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Springhetti P, Abdoun K, Clavel MA. Sex Differences in Aortic Stenosis: From the Pathophysiology to the Intervention, Current Challenges, and Future Perspectives. J Clin Med 2024; 13:4237. [PMID: 39064275 PMCID: PMC11278486 DOI: 10.3390/jcm13144237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2024] [Revised: 07/16/2024] [Accepted: 07/17/2024] [Indexed: 07/28/2024] Open
Abstract
Calcific aortic stenosis (AS) is a major cause of morbidity and mortality in high-income countries. AS presents sex-specific features impacting pathophysiology, outcomes, and management strategies. In women, AS often manifests with a high valvular fibrotic burden, small valvular annuli, concentric left ventricular (LV) remodeling/hypertrophy, and, frequently, supernormal LV ejection fraction coupled with diastolic dysfunction. Paradoxical low-flow low-gradient AS epitomizes these traits, posing significant challenges post-aortic valve replacement due to limited positive remodeling and significant risk of patient-prosthesis mismatch. Conversely, men present more commonly with LV dilatation and dysfunction, indicating the phenotype of classical low-flow low-gradient AS, i.e., with decreased LV ejection fraction. However, these distinctions have not been fully incorporated into guidelines for AS management. The only treatment for AS is aortic valve replacement; women are frequently referred late, leading to increased heart damage caused by AS. Therefore, it is important to reassess surgical planning and timing to minimize irreversible cardiac damage in women. The integrity and the consideration of sex differences in the management of AS is critical. Further research, including sufficient representation of women, is needed to investigate these differences and to develop individualized, sex-specific management strategies.
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Affiliation(s)
- Paolo Springhetti
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, QC G1V 4G5, Canada; (P.S.); (K.A.)
- Department of Medicine, Division of Cardiology, University of Verona, 37129 Verona, Italy
| | - Kathia Abdoun
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, QC G1V 4G5, Canada; (P.S.); (K.A.)
| | - Marie-Annick Clavel
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, QC G1V 4G5, Canada; (P.S.); (K.A.)
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2
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Gać P, Jaworski A, Grajnert F, Kicman K, Trejtowicz-Sutor A, Witkowski K, Poręba M, Poręba R. Aortic Valve Calcium Score: Applications in Clinical Practice and Scientific Research-A Narrative Review. J Clin Med 2024; 13:4064. [PMID: 39064103 PMCID: PMC11277735 DOI: 10.3390/jcm13144064] [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: 05/25/2024] [Revised: 06/29/2024] [Accepted: 07/08/2024] [Indexed: 07/28/2024] Open
Abstract
In this narrative review, we investigate the essential role played by the computed tomography Aortic Valve Calcium Score (AVCS) in the cardiovascular diagnostic landscape, with a special focus on its implications for clinical practice and scientific research. Calcific aortic valve stenosis is the most prevalent type of aortic stenosis (AS) in industrialized countries, and due to the aging population, its prevalence is increasing. While transthoracic echocardiography (TTE) remains the gold standard, AVCS stands out as an essential complementary tool in evaluating patients with AS. The advantage of AVCS is its independence from flow; this allows for a more precise evaluation of patients with discordant findings in TTE. Further clinical applications of AVCS include in the assessment of patients before transcatheter aortic valve replacement (TAVR), as it helps in predicting outcomes and provides prognostic information post-TAVR. Additionally, we describe different AVCS thresholds regarding gender and the anatomical variations of the aortic valve. Finally, we discuss various scientific studies where AVCS was applied. As AVCS has some limitations, due to the pathophysiologies of AS extending beyond calcification and gender differences, scientists strive to validate contrast-enhanced AVCS. Furthermore, research on developing radiation-free methods of measuring calcium content is ongoing.
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Affiliation(s)
- Paweł Gać
- Centre of Diagnostic Imaging, 4th Military Hospital, Rudolfa Weigla 5, 50-981 Wrocław, Poland; (P.G.); (A.T.-S.); (K.W.)
- Department of Population Health, Division of Environmental Health and Occupational Medicine, Wroclaw Medical University, J. Mikulicza-Radeckiego 7, 50-345 Wrocław, Poland
| | - Arkadiusz Jaworski
- Healthcare Team “County Hospital” in Sochaczew, Batalionow Chlopskich 3/7, 96-500 Sochaczew, Poland
| | - Filip Grajnert
- 4th Military Hospital, Rudolfa Weigla 5, 50-981 Wrocław, Poland;
| | - Katarzyna Kicman
- Healthcare Team “County Hospital” in Sochaczew, Batalionow Chlopskich 3/7, 96-500 Sochaczew, Poland
| | - Agnieszka Trejtowicz-Sutor
- Centre of Diagnostic Imaging, 4th Military Hospital, Rudolfa Weigla 5, 50-981 Wrocław, Poland; (P.G.); (A.T.-S.); (K.W.)
| | - Konrad Witkowski
- Centre of Diagnostic Imaging, 4th Military Hospital, Rudolfa Weigla 5, 50-981 Wrocław, Poland; (P.G.); (A.T.-S.); (K.W.)
| | - Małgorzata Poręba
- Department of Paralympic Sports, Wroclaw University of Health and Sport Sciences, Witelona 25a, 51-617 Wrocław, Poland
| | - Rafał Poręba
- Department of Internal and Occupational Diseases, Hypertension and Clinical Oncology, Wroclaw Medical University, Borowska 213, 50-556 Wrocław, Poland;
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3
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Aslam FN, Lugo-Fagundo N, Reddy P, Gharacholou SM, El Sabbagh A. Exercise Cardiac Catheterization for Hemodynamic Evaluation of Paradoxical Low-Flow Low-Gradient Severe Aortic Stenosis. JACC Case Rep 2024; 29:102306. [PMID: 38708427 PMCID: PMC11068946 DOI: 10.1016/j.jaccas.2024.102306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 02/20/2024] [Accepted: 02/21/2024] [Indexed: 05/07/2024]
Abstract
Patients with paradoxical low-flow low-gradient aortic stenosis pose a diagnostic challenge when it comes to assessing the severity of aortic stenosis (AS) noninvasively. We describe 2 patients who underwent exercise cardiac catheterization to augment their cardiac output and assess the severity of AS invasively to allow differentiation of true severe AS from pseudo-severe AS.
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Affiliation(s)
- Faaiq N. Aslam
- Department of Internal Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Nahyr Lugo-Fagundo
- Department of Cardiovascular Disease, Mayo Clinic, Jacksonville, Florida, USA
| | - Prajwal Reddy
- Department of Cardiovascular Disease, Mayo Clinic, Jacksonville, Florida, USA
| | | | - Abdallah El Sabbagh
- Department of Cardiovascular Disease, Mayo Clinic, Jacksonville, Florida, USA
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4
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Sharma N, Sachedina AK, Kumar S. Low-flow, Low-gradient Severe Aortic Stenosis: A Review. Heart Int 2023; 17:8-12. [PMID: 37456345 PMCID: PMC10339455 DOI: 10.17925/hi.2023.17.1.8] [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: 10/31/2022] [Accepted: 11/25/2022] [Indexed: 07/18/2023] Open
Abstract
Aortic stenosis (AS) is a common valve pathology experienced by patients worldwide. There are limited population-based studies assessing its prevalence; however, epidemiological studies emphasize that the burden of disease is growing. Recognizing AS relies on accurate clinical assessment and diagnostic investigations. Patients who develop severe AS are often referred to the heart team for assessment of aortic valve intervention. Although echocardiography has traditionally been used to screen and monitor the progression of AS, there can be discordance between measurements in a low-flow state. Such patients may have truly severe AS and potentially derive long-term benefit from aortic valve intervention. Accurately identifying these patients with the use of ancillary testing has been the focus of research for several years. In this article, we discuss the contemporary approaches and challenges in identifying and managing patients with low-flow, low-gradient severe AS.
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Affiliation(s)
- Nishant Sharma
- Libin Cardiovascular Institute, Foothills Medical Centre, University of Calgary, Calgary, Canada
| | - Ayaaz K Sachedina
- Libin Cardiovascular Institute, Foothills Medical Centre, University of Calgary, Calgary, Canada
| | - Sachin Kumar
- Memorial Hermann-Texas Medical Center, University of Texas Health Science Center, Houston, TX, USA
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5
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Grigoryan K, Demetrescu C, Kasouridis I, Abiola O, Masci PG, Oguz D, Benedetti G, SzeMun M, Parwani P, Preston R, Chiribiri A, Hancock J, Patterson T, Redwood S, Prendergast B, Grapsa J. Multimodality Imaging in Valvular Structural Interventions. Card Fail Rev 2022; 8:e31. [PMID: 36644647 PMCID: PMC9820006 DOI: 10.15420/cfr.2022.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 05/30/2022] [Indexed: 11/19/2022] Open
Abstract
Structural valvular interventions have skyrocketed in the past decade with new devices becoming available and indications for patients who would previously have been deemed inoperable. Furthermore, while echocardiography is the main imaging tool and the first line for patient screening, cardiac magnetic resonance and CT are now essential tools in pre-planning and post-procedural follow-up. This review aims to address imaging modalities and their scope in aortic, mitral and tricuspid structural valvular interventions, including multimodality imaging. Pulmonary valve procedures, which are mostly carried out in patients with congenital problems, are discussed. This article presents a guide on individualised imaging approcahes on each of the available interventional procedures.
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Affiliation(s)
- Karine Grigoryan
- Department of Cardiology, Guys and St Thomas’ NHS Foundation TrustLondon, UK
| | - Camelia Demetrescu
- Department of Cardiology, Guys and St Thomas’ NHS Foundation TrustLondon, UK
| | - Ioannis Kasouridis
- Department of Cardiology, Guys and St Thomas’ NHS Foundation TrustLondon, UK
| | - Olukayode Abiola
- Department of Cardiology, Guys and St Thomas’ NHS Foundation TrustLondon, UK
| | - Pier Giorgio Masci
- Department of Cardiac Magnetic Resonance, Guys and St Thomas’ NHS Foundation TrustLondon, UK
| | - Didem Oguz
- Department of Cardiology, Massachusetts General Hospital, Harvard Medical SchoolBoston, Massachusetts, US
| | - Giulia Benedetti
- Department of Radiology, Guys and St Thomas’ NHS Foundation TrustLondon, UK
| | - Mak SzeMun
- Department of Radiology, Guys and St Thomas’ NHS Foundation TrustLondon, UK
| | - Purvi Parwani
- Division of Cardiology, Department of Medicine, Loma Linda University HealthCalifornia, US
| | - Rebecca Preston
- Department of Radiology, Guys and St Thomas’ NHS Foundation TrustLondon, UK
| | - Amedeo Chiribiri
- Department of Cardiac Magnetic Resonance, Guys and St Thomas’ NHS Foundation TrustLondon, UK
| | - Jane Hancock
- Department of Cardiology, Guys and St Thomas’ NHS Foundation TrustLondon, UK
| | - Tiffany Patterson
- Department of Cardiology, Guys and St Thomas’ NHS Foundation TrustLondon, UK
| | - Simon Redwood
- Department of Cardiology, Guys and St Thomas’ NHS Foundation TrustLondon, UK
| | - Bernard Prendergast
- Department of Cardiology, Guys and St Thomas’ NHS Foundation TrustLondon, UK
| | - Julia Grapsa
- Department of Cardiology, Guys and St Thomas’ NHS Foundation TrustLondon, UK
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Dietrich L, Kibler M, Matsushita K, Marchandot B, Trimaille A, Reydel A, Diop B, Truong PD, Trung AM, Trinh A, Carmona A, Hess S, Jesel L, Ohlmann P, Morel O. Impact of Primary Hemostasis Disorders on Late Major Bleeding Events among Anticoagulated Atrial Fibrillation Patients Treated by TAVR. J Clin Med 2021; 11:212. [PMID: 35011952 PMCID: PMC8746148 DOI: 10.3390/jcm11010212] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 12/21/2021] [Accepted: 12/29/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Bleeding events are among the striking complications following transcatheter aortic valve replacement (TAVR), and bleeding prediction models are crucially warranted. Several studies have highlighted that primary hemostasis disorders secondary to persistent loss of high-molecular-weight (HMW) multimers of the von Willebrand factor (vWF) and assessed by adenosine diphosphate closure time (CT-ADP) may be a strong predictor of late major/life-threatening bleeding complications (MLBCs). Pre-existing atrial fibrillation (AF) is a frequent comorbidity in TAVR patients and potentially associated with increased bleeding events after the procedure. OBJECTIVES This study evaluated the impact of ongoing primary hemostasis disorders, as assessed by post-procedural CT-ADP > 180 s, on clinical events after TAVR among anticoagulated AF patients. METHODS An ongoing primary hemostasis disorder was defined by post-procedure CT-ADP > 180 s. Bleeding complications were assessed according to the Valve Academic Research Consortium-2 (VARC-2) criteria. The primary endpoint was the occurrence of late MLBCs at one-year follow-up. The secondary endpoint was a composite of mortality, stroke, myocardial infarction, and rehospitalization for heart failure. RESULTS In total, 384 TAVR patients were included in the analysis. Of these patients, 57 patients (14.8%) had a prolongated CT-ADP > 180 s. Increased MLBCs were observed in patients with CT-ADP > 180 s (35.1% versus 1.2%; p < 0.0001). Conversely, the occurrence of the composite endpoint did not differ between the groups. Multivariate analysis identified CT-ADP > 180 s (HR 28.93; 95% CI 9.74-85.95; p < 0.0001), bleeding history, paradoxical aortic stenosis (AS), and major vascular complications following TAVR as independent predictors of late MLBCs. CONCLUSION Among patients with anticoagulated AF, a post-procedural CT-ADP > 180 s was identified as a strong independent predictor of late MLBCs. These findings suggest that persistent primary hemostasis disorders contribute to a higher risk of late bleeding events and should be considered for a tailored, risk-adjusted antithrombotic therapy after TAVR.
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Affiliation(s)
- Laurent Dietrich
- Centre Hospitalier Universitaire, Pôle d’Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Université de Strasbourg, 67000 Strasbourg, France; (L.D.); (K.M.); (B.M.); (A.T.); (A.R.); (B.D.); (A.T.); (A.C.); (S.H.); (L.J.); (P.O.); (O.M.)
| | - Marion Kibler
- Centre Hospitalier Universitaire, Pôle d’Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Université de Strasbourg, 67000 Strasbourg, France; (L.D.); (K.M.); (B.M.); (A.T.); (A.R.); (B.D.); (A.T.); (A.C.); (S.H.); (L.J.); (P.O.); (O.M.)
| | - Kensuke Matsushita
- Centre Hospitalier Universitaire, Pôle d’Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Université de Strasbourg, 67000 Strasbourg, France; (L.D.); (K.M.); (B.M.); (A.T.); (A.R.); (B.D.); (A.T.); (A.C.); (S.H.); (L.J.); (P.O.); (O.M.)
- Institut National de la Santé et de la Recherche Médicale (INSERM), Nano Médecine Régénérative, Unité Mixte de Recherche 1260, Faculté de Pharmacie, Université de Strasbourg, 67400 Illkirch, France
| | - Benjamin Marchandot
- Centre Hospitalier Universitaire, Pôle d’Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Université de Strasbourg, 67000 Strasbourg, France; (L.D.); (K.M.); (B.M.); (A.T.); (A.R.); (B.D.); (A.T.); (A.C.); (S.H.); (L.J.); (P.O.); (O.M.)
| | - Antonin Trimaille
- Centre Hospitalier Universitaire, Pôle d’Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Université de Strasbourg, 67000 Strasbourg, France; (L.D.); (K.M.); (B.M.); (A.T.); (A.R.); (B.D.); (A.T.); (A.C.); (S.H.); (L.J.); (P.O.); (O.M.)
| | - Antje Reydel
- Centre Hospitalier Universitaire, Pôle d’Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Université de Strasbourg, 67000 Strasbourg, France; (L.D.); (K.M.); (B.M.); (A.T.); (A.R.); (B.D.); (A.T.); (A.C.); (S.H.); (L.J.); (P.O.); (O.M.)
| | - Bamba Diop
- Centre Hospitalier Universitaire, Pôle d’Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Université de Strasbourg, 67000 Strasbourg, France; (L.D.); (K.M.); (B.M.); (A.T.); (A.R.); (B.D.); (A.T.); (A.C.); (S.H.); (L.J.); (P.O.); (O.M.)
| | - Phi Dinh Truong
- Vietnam National Heart Institute, Bach Mai Hospital, Hanoi 100000, Vietnam; (P.D.T.); (A.M.T.)
| | - Anh Mai Trung
- Vietnam National Heart Institute, Bach Mai Hospital, Hanoi 100000, Vietnam; (P.D.T.); (A.M.T.)
| | - Annie Trinh
- Centre Hospitalier Universitaire, Pôle d’Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Université de Strasbourg, 67000 Strasbourg, France; (L.D.); (K.M.); (B.M.); (A.T.); (A.R.); (B.D.); (A.T.); (A.C.); (S.H.); (L.J.); (P.O.); (O.M.)
| | - Adrien Carmona
- Centre Hospitalier Universitaire, Pôle d’Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Université de Strasbourg, 67000 Strasbourg, France; (L.D.); (K.M.); (B.M.); (A.T.); (A.R.); (B.D.); (A.T.); (A.C.); (S.H.); (L.J.); (P.O.); (O.M.)
| | - Sébastien Hess
- Centre Hospitalier Universitaire, Pôle d’Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Université de Strasbourg, 67000 Strasbourg, France; (L.D.); (K.M.); (B.M.); (A.T.); (A.R.); (B.D.); (A.T.); (A.C.); (S.H.); (L.J.); (P.O.); (O.M.)
| | - Laurence Jesel
- Centre Hospitalier Universitaire, Pôle d’Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Université de Strasbourg, 67000 Strasbourg, France; (L.D.); (K.M.); (B.M.); (A.T.); (A.R.); (B.D.); (A.T.); (A.C.); (S.H.); (L.J.); (P.O.); (O.M.)
- Institut National de la Santé et de la Recherche Médicale (INSERM), Nano Médecine Régénérative, Unité Mixte de Recherche 1260, Faculté de Pharmacie, Université de Strasbourg, 67400 Illkirch, France
| | - Patrick Ohlmann
- Centre Hospitalier Universitaire, Pôle d’Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Université de Strasbourg, 67000 Strasbourg, France; (L.D.); (K.M.); (B.M.); (A.T.); (A.R.); (B.D.); (A.T.); (A.C.); (S.H.); (L.J.); (P.O.); (O.M.)
| | - Olivier Morel
- Centre Hospitalier Universitaire, Pôle d’Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Université de Strasbourg, 67000 Strasbourg, France; (L.D.); (K.M.); (B.M.); (A.T.); (A.R.); (B.D.); (A.T.); (A.C.); (S.H.); (L.J.); (P.O.); (O.M.)
- Institut National de la Santé et de la Recherche Médicale (INSERM), Nano Médecine Régénérative, Unité Mixte de Recherche 1260, Faculté de Pharmacie, Université de Strasbourg, 67400 Illkirch, France
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Huang G, Chen H, Zhang W, He F. Transcatheter Aortic Valve Implantation Assisted by Extracorporeal Membrane Oxygenation for the Treatment of Aortic Stenosis with Cardiogenic Shock. Arq Bras Cardiol 2021; 117:33-37. [PMID: 34287474 PMCID: PMC8291898 DOI: 10.36660/abc.20201358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 04/28/2021] [Indexed: 11/18/2022] Open
Affiliation(s)
- Gangping Huang
- Departamento de Cirurgia Cardíaca, Hospital Sir Run Run Shaw, Escola de Medicina, Universidade de Zhejiang, Zhejiang - China
| | - Huaidong Chen
- Departamento de Cirurgia Cardíaca, Hospital Sir Run Run Shaw, Escola de Medicina, Universidade de Zhejiang, Zhejiang - China
| | - Weimin Zhang
- Departamento de Cirurgia Cardíaca, Hospital Sir Run Run Shaw, Escola de Medicina, Universidade de Zhejiang, Zhejiang - China
| | - Fan He
- Departamento de Cirurgia Cardíaca, Hospital Sir Run Run Shaw, Escola de Medicina, Universidade de Zhejiang, Zhejiang - China
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8
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Alsidawi S, Khan S, Pislaru SV, Thaden JJ, El-Am EA, Scott CG, Morant K, Oguz D, Luis SA, Padang R, Lane CE, McCully RB, Pellikka PA, Oh JK, Nkomo VT. High Prevalence of Severe Aortic Stenosis in Low-Flow State Associated With Atrial Fibrillation. Circ Cardiovasc Imaging 2021; 14:e012453. [PMID: 34250815 DOI: 10.1161/circimaging.120.012453] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) is a low-flow state and may underestimate aortic stenosis (AS) severity. Single-high Doppler signals (HS) consistent with severe AS (peak velocity ≥4 m/s or mean gradient ≥40 mm Hg) are averaged down in current practice. The objective for the study was to determine the significance of HS in AF low-gradient AS (LGAS). METHODS One thousand five hundred forty-one patients with aortic valve area ≤1 cm2 and left ventricular ejection fraction ≥50% were identified and classified as high-gradient AS (HGAS) (≥40 mm Hg) and LGAS (<40 mm Hg), and AF versus sinus rhythm (SR). Available computed tomography aortic valve calcium scores (AVCS) were retrieved from the medical record. Outcomes were assessed. RESULTS Mean age was 76±11 years, female 47%. Mean gradient was 51±12 in SR-HGAS, 48±10 in AF-HGAS, 31±5 in SR-LGAS, and 29±7 mm Hg in AF-LGAS, all P≤0.001 versus SR-HGAS; HS were present in 33% of AF-LGAS. AVCS were available in 34%. Compared with SR-HGAS (2409 arbitrary units; interquartile range, 1581-3462) AVCS were higher in AF-HGAS (2991 arbitrary units; IQR1978-4229, P=0.001), not different in AF-LGAS (2399 arbitrary units; IQR1817-2810, P=0.47), and lower in SR-LGAS (1593 arbitrary units; IQR945-1832, P<0.001); AVCS in AF-LGAS were higher when HS were present (P=0.048). Compared with SR-HGAS, the age-, sex-, comorbidity index-, and time-dependent aortic valve replacement-adjusted mortality risk was higher in AF-HGAS (hazard ratio=1.82 [1.40-2.36], P<0.001) and AF-LGAS with HS (hazard ratio=1.54 [1.04-2.26], P=0.03) but not different in AF-LGAS without HS or SR-LGAS (both P=not significant). CONCLUSIONS Severe AS was common in AF-LGAS. AVCS in AF-LGAS were not different from SR-HGAS. AVCS were higher and mortality worse in AF-LGAS when HS were present.
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Affiliation(s)
- Said Alsidawi
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (S.A., S.K., S.V.P., J.J.T., E.A.E.-A., K.M., D.O., S.A.L., R.P., C.E.L., R.B.M., P.A.P., J.K.O., V.T.N.).,Minneapolis Heart Institute, Minneapolis, MN (S.A.)
| | - Sana Khan
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (S.A., S.K., S.V.P., J.J.T., E.A.E.-A., K.M., D.O., S.A.L., R.P., C.E.L., R.B.M., P.A.P., J.K.O., V.T.N.).,University of Minnesota, Minneapolis, MN (S.K.)
| | - Sorin V Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (S.A., S.K., S.V.P., J.J.T., E.A.E.-A., K.M., D.O., S.A.L., R.P., C.E.L., R.B.M., P.A.P., J.K.O., V.T.N.)
| | - Jeremy J Thaden
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (S.A., S.K., S.V.P., J.J.T., E.A.E.-A., K.M., D.O., S.A.L., R.P., C.E.L., R.B.M., P.A.P., J.K.O., V.T.N.)
| | - Edward A El-Am
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (S.A., S.K., S.V.P., J.J.T., E.A.E.-A., K.M., D.O., S.A.L., R.P., C.E.L., R.B.M., P.A.P., J.K.O., V.T.N.).,Department of Medicine, Indiana University School of Medicine, Indianapolis (E.A.E.-A.)
| | | | - Kareem Morant
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (S.A., S.K., S.V.P., J.J.T., E.A.E.-A., K.M., D.O., S.A.L., R.P., C.E.L., R.B.M., P.A.P., J.K.O., V.T.N.).,North York General Hospital, Toronto, ON, Canada (K.M.)
| | - Didem Oguz
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (S.A., S.K., S.V.P., J.J.T., E.A.E.-A., K.M., D.O., S.A.L., R.P., C.E.L., R.B.M., P.A.P., J.K.O., V.T.N.)
| | - Sushil A Luis
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (S.A., S.K., S.V.P., J.J.T., E.A.E.-A., K.M., D.O., S.A.L., R.P., C.E.L., R.B.M., P.A.P., J.K.O., V.T.N.)
| | - Ratnasari Padang
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (S.A., S.K., S.V.P., J.J.T., E.A.E.-A., K.M., D.O., S.A.L., R.P., C.E.L., R.B.M., P.A.P., J.K.O., V.T.N.)
| | - Colleen E Lane
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (S.A., S.K., S.V.P., J.J.T., E.A.E.-A., K.M., D.O., S.A.L., R.P., C.E.L., R.B.M., P.A.P., J.K.O., V.T.N.)
| | - Robert B McCully
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (S.A., S.K., S.V.P., J.J.T., E.A.E.-A., K.M., D.O., S.A.L., R.P., C.E.L., R.B.M., P.A.P., J.K.O., V.T.N.)
| | - Patricia A Pellikka
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (S.A., S.K., S.V.P., J.J.T., E.A.E.-A., K.M., D.O., S.A.L., R.P., C.E.L., R.B.M., P.A.P., J.K.O., V.T.N.)
| | - Jae K Oh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (S.A., S.K., S.V.P., J.J.T., E.A.E.-A., K.M., D.O., S.A.L., R.P., C.E.L., R.B.M., P.A.P., J.K.O., V.T.N.)
| | - Vuyisile T Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (S.A., S.K., S.V.P., J.J.T., E.A.E.-A., K.M., D.O., S.A.L., R.P., C.E.L., R.B.M., P.A.P., J.K.O., V.T.N.)
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Reid A, Blanke P, Bax JJ, Leipsic J. Multimodality imaging in valvular heart disease: how to use state-of-the-art technology in daily practice. Eur Heart J 2021; 42:1912-1925. [PMID: 33186469 DOI: 10.1093/eurheartj/ehaa768] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 06/15/2020] [Accepted: 09/08/2020] [Indexed: 12/16/2022] Open
Abstract
Our understanding of the complexities of valvular heart disease (VHD) has evolved in recent years, primarily because of the increased use of multimodality imaging (MMI). Whilst echocardiography remains the primary imaging technique, the contemporary evaluation of patients with VHD requires comprehensive analysis of the mechanism of valvular dysfunction, accurate quantification of severity, and active exclusion extravalvular consequences. Furthermore, advances in surgical and percutaneous therapies have driven the need for meticulous multimodality imaging to aid in patient and procedural selection. Fundamental decision-making regarding whom, when, and how to treat patients with VHD has become more complex. There has been rapid technological advancement in MMI; many techniques are now available in routine clinical practice, and their integration into has the potential to truly individualize management strategies. This review provides an overview of the current evidence for the use of MMI in VHD, and how various techniques within each modality can be used practically to answer clinical conundrums.
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Affiliation(s)
- Anna Reid
- Department of Radiology and Cardiology, Center for Heart Lung Innovation, St. Paul's Hospital, University of British Columbia, 1081 Burrard Street, Vancouver V6Z1Y6, BC, Canada
| | - Philipp Blanke
- Department of Radiology and Cardiology, Center for Heart Lung Innovation, St. Paul's Hospital, University of British Columbia, 1081 Burrard Street, Vancouver V6Z1Y6, BC, Canada
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, Netherlands
| | - Jonathon Leipsic
- Department of Radiology and Cardiology, Center for Heart Lung Innovation, St. Paul's Hospital, University of British Columbia, 1081 Burrard Street, Vancouver V6Z1Y6, BC, Canada
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Saito Y, Lewis EE, Raval A, Gimelli G, Jacobson K, Osaki S. Prognosis of paradoxical low-flow low-gradient aortic stenosis after transcatheter aortic valve replacement. J Cardiovasc Med (Hagerstown) 2021; 22:486-491. [PMID: 33229861 DOI: 10.2459/jcm.0000000000001139] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS In paradoxical low-flow low-gradient severe aortic stenosis (PLFLG AS) patients, stroke volume index (SVI) is reduced despite preserved left ventricular ejection fraction (LVEF). Although reduced SVI is already known as a poor prognostic predictor, the outcomes of PLFLG AS patients after transcatheter aortic valve replacement (TAVR) have not been clearly defined. We retrospectively investigated the post-TAVR outcomes of PLFLG AS patients in comparison with normal-flow high-gradient aortic stenosis (NFHG AS) patients. METHODS The current observational study included 245 patients with NFHG AS (mean transaortic pressure gradient ≥40 mmHg and LVEF ≥ 50%) and 48 patients with PLFLG AS (mean transaortic pressure gradient <40 mmHg, LVEF ≥ 50% and SVI < 35 ml/m2). The endpoints were all-cause mortality, hospitalization for valve-related symptoms or worsening congestive heart failure and New York Heart Association functional class III or IV. RESULTS PLFLG AS patients had a significantly higher proportion with a history of atrial fibrillation/flutter as compared with NFHG AS patients. All-cause mortality of PLFLG AS patients was worse than that of NFHG AS patients (P = 0.047). Hospitalization for valve-related symptoms or worsening congestive heart failure was more frequent in PLFLG AS patients than in NFHG AS patients (P = 0.041). New York Heart Association functional class III-IV after TAVR was more frequently observed in PLFLG AS patients (P = 0.019). CONCLUSION The outcomes of PLFLG AS patients were worse than those of NFHG AS patients in this study. Preexisting atrial fibrillation/flutter was frequent in PLFLG AS patients, and may affect their post-TAVR outcomes. Therefore, closer post-TAVR follow-up should be considered for these patients.
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Affiliation(s)
| | - Erik E Lewis
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | | | | | | | - Satoru Osaki
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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11
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Impact of Surgical and Transcatheter Aortic Valve Replacement in Low-Gradient Aortic Stenosis: A Meta-Analysis. JACC Cardiovasc Interv 2021; 14:1481-1492. [PMID: 33939605 DOI: 10.1016/j.jcin.2021.04.038] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 04/21/2021] [Accepted: 04/27/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVES The aim of this study was to assess the impact of aortic valve replacement (AVR) on survival in patients with each subclass of low-gradient (LG) aortic stenosis (AS) and to compare outcomes following surgical AVR (SAVR) and transcatheter AVR (TAVR). BACKGROUND LG severe AS encompasses a wide variety of pathophysiology, including classical low-flow, LG (LF-LG), paradoxical LF-LG, and normal-flow, LG (NF-LG) AS, and uncertainty exists regarding the impact of AVR on each subclass of LG AS. METHODS PubMed and Embase were queried through October 2020 to identify studies comparing survival with different management strategies (SAVR, TAVR, and conservative) in patients with LG AS. Pairwise meta-analysis comparing AVR versus conservative management and network meta-analysis comparing SAVR versus TAVR versus conservative management were performed. RESULTS Thirty-two studies with a total of 6,515 patients and a median follow-up time of 24.2 months (interquartile range: 36.5 months) were included. AVR was associated with a significant decrease in all-cause mortality in classical LF-LG (hazard ratio [HR]: 0.42; 95% confidence interval [CI]: 0.36 to 0.48), paradoxical LF-LG (HR: 0.41; 95% CI: 0.29 to 0.57), and NF-LG (HR: 0.41; 95% CI: 0.27 to 0.62) AS compared with conservative management. SAVR and TAVR were each associated with a decrease in all-cause mortality in classical LF-LG (HR: 0.46 [95% CI: 0.38 to 0.55] and 0.49 [95% CI: 0.37 to 0.64], respectively), paradoxical LF-LG (HR: 0.42 [95% CI: 0.28 to 0.65] and 0.42 [95% CI: 0.25 to 0.72], respectively), and NF-LG (HR: 0.40 [95% CI: 0.21 to 0.77] and 0.46 [95% CI: 0.26 to 0.84], respectively) AS compared with conservative management. No significant difference was observed between SAVR and TAVR. CONCLUSIONS In all subclasses of LG AS, AVR was associated with a significant decrease in all-cause mortality regardless of surgical or transcatheter approach.
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Choe YH, Kim SM, Park SJ. Computed tomography and magnetic resonance imaging assessment of aortic valve stenosis: an update. PRECISION AND FUTURE MEDICINE 2020. [DOI: 10.23838/pfm.2020.00093] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
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Guzzetti E, Annabi MS, Pibarot P, Clavel MA. Multimodality Imaging for Discordant Low-Gradient Aortic Stenosis: Assessing the Valve and the Myocardium. Front Cardiovasc Med 2020; 7:570689. [PMID: 33344514 PMCID: PMC7744378 DOI: 10.3389/fcvm.2020.570689] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 10/12/2020] [Indexed: 01/29/2023] Open
Abstract
Aortic stenosis (AS) is a disease of the valve and the myocardium. A correct assessment of the valve disease severity is key to define the need for aortic valve replacement (AVR), but a better understanding of the myocardial consequences of the increased afterload is paramount to optimize the timing of the intervention. Transthoracic echocardiography remains the cornerstone of AS assessment, as it is universally available, and it allows a comprehensive structural and hemodynamic evaluation of both the aortic valve and the rest of the heart. However, it may not be sufficient as a significant proportion of patients with severe AS presents with discordant grading (i.e., an AVA ≤ 1 cm2 and a mean gradient <40 mmHg) which raises uncertainty about the true severity of AS and the need for AVR. Several imaging modalities (transesophageal or stress echocardiography, computed tomography, cardiovascular magnetic resonance, positron emission tomography) exist that allow a detailed assessment of the stenotic aortic valve and the myocardial remodeling response. This review aims to provide an updated overview of these multimodality imaging techniques and seeks to highlight a practical approach to help clinical decision making in the challenging group of patients with discordant low-gradient AS.
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Affiliation(s)
- Ezequiel Guzzetti
- Institut Universitaire de Cardiologie et de Pneumologie de Québec (Quebec Heart & Lung Institute), Quebec, QC, Canada
| | - Mohamed-Salah Annabi
- Institut Universitaire de Cardiologie et de Pneumologie de Québec (Quebec Heart & Lung Institute), Quebec, QC, Canada
| | - Philippe Pibarot
- Institut Universitaire de Cardiologie et de Pneumologie de Québec (Quebec Heart & Lung Institute), Quebec, QC, Canada
| | - Marie-Annick Clavel
- Institut Universitaire de Cardiologie et de Pneumologie de Québec (Quebec Heart & Lung Institute), Quebec, QC, Canada
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Hosadurg N, Koethe B, Huang D, Weintraub AR, Patel AR, Wessler BS. Paradoxical Low-Flow Low-Gradient Aortic Stenosis: Effect of Low Transvalvular Flow Conditions on Indexed Stroke Volume after Transcatheter Aortic Valve Replacement. J Am Soc Echocardiogr 2020; 33:1528-1531. [PMID: 32888758 DOI: 10.1016/j.echo.2020.07.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 07/16/2020] [Accepted: 07/18/2020] [Indexed: 11/17/2022]
Affiliation(s)
- Nisha Hosadurg
- Division of Internal Medicine, Tufts Medical Center, Boston, Massachusetts
| | - Benjamin Koethe
- Predictive Analytics and Comparative Effectiveness (PACE) Center, Tufts Medical Center, Boston, Massachusetts
| | - Dou Huang
- Division of Internal Medicine, Tufts Medical Center, Boston, Massachusetts
| | | | - Ayan R Patel
- Cardiovascular Center, Tufts Medical Center, Boston, Massachusetts
| | - Benjamin S Wessler
- Predictive Analytics and Comparative Effectiveness (PACE) Center, Tufts Medical Center, Boston, Massachusetts; Cardiovascular Center, Tufts Medical Center, Boston, Massachusetts
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Serum Biomarkers of Cardiovascular Remodelling Reflect Extra-Valvular Cardiac Damage in Patients with Severe Aortic Stenosis. Int J Mol Sci 2020; 21:ijms21114174. [PMID: 32545310 PMCID: PMC7312014 DOI: 10.3390/ijms21114174] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 06/03/2020] [Accepted: 06/08/2020] [Indexed: 12/20/2022] Open
Abstract
In patients with aortic stenosis (AS), a novel staging classification of extra-valvular left and right heart damage with prognostic relevance was introduced in 2017. The aim of the study was to evaluate the biomarkers of cardiovascular tissue remodelling in relation to this novel staging classification. Patients were categorized according to the novel staging classification into stages 0 to 4. The levels of matrix metalloproteinase 9 (MMP-9), tissue inhibitor of metalloproteinases 1 (TIMP-1), B and C domain containing tenascin-C (B+ Tn-C, C+ Tn-C), the ED-A and ED-B domain containing fibronectin (ED-A+ Fn, ED-B+ Fn), endothelin 1 (ET-1) and neutrophil gelatinase-associated lipocalin (NGAL) were determined in serum by ELISA. There were significantly decreased serum levels of MMP-9 and increased levels of B+ Tn-C and C+ Tn-C when comparing stages 0 and 1 with stage 2, with no further dynamics in stages 3 and 4. In contrast, for TIMP-1, C+ Tn-C, ED-A+ Fn, ET-1 and NGAL, significantly increased serum levels could be detected in stages 3 and 4 compared to both stages 0 and 1 and stage 2. ED-A+ Fn and ET-1 could be identified as independent predictors of the presence of stage 3 and/or 4. To the best of our knowledge, this is the first study identifying novel serum biomarkers differentially reflecting the patterns of left and right heart extra-valvular damage in patients suffering from AS. Our findings might indicate a more precise initial diagnosis and risk stratification.
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