (−7.0 ± 2.8 vs. −14.5 ± 2.5%; P < 0.001) and was only mildly reduced in the ACF group (−13.2 ± 2.4 vs. −15.4 ± 2.0%, P < 0.05). In contrast with these findings, PRSW and GMWI were comparable with sham in TAC (110 ± 26 vs. 116 ± 68 mmHg; 1687 ± 275 mmHg% vs. 1537 ± 662 mmHg%; both P = NS), while it was found to be significantly reduced in ACF (58 ± 14 vs. 111 ± 40 mmHg; 1328 ± 411 vs. 1934 ± 308 mmHg%, both P < 0.01). In the pooled population, GMWI (r = 0.70; P < 0.001) but not GLS (r = −0.23; P = 0.12) showed a strong correlation with PRSW. GLS correlated with interstitial (r = 0.61; P < 0.001) and perivascular fibrosis area (r = 0.54; P < 0.001), and also with myocardial ANP (r = 0.85; P < 0.001) and BNP relative mRNA expression (r = 0.75; P < 0.001), while GMWI demonstrated no or only marginal correlation with these parameters. Conclusions Being significantly influenced by loading conditions, GLS may not be a reliable marker of LV contractility in heart failure induced by pressure or volume overload. GMWI better reflects contractility in haemodynamic overload states, making it a more robust marker of systolic function, while GLS should be considered as an integrative marker, incorporating systolic function, haemodynamic loading state, and adverse tissue remodelling of the LV.
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Affiliation(s)
- Bálint Károly Lakatos
- Heart and Vascular Center, Semmelweis University, Városmajor St. 68, Budapest, H-1122, Hungary
| | - Mihály Ruppert
- Heart and Vascular Center, Semmelweis University, Városmajor St. 68, Budapest, H-1122, Hungary
| | - Márton Tokodi
- Heart and Vascular Center, Semmelweis University, Városmajor St. 68, Budapest, H-1122, Hungary
| | - Attila Oláh
- Heart and Vascular Center, Semmelweis University, Városmajor St. 68, Budapest, H-1122, Hungary
| | - Szilveszter Braun
- Heart and Vascular Center, Semmelweis University, Városmajor St. 68, Budapest, H-1122, Hungary
| | - Christian Karime
- Heart and Vascular Center, Semmelweis University, Városmajor St. 68, Budapest, H-1122, Hungary
| | - Zsuzsanna Ladányi
- Heart and Vascular Center, Semmelweis University, Városmajor St. 68, Budapest, H-1122, Hungary
| | - Alex Ali Sayour
- Heart and Vascular Center, Semmelweis University, Városmajor St. 68, Budapest, H-1122, Hungary
| | - Bálint András Barta
- Heart and Vascular Center, Semmelweis University, Városmajor St. 68, Budapest, H-1122, Hungary
| | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, Városmajor St. 68, Budapest, H-1122, Hungary
| | - Tamás Radovits
- Heart and Vascular Center, Semmelweis University, Városmajor St. 68, Budapest, H-1122, Hungary
| | - Attila Kovács
- Heart and Vascular Center, Semmelweis University, Városmajor St. 68, Budapest, H-1122, Hungary
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Ruppert M, Lakatos BK, Braun S, Tokodi M, Karime C, Oláh A, Sayour AA, Hizoh I, Barta BA, Merkely B, Kovács A, Radovits T. Longitudinal Strain Reflects Ventriculoarterial Coupling Rather Than Mere Contractility in Rat Models of Hemodynamic Overload–Induced Heart Failure. J Am Soc Echocardiogr 2020; 33:1264-1275.e4. [DOI: 10.1016/j.echo.2020.05.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 05/13/2020] [Accepted: 05/14/2020] [Indexed: 02/07/2023]
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Fischer-Rasokat U, Renker M, Liebetrau C, Weferling M, Rolf A, Doss M, Möllmann H, Walther T, Hamm CW, Kim WK. Outcome of patients with heart failure after transcatheter aortic valve implantation. PLoS One 2019; 14:e0225473. [PMID: 31770401 PMCID: PMC6879149 DOI: 10.1371/journal.pone.0225473] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 11/04/2019] [Indexed: 12/12/2022] Open
Abstract
AIMS Patients with aortic stenosis (AS) may have concomitant heart failure (HF) that determines prognosis despite successful transcatheter aortic valve implantation (TAVI). We compared outcomes of TAVI patients with low stroke volume index (SVI) ≤35 ml/m2 body surface area in different HF classes. METHODS AND RESULTS Patients treated by transfemoral TAVI at our center (n = 1822) were classified as 1) 'HF with preserved ejection fraction (EF)' (HFpEF, EF ≥50%), 2) 'HF with mid-range EF' (HFmrEF, EF 40-49%), or 3) 'HF with reduced EF' (HFrEF, EF <40%). Patients with SVI >35 ml/m2 served as controls. The prevalence of cardiovascular disease and symptoms increased stepwise from controls (n = 968) to patients with HFpEF (n = 591), HFmrEF (n = 97), and HFrEF (n = 166). Mortality tended to be highest in HFrEF patients 30 days post-procedure, and it became significant after one year: 10.2% (controls), 13.5% (HFpEF), 13.4% (HFmrEF), and 23.5% (HFrEF). However, symptomatic improvement in survivors of all groups was achieved in the majority of patients without differences among groups. CONCLUSIONS Patients with AS and HF benefit from TAVI with respect to symptom alleviation. TAVI in patients with HFpEF and HFmrEF led to an identical, favorable post-procedural prognosis that was significantly better than that of patients with HFrEF, which remains a high-risk population.
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Affiliation(s)
- Ulrich Fischer-Rasokat
- Department of Cardiology, Kerckhoff Heart Center, Bad Nauheim, Germany
- Department of Cardiology and Angiology, Medical Clinic I, University Hospital of Giessen, Giessen, Germany
- * E-mail:
| | - Matthias Renker
- Department of Cardiology, Kerckhoff Heart Center, Bad Nauheim, Germany
- Department of Cardiac Surgery, Kerckhoff Heart Center, Bad Nauheim, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site RheinMain, Bad Nauheim, Germany
| | - Christoph Liebetrau
- Department of Cardiology, Kerckhoff Heart Center, Bad Nauheim, Germany
- Department of Cardiology and Angiology, Medical Clinic I, University Hospital of Giessen, Giessen, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site RheinMain, Bad Nauheim, Germany
| | - Maren Weferling
- Department of Cardiology, Kerckhoff Heart Center, Bad Nauheim, Germany
| | - Andreas Rolf
- Department of Cardiology, Kerckhoff Heart Center, Bad Nauheim, Germany
- Department of Cardiology and Angiology, Medical Clinic I, University Hospital of Giessen, Giessen, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site RheinMain, Bad Nauheim, Germany
| | - Mirko Doss
- Department of Cardiac Surgery, Kerckhoff Heart Center, Bad Nauheim, Germany
| | - Helge Möllmann
- Department of Cardiology, Medical Clinic I, St. Johannes Hospital, Dortmund, Germany
| | - Thomas Walther
- Department of Cardiac Surgery, Kerckhoff Heart Center, Bad Nauheim, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site RheinMain, Bad Nauheim, Germany
- Department of Cardiac, Thoracic and Thoracic Vascular Surgery, University Hospital of the Goethe University, Frankfurt/Main, Germany
| | - Christian W. Hamm
- Department of Cardiology, Kerckhoff Heart Center, Bad Nauheim, Germany
- Department of Cardiology and Angiology, Medical Clinic I, University Hospital of Giessen, Giessen, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site RheinMain, Bad Nauheim, Germany
| | - Won-Keun Kim
- Department of Cardiology, Kerckhoff Heart Center, Bad Nauheim, Germany
- Department of Cardiology and Angiology, Medical Clinic I, University Hospital of Giessen, Giessen, Germany
- Department of Cardiac Surgery, Kerckhoff Heart Center, Bad Nauheim, Germany
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Marino PN, Binda G, Calzaducca E, Panizza A, Ferrari I, Bellacosa I, Ambrosio G. Transcatheter aortic valve replacement acutely improves left ventricular mechanical efficiency in severe aortic stenosis: effects of different phenotypes. Clin Res Cardiol 2019; 109:819-831. [PMID: 31748862 DOI: 10.1007/s00392-019-01570-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 11/06/2019] [Indexed: 12/13/2022]
Abstract
AIM Aortic stenosis is a frequent valvular disease, with transcatheter aortic valve implantation (TAVI) being performed when surgical replacement is at increased risk. However, TAVI-induced effects on myocardial efficiency are unknown. We aimed to investigate changes in LV mechano-energetic pre-/post-TAVI and their prognostic impact. METHODS A total of 46 patients (25 males) received transesophageal and simultaneous radial pressure plus transaortic gradient monitoring before/immediately after prosthesis deployment. Efficiency was computed as external work/potential energy, as derived from LV pressure-volume plots; myocardial oxygen consumption (MVO2) was estimated as PWImod, i.e. a noninvasively validated alternative for MVO2 estimation. RESULTS TAVI was successful in all patients, peak transaortic gradient decreasing - 40 ± 20 mmHg (p < 0.001). Efficiency improved post-TAVI (+ 0.6 ± 0.12; p = 0.004), with a concomitant PWImod reduction (- 16 ± 31%; p < 0.001). When contextualized to fixed PWImod value (5 ml/min/100 g), efficiency significantly affected survival (p = 0.029). Over 1026 ± 450-day follow-up, a change in efficiency pre-/post-TAVI ≤ 0.021 (median of the difference) predicted more deaths from any cause (30%) as compared with a change > 0.021 (17%), particularly in those patients with a pre-TAVI mean high-gradient (HG ≥ 40 mmHg) phenotype (p < 0.05). In particular, HG patients exhibited the lowest efficiency/PWImod ratio pre-/post-TAVI (p = 0.048), relative to the other aortic stenosis patients, suggestive of an unfavourable matching between cardiac function and metabolic demand, which foreshortens some intrinsic damaged muscle condition in these patients. CONCLUSION LV mechanical efficiency improves immediately post-TAVI, notwithstanding an inhomogeneous mechano-energetic matching among the aortic stenosis patients, which can impact negatively on their long-term prognosis, particularly in those with the HG phenotype.
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Affiliation(s)
- Paolo N Marino
- Department of Translational Medicine, Università del Piemonte Orientale, Via Solaroli 17, 28100, Novara, Italy.
| | - G Binda
- Cardiology Division, Azienda Ospedaliera Universitaria "Maggiore Della Carità", Novara, Italy
- MultiMedica IRCCS, Milan, Italy
| | - E Calzaducca
- Cardiology Division, Azienda Ospedaliera Universitaria "Maggiore Della Carità", Novara, Italy
| | - A Panizza
- Cardiology Division, Azienda Ospedaliera Universitaria "Maggiore Della Carità", Novara, Italy
| | - I Ferrari
- Cardiology Division, Azienda Ospedaliera Universitaria "Maggiore Della Carità", Novara, Italy
| | - I Bellacosa
- Cardiology Division, Azienda Ospedaliera Universitaria "Maggiore Della Carità", Novara, Italy
| | - G Ambrosio
- Section of Cardiology and Cardiovascular Pathophysiology, Department of Medicine, Perugia University, Perugia, Italy
- MultiMedica IRCCS, Milan, Italy
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Hagendorff A, Knebel F, Helfen A, Knierim J, Sinning C, Stöbe S, Fehske W, Ewen S. Expert consensus document on the assessment of the severity of aortic valve stenosis by echocardiography to provide diagnostic conclusiveness by standardized verifiable documentation. Clin Res Cardiol 2019; 109:271-288. [PMID: 31482241 DOI: 10.1007/s00392-019-01539-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Accepted: 08/14/2019] [Indexed: 02/06/2023]
Abstract
According to recent recommendations on echocardiographic assessment of aortic valve stenosis direct measurement of transvalvular peak jet velocity, calculation of transvalvular mean gradient from the velocities using the Bernoulli equation and calculation of the effective aortic valve area by continuity equation are the appropriate primary key instruments for grading severity of aortic valve stenosis. It is obvious that no gold standard can be declared for grading the severity of aortic stenosis. Thus, conclusions of the exclusive evaluation of aortic stenosis by Doppler echocardiography seem to be questionable due to the susceptibility to errors caused by methodological limitations, mathematical simplifications and inappropriate documentation. The present paper will address practical issues of echocardiographic documentation to satisfy the needs to analyze different scenarios of aortic stenosis due to various flow conditions and pressure gradients. Transesophageal and multidimensional echocardiography should be implemented for reliable measurement of geometric aortic valve area and of cardiac dimensions at an early stage of the diagnostic procedure to avoid misinterpretation due to inconsistent results.
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Affiliation(s)
- Andreas Hagendorff
- Department of Cardiology, University of Leipzig, Klinik und Poliklinik für Kardiologie, Liebigstraße 20, 04103, Leipzig, Germany.
| | - Fabian Knebel
- Department of Cardiology and Angiology, Universitätsmedizin Berlin, Campus Charité Mitte, Charitéplatz 1, 10117, Berlin, Germany
| | - Andreas Helfen
- Department of Cardiology, St. Marien Hospital Lünen, Altstadtstraße 23, 44534, Lünen, Germany
| | - Jan Knierim
- Department of Cardiovascular Surgery, University of Berlin, Deutsches Herzzentrum Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Christoph Sinning
- Department of Cardiology, University of Hamburg-Eppendorf, Martinistraße 52, 20251, Hamburg, Germany
| | - Stephan Stöbe
- Department of Cardiology, University of Leipzig, Liebigstraße 20, 04103, Leipzig, Germany
| | - Wolfgang Fehske
- Department of Cardiology St, Vinzenz-Hospital Köln, Merheimer Straße 221, 50733, Köln, Germany
| | - Sebastian Ewen
- Klinik für Innere Medizin III, Kardiologie, Angiologie Und Internistische Intensivmedizin, Universitätsklinikum Des Saarlandes, Kirrberger Str., 66421, Homburg, Germany
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11
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Jobs A, Abdin A, de Waha-Thiele S, Eitel I, Thiele H, de Wit C, Vonthein R. Angiotensin-converting-enzyme inhibitors in hemodynamic congestion: a meta-analysis of early studies. Clin Res Cardiol 2019; 108:1240-1248. [DOI: 10.1007/s00392-019-01456-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 03/13/2019] [Indexed: 02/08/2023]
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