1
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Velders BJJ, Groenwold RHH, Ajmone Marsan N, Kappetein AP, Wijngaarden RAFDLV, Braun J, Klautz RJM, Vriesendorp MD. Improving accuracy in diagnosing aortic stenosis severity: An in-depth analysis of echocardiographic measurement error through literature review and simulation study. Echocardiography 2023; 40:892-902. [PMID: 37519290 DOI: 10.1111/echo.15664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 07/10/2023] [Accepted: 07/23/2023] [Indexed: 08/01/2023] Open
Abstract
AIMS The present guidelines advise replacing the aortic valve for individuals with severe aortic stenosis (AS) based on various echocardiographic parameters. Accurate measurements are essential to avoid misclassification and unnecessary interventions. The objective of this study was to evaluate the influence of measurement error on the echocardiographic evaluation of the severity of AS. METHODS AND RESULTS A systematic review was performed to examine whether measurement errors are reported in studies focusing on the prognostic value of peak aortic jet velocity (Vmax ), mean pressure gradient (MPG), and effective orifice area (EOA) in asymptomatic patients with AS. Out of the 37 studies reviewed, 17 (46%) acknowledged the existence of measurement errors, but none of them utilized methods to address them. Secondly, the magnitude of potential errors was collected from available literature for use in clinical simulations. Interobserver variability ranged between 0.9% and 8.3% for Vmax and MPG but was higher for EOA (range 7.7%-12.7%), indicating lower reliability. Assuming a circular left ventricular outflow tract area led to a median underestimation of EOA by 23% compared to planimetry by other modalities. A clinical simulation resulted in the reclassification of 42% of patients, shifting them from a diagnosis of severe AS to moderate AS. CONCLUSIONS Measurement errors are underreported in studies on echocardiographic assessment of AS severity. These errors can lead to misclassification and misdiagnosis. Clinicians and scientists should be aware of the implications for accurate clinical decision-making and assuring research validity.
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Affiliation(s)
- Bart J J Velders
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Rolf H H Groenwold
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Biomedical Data Science, Leiden University Medical Center, Leiden, The Netherlands
| | - Nina Ajmone Marsan
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Arie-Pieter Kappetein
- Global Clinical Operations, Coronary and Structural Heart, Medtronic, Maastricht, The Netherlands
| | | | - Jerry Braun
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Robert J M Klautz
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Michiel D Vriesendorp
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
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Manzo R, Ilardi F, Nappa D, Mariani A, Angellotti D, Immobile Molaro M, Sgherzi G, Castiello DS, Simonetti F, Santoro C, Canonico ME, Avvedimento M, Piccolo R, Franzone A, Esposito G. Echocardiographic Evaluation of Aortic Stenosis: A Comprehensive Review. Diagnostics (Basel) 2023; 13:2527. [PMID: 37568890 PMCID: PMC10417789 DOI: 10.3390/diagnostics13152527] [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: 06/26/2023] [Revised: 07/24/2023] [Accepted: 07/25/2023] [Indexed: 08/13/2023] Open
Abstract
Echocardiography represents the most important diagnostic tool in the evaluation of aortic stenosis. The echocardiographic assessment of its severity should always be performed through a standardized and stepwise approach in order to achieve a comprehensive evaluation. The latest technical innovations in the field of echocardiography have improved diagnostic accuracy, guaranteeing a better and more detailed evaluation of aortic valve anatomy. An early diagnosis is of utmost importance since it shortens treatment delays and improves patient outcomes. Echocardiography plays a key role also in the evaluation of all the structural changes related to aortic stenosis. Detailed evaluation of subtle and subclinical changes in left ventricle function has a prognostic significance: scientific efforts have been addressed to identify the most accurate global longitudinal strain cut-off value able to predict adverse outcomes. Moreover, in recent years the role of artificial intelligence is increasingly emerging as a promising tool able to assist cardiologists in aortic stenosis screening and diagnosis, especially by reducing the rate of aortic stenosis misdiagnosis.
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Affiliation(s)
| | - Federica Ilardi
- Department of Advanced Biomedical Sciences, Division of Cardiology, Federico II University, 80131 Naples, Italy
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3
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Šeman M, Stephens AF, Walton A, Duffy SJ, McGiffin D, Nanayakkara S, Kaye DM, Gregory SD, Stub D. Impact of Concomitant Mitral Regurgitation on the Hemodynamic Indicators of Aortic Stenosis. J Am Heart Assoc 2023; 12:e025648. [PMID: 36789874 PMCID: PMC10111497 DOI: 10.1161/jaha.122.025648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 12/14/2022] [Indexed: 02/16/2023]
Abstract
Background In patients with aortic stenosis (AS), the presence of mitral regurgitation (MR) can lead to underestimation of AS severity and worse clinical outcomes. The objective of this study was to characterize the magnitude of the effects of concomitant MR on hemodynamic indicators of AS severity using clinical data and a computational cardiovascular simulation. Methods and Results Echocardiographic data from 1427 patients with severe AS were used to inform a computational cardiovascular system model, and varying degrees of MR and AS were simulated. Hemodynamic data, including left ventricular and aortic pressure waveforms, were generated for all simulations. Simulated reduction in mean transaortic pressure gradient (MPG) associated with MR was then used to calculate the adjusted MPG in the clinical cohort. MR was present in 861 (60%) patients. Compared with patients without MR, patients with MR had a lower aortic-valve area (0.83±0.2 cm2 versus 0.75±0.2; P<0.001) and were more likely to have a low-gradient pattern (MPG <40 mm Hg) (45% versus 54%; P<0.001). Simulations showed that the presence of concomitant mild, moderate, and severe MR with AS was accompanied by a mean reduction in MPG of 10%, 29%, and 40%, respectively. For patients with MR, their calculated adjusted MPG was on average 24% higher than their MPG (52±22 versus 42±16 mm Hg). Of the 467 patients with low-gradient AS and MR, 240 (51%) would reclassify as high gradient based on their adjusted MPG. Conclusions Concomitant MR results in lower MPG and reduced forward flow compared with isolated AS. Careful quantitation of MR should be factored into the assessment of AS severity to mitigate for potential underestimation.
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Affiliation(s)
- Michael Šeman
- School of Public Health and Preventative MedicineMonash UniversityMelbourneAustralia
- Cardio‐Respiratory Engineering and Technology LaboratoryBaker Heart and Diabetes InstituteMelbourneAustralia
- Department of Cardiology – Alfred HealthMelbourneAustralia
| | - Andrew F. Stephens
- Cardio‐Respiratory Engineering and Technology LaboratoryBaker Heart and Diabetes InstituteMelbourneAustralia
- Department of Mechanical and Aerospace EngineeringMonash UniversityMelbourneAustralia
| | - Antony Walton
- Department of Cardiology – Alfred HealthMelbourneAustralia
- Baker IDI Heart and Diabetes Institute and Alfred HospitalMelbourneAustralia
- School of Medicine, Monash UniversityMelbourneAustralia
| | - Stephen J. Duffy
- School of Public Health and Preventative MedicineMonash UniversityMelbourneAustralia
- Department of Cardiology – Alfred HealthMelbourneAustralia
- Baker IDI Heart and Diabetes Institute and Alfred HospitalMelbourneAustralia
| | - David McGiffin
- Cardio‐Respiratory Engineering and Technology LaboratoryBaker Heart and Diabetes InstituteMelbourneAustralia
- School of Medicine, Monash UniversityMelbourneAustralia
- Department of Cardiothoracic Surgery – Alfred HealthMelbourneAustralia
| | - Shane Nanayakkara
- Department of Cardiology – Alfred HealthMelbourneAustralia
- Baker IDI Heart and Diabetes Institute and Alfred HospitalMelbourneAustralia
- School of Medicine, Monash UniversityMelbourneAustralia
| | - David M. Kaye
- Cardio‐Respiratory Engineering and Technology LaboratoryBaker Heart and Diabetes InstituteMelbourneAustralia
- Department of Cardiology – Alfred HealthMelbourneAustralia
- Baker IDI Heart and Diabetes Institute and Alfred HospitalMelbourneAustralia
- School of Medicine, Monash UniversityMelbourneAustralia
| | - Shaun D. Gregory
- Cardio‐Respiratory Engineering and Technology LaboratoryBaker Heart and Diabetes InstituteMelbourneAustralia
- Department of Mechanical and Aerospace EngineeringMonash UniversityMelbourneAustralia
| | - Dion Stub
- School of Public Health and Preventative MedicineMonash UniversityMelbourneAustralia
- Cardio‐Respiratory Engineering and Technology LaboratoryBaker Heart and Diabetes InstituteMelbourneAustralia
- Department of Cardiology – Alfred HealthMelbourneAustralia
- Baker IDI Heart and Diabetes Institute and Alfred HospitalMelbourneAustralia
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4
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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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5
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Li T, Liu Z, Hu J, Chen L, Chen T, Tang Q, Yu B, Zhao B, Mao C, Wan M. A Universal Chemotactic Targeted Delivery Strategy for Inflammatory Diseases. ADVANCED MATERIALS (DEERFIELD BEACH, FLA.) 2022; 34:e2206654. [PMID: 36122571 DOI: 10.1002/adma.202206654] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 09/13/2022] [Indexed: 06/15/2023]
Abstract
Above 50% of deaths can be attributed to chronic inflammatory diseases; thus, the construction of drug delivery systems based on effective interaction of inflammatory factors with chemotactic nanoparticles is meaningful. Herein, a zwitterion-based artificial chemotactic nanomotor is proposed for universal precise targeting strategy in vivo, where the high level of reactive oxygen species (ROS) and inducible nitric oxide synthase (iNOS) in inflammatory sites are used as a chemoattractant. Multidimensional static models, dynamic models, and in vivo models are established to evaluate chemotactic performance. The results show that the upregulated ROS and iNOS can induce the chemotaxis of nanomotors to diseased tissues in inflammation-related disease models. Further, mesoscale hydrodynamics simulations are performed to explain the chemotactic behavior of the nanomotors. Such a chemotactic delivery strategy is expected to improve delivery efficiency and may be applicable to a variety of inflammatory diseases.
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Affiliation(s)
- Ting Li
- National and Local Joint Engineering Research Center of Biomedical Functional Materials, School of Chemistry and Materials Science, Nanjing Normal University, Nanjing, 210023, China
| | - Zhiyong Liu
- National and Local Joint Engineering Research Center of Biomedical Functional Materials, School of Chemistry and Materials Science, Nanjing Normal University, Nanjing, 210023, China
| | - Jinglei Hu
- Kuang Yaming Honors School, Nanjing University, Nanjing, 210023, China
| | - Lin Chen
- National and Local Joint Engineering Research Center of Biomedical Functional Materials, School of Chemistry and Materials Science, Nanjing Normal University, Nanjing, 210023, China
| | - Tiantian Chen
- National and Local Joint Engineering Research Center of Biomedical Functional Materials, School of Chemistry and Materials Science, Nanjing Normal University, Nanjing, 210023, China
| | - Qianqian Tang
- National and Local Joint Engineering Research Center of Biomedical Functional Materials, School of Chemistry and Materials Science, Nanjing Normal University, Nanjing, 210023, China
| | - Bixia Yu
- National and Local Joint Engineering Research Center of Biomedical Functional Materials, School of Chemistry and Materials Science, Nanjing Normal University, Nanjing, 210023, China
| | - Bo Zhao
- National and Local Joint Engineering Research Center of Biomedical Functional Materials, School of Chemistry and Materials Science, Nanjing Normal University, Nanjing, 210023, China
| | - Chun Mao
- National and Local Joint Engineering Research Center of Biomedical Functional Materials, School of Chemistry and Materials Science, Nanjing Normal University, Nanjing, 210023, China
| | - Mimi Wan
- National and Local Joint Engineering Research Center of Biomedical Functional Materials, School of Chemistry and Materials Science, Nanjing Normal University, Nanjing, 210023, China
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6
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2020 ACC/AHA guideline for the management of patients with valvular heart disease: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Thorac Cardiovasc Surg 2021; 162:e183-e353. [PMID: 33972115 DOI: 10.1016/j.jtcvs.2021.04.002] [Citation(s) in RCA: 90] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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7
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Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2021; 143:e72-e227. [PMID: 33332150 DOI: 10.1161/cir.0000000000000923] [Citation(s) in RCA: 555] [Impact Index Per Article: 185.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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8
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Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2021; 77:e25-e197. [PMID: 33342586 DOI: 10.1016/j.jacc.2020.11.018] [Citation(s) in RCA: 837] [Impact Index Per Article: 279.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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9
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Izumi C, Eishi K, Ashihara K, Arita T, Otsuji Y, Kunihara T, Komiya T, Shibata T, Seo Y, Daimon M, Takanashi S, Tanaka H, Nakatani S, Ninami H, Nishi H, Hayashida K, Yaku H, Yamaguchi J, Yamamoto K, Watanabe H, Abe Y, Amaki M, Amano M, Obase K, Tabata M, Miura T, Miyake M, Murata M, Watanabe N, Akasaka T, Okita Y, Kimura T, Sawa Y, Yoshida K. JCS/JSCS/JATS/JSVS 2020 Guidelines on the Management of Valvular Heart Disease. Circ J 2020; 84:2037-2119. [DOI: 10.1253/circj.cj-20-0135] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Chisato Izumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Kiyoyuki Eishi
- Division of Cardiovascular Surgery, Nagasaki University Graduate School of Biomedical Sciences
| | - Kyomi Ashihara
- Department of Cardiology, Tokyo Women’s Medical University Hospital
| | - Takeshi Arita
- Division of Cardiovascular Medicine Heart & Neuro-Vascular Center, Fukuoka Wajiro
| | - Yutaka Otsuji
- Department of Cardiology, Hospital of University of Occupational and Environmental Health
| | - Takashi Kunihara
- Department of Cardiac Surgery, The Jikei University School of Medicine
| | - Tatsuhiko Komiya
- Department of Cardiovascular Surgery, Kurashiki Central Hospital
| | - Toshihiko Shibata
- Department of Cardiovascular Surgery, Osaka City University Postgraduate of Medicine
| | - Yoshihiro Seo
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences
| | - Masao Daimon
- Department of Clinical Laboratory/Cardiology, The University of Tokyo Hospital
| | | | | | - Satoshi Nakatani
- Division of Health Sciences, Osaka University Graduate School of Medicine
| | - Hiroshi Ninami
- Department of Cardiac Surgery, Tokyo Women’s Medical University
| | - Hiroyuki Nishi
- Department of Cardiovascular Surgery, Osaka General Medical Center
| | | | - Hitoshi Yaku
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine
| | | | - Kazuhiro Yamamoto
- Division of Cardiovascular Medicine, Endocrinology and Metabolism, Faculty of Medicine, Tottori University
| | | | - Yukio Abe
- Department of Cardiology, Osaka City General Hospital
| | - Makoto Amaki
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Masashi Amano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Kikuko Obase
- Division of Cardiovascular Surgery, Nagasaki University Graduate School of Biomedical Sciences
| | - Minoru Tabata
- Department of Cardiovascular Surgery, Tokyo Bay Urayasu Ichikawa Medical Center
| | - Takashi Miura
- Division of Cardiovascular Surgery, Nagasaki University Graduate School of Biomedical Sciences
| | | | - Mitsushige Murata
- Department of Laboratory Medicine, Tokai University Hachioji Hospital
| | - Nozomi Watanabe
- Department of Cardiology, Miyazaki Medical Association Hospital
| | - Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Yutaka Okita
- Department of Cardiovascular Surgery, Takatsuki Hospital
| | - Takeshi Kimura
- Department of Cardiology, Kyoto University Graduate School of Medicine
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Kiyoshi Yoshida
- Department of Cardiology, Sakakibara Heart Institute of Okayama
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10
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[A Case of Change from Normal-flow High-pressure Gradient Severe Aortic Stenosis to Paradoxical Low-flow Low-pressure Gradient Severe Aortic Stenosis]. J UOEH 2020; 42:291-295. [PMID: 32879194 DOI: 10.7888/juoeh.42.291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
We report a case of a 77-year-old male who had been diagnosed with normal-flow high-pressure gradient severe aortic stenosis (AS) two years previously. In accordance with his wishes, it was decided not to perform surgery. He visited our hospital with anorexia and weight loss and was diagnosed with gastric cancer. Echocardiography showed a change to paradoxical low-flow low-pressure gradient severe AS (PLFLPG AS). A decrease in stroke volume is typically associated with a smaller LV size, but the reason for a smaller LV size in PLFLPG AS remains unclear. In this case, the change to PLFLPG AS was thought to be due to a decrease in whole body oxygen consumption, and this may help to understand the pathology.
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11
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Kitai T, Tsutsui RS. The contemporary role of echocardiography in the assessment and management of aortic stenosis. J Med Ultrason (2001) 2019; 47:71-80. [PMID: 31792637 DOI: 10.1007/s10396-019-00991-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Accepted: 11/11/2019] [Indexed: 10/25/2022]
Abstract
Aortic stenosis (AS) represents a major healthcare issue because of its ever-increasing prevalence, poor prognosis, and complex pathophysiology. Echocardiography plays a central role in providing a comprehensive morphological and hemodynamic evaluation of AS. The diagnosis of severe AS is currently based on three hemodynamic parameters including maximal jet velocity, mean pressure gradient (mPG) across the aortic valve, and aortic valve area (AVA). However, inconsistent grading of AS severity is common when the AVA is < 1.0 cm2 but the mPG is < 40 mmHg, also known as low-gradient AS (LGAS). Special attention should be paid to patients with symptomatic LGAS with low stroke volume and/or low ejection fraction because this entity is more difficult to diagnose and has a worse prognosis. Stress echocardiography testing plays an important role in this disease entity. Elderly patients with prohibitive comorbidities for surgical aortic valve replacement (AVR) were without procedural options until the advent of transcatheter AVR (TAVR), which has dramatically changed these circumstances. Along with computed tomography, echocardiography plays a vital role in the periprocedural assessment of the aortic valve and surrounding apparatus. This review describes the evolution of the role of echocardiography in the diagnosis and management of AS, the complexity of the aortic apparatus, and the increased need for expert use of three-dimensional echocardiography.
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Affiliation(s)
- Takeshi Kitai
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-minamimachi, Chuo-ku, Kobe, 650-0047, Japan. .,Center for Clinical Research, Kobe City Medical Center General Hospital, Kobe, Japan.
| | - Rayji S Tsutsui
- Heart and Vascular Institute, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
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12
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Contemporary Imaging of Aortic Stenosis. Heart Lung Circ 2019; 28:1310-1319. [PMID: 31266725 DOI: 10.1016/j.hlc.2019.05.177] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 04/29/2019] [Accepted: 05/17/2019] [Indexed: 12/26/2022]
Abstract
Degenerative or fibrocalcific aortic stenosis (AS) is now the most common native valvular heart disease assessed and managed by cardiologists in developed countries. Transthoracic echocardiography remains the quintessential imaging modality for the non-invasive characterisation of AS due to its widespread availability, superior assessment of flow haemodynamics, and a wealth of prognostic data accumulated over decades of clinical utility and research applications. With expanding technologies and increasing availability of treatment options such as transcatheter aortic valve replacements, in addition to conventional surgical approaches, accurate and precise assessment of AS severity is critical to guide decisions for and timing of interventions. Despite clear guideline echocardiographic parameters demarcating severe AS, discrepancies between transvalvular velocities, gradients, and calculated valve areas are commonly encountered in clinical practice. This often results in diagnostically challenging cases with significant implications. Greater emphasis must be placed on the quality of performance of basic two dimensional (2D) and Doppler measurements (attention to detail ensuring accuracy and precision), incorporating ancillary haemodynamic surrogates, understanding study- or patient-specific confounders, and recognising the role and limitations of stress echocardiography in the subgroups of low-flow low-gradient AS. A multiparametric approach, along with the incorporation of multimodality imaging (cardiac computed tomography or magnetic resonance imaging) in certain scenarios, is now mandatory to avoid incorrect misclassification of severe AS. This is essential to ensure appropriate selection of patients who would most benefit from interventions on the aortic valve to relieve the afterload mismatch resulting from truly severe valvular stenosis.
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13
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Onoue T, Iwataki M, Araki M, Itoh H, Isotani A, Umeda H, Fukuda S, Nagata Y, Tsuda Y, Fujino Y, Hanyu M, Ando K, Shirai S, Takeuchi M, Saeki S, Levine RA, Otsuji Y. Insights into the mechanism of paradoxical low-flow, low-pressure gradient severe aortic stenosis: association with reduced O 2 consumption by the whole body. Am J Physiol Heart Circ Physiol 2019; 316:H840-H848. [PMID: 30681367 DOI: 10.1152/ajpheart.00715.2018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The mechanism of reduced stroke volume index (SVi) in paradoxical low-flow, low-pressure gradient (PLFLPG) aortic stenosis (AS) remains unclarified. Guyton et al. ( 21 ) demonstrated that SVi is determined by whole body O2 consumption (V̇o2) in many subjects, including patients with heart disease. We hypothesized that reduced SVi in PLFLPG AS is associated with reduced V̇o2 by the whole body. This study investigated the relationship between V̇o2, SVi, and AS severity in patients with AS to examine the association between reduced V̇o2 and PLFLPG AS. In 59 patients (24 men and 35 women, mean age: 78 ± 7 yr old) with severe AS, SVi, AS severity, and type were evaluated by echocardiography, and V̇o2 was measured by the fraction of O2 in expired gases. SVi and V̇o2 were significantly decreased in 20 patients with PLFLPG AS compared with 39 patients with non-PLFLPG AS (30 ± 4 vs. 41 ± 7 ml/m2 and 2.4 ± 0.5 vs. 3.0 ± 0.5 ml·min-1·kg-1, respectively, P < 0.01). The SVi-to-V̇o2 ratio was not different between the two groups (13.1 ± 2.6 vs. 13.6 ± 2.1, not significant). SVi was independently correlated with V̇o2 ( r = 0.74, P < 0.01) but not with the aortic valve area index. Categorized PLFLPG AS was also significantly associated with reduced V̇o2 ( P < 0.001). PLFLPG AS is associated with reduced V̇o2 by the whole body, which may offer insights into the mechanism of PLFLPG AS. NEW & NOTEWORTHY Paradoxical low-flow, low-pressure gradient severe aortic stenosis (PLFLPG AS) is an important and problematic subtype, and its central pathophysiology with reduced stroke volume is yet to be clarified. We hypothesized and subsequently clarified that reduced stroke volume in PLFLPG AS is associated with reduced O2 consumption by the whole body. This study suggests important insights into the mechanism of PLFLPG AS and may further promote studies to investigate further mechanisms and novel treatment.
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Affiliation(s)
- Takeshi Onoue
- Second Department of Internal Medicine, University of Occupational and Environmental Health, School of Medicine , Kitakyushu , Japan
| | - Mai Iwataki
- Second Department of Internal Medicine, University of Occupational and Environmental Health, School of Medicine , Kitakyushu , Japan
| | - Masaru Araki
- Second Department of Internal Medicine, University of Occupational and Environmental Health, School of Medicine , Kitakyushu , Japan
| | - Hideaki Itoh
- Department of Rehabilitation Medicine, University of Occupational and Environmental Health, School of Medicine , Kitakyushu , Japan
| | - Akihiro Isotani
- Department of Cardiology, Kokura Memorial Hospital , Kitakyushu , Japan
| | - Hiromi Umeda
- Department of Echocardiography, Kokura Memorial Hospital , Kitakyushu , Japan
| | - Shota Fukuda
- Second Department of Internal Medicine, University of Occupational and Environmental Health, School of Medicine , Kitakyushu , Japan
| | - Yasufumi Nagata
- Second Department of Internal Medicine, University of Occupational and Environmental Health, School of Medicine , Kitakyushu , Japan
| | - Yuki Tsuda
- Second Department of Internal Medicine, University of Occupational and Environmental Health, School of Medicine , Kitakyushu , Japan
| | - Yoshihisa Fujino
- Department of Environmental Epidemiology, University of Occupational and Environmental Health, School of Medicine , Kitakyushu , Japan
| | - Michiya Hanyu
- Department of Cardiovascular Surgery, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Kenji Ando
- Department of Cardiology, Kokura Memorial Hospital , Kitakyushu , Japan
| | - Shinichi Shirai
- Department of Cardiology, Kokura Memorial Hospital , Kitakyushu , Japan
| | - Masaaki Takeuchi
- Department of Laboratory and Transfusion Medicine, University of Occupational and Environmental Health, School of Medicine , Kitakyushu , Japan
| | - Satoru Saeki
- Department of Rehabilitation Medicine, University of Occupational and Environmental Health, School of Medicine , Kitakyushu , Japan
| | - Robert A Levine
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital , Boston
| | - Yutaka Otsuji
- Second Department of Internal Medicine, University of Occupational and Environmental Health, School of Medicine , Kitakyushu , Japan
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Baumgartner H, Hung J, Bermejo J, Chambers JB, Edvardsen T, Goldstein S, Lancellotti P, LeFevre M, Miller F, Otto CM. Recommendations on the echocardiographic assessment of aortic valve stenosis: a focused update from the European Association of Cardiovascular Imaging and the American Society of Echocardiography. Eur Heart J Cardiovasc Imaging 2018; 18:254-275. [PMID: 28363204 DOI: 10.1093/ehjci/jew335] [Citation(s) in RCA: 438] [Impact Index Per Article: 73.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 12/23/2016] [Indexed: 02/07/2023] Open
Abstract
Echocardiography is the key tool for the diagnosis and evaluation of aortic stenosis. Because clinical decision-making is based on the echocardiographic assessment of its severity, it is essential that standards are adopted to maintain accuracy and consistency across echocardiographic laboratories. Detailed recommendations for the echocardiographic assessment of valve stenosis were published by the European Association of Echocardiography and the American Society of Echocardiography in 2009. In the meantime, numerous new studies on aortic stenosis have been published with particular new insights into the difficult subgroup of low gradient aortic stenosis making an update of recommendations necessary. The document focuses in particular on the optimization of left ventricular outflow tract assessment, low flow, low gradient aortic stenosis with preserved ejection fraction, a new classification of aortic stenosis by gradient, flow and ejection fraction, and a grading algorithm for an integrated and stepwise approach of artic stenosis assessment in clinical practice.
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Affiliation(s)
- Helmut Baumgartner
- Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster, Muenster, Germany
| | - Judy Hung
- Division of Cardiology, Massachusetts General Hospital, Boston, MA, USA
| | - Javier Bermejo
- Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense de Madrid and CIBERCV, Madrid, Spain
| | | | - Thor Edvardsen
- Department of Cardiology and Center for Cardiological Innovation, Oslo University Hospital, Oslo and University of Oslo, Oslo, Norway
| | | | - Patrizio Lancellotti
- Universtiy of Liège Hospital, GIGA Cardiovascular Science, Heart Valve Clinic, Imaging Cardiology, Liège, Belgium and Gruppo Villa Maria Care and Research, Anthea Hospital, Bari, Italy
| | | | | | - Catherine M Otto
- Division of Cardiology, University of Washington School of Medicine, Seattle, WA, USA
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15
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Gamaza-Chulián S, Díaz-Retamino E, Camacho-Freire S, Ruiz-Fernández D, Gutiérrez-Barrios A, Oneto-Otero J. Acceleration Time and Ratio of Acceleration Time to Ejection Time in Aortic Stenosis: New Echocardiographic Diagnostic Parameters. J Am Soc Echocardiogr 2017; 30:947-955. [DOI: 10.1016/j.echo.2017.06.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Indexed: 02/05/2023]
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16
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Ringle A, Levy F, Ennezat PV, Le Goffic C, Castel AL, Delelis F, Menet A, Malaquin D, Graux P, Vincentelli A, Tribouilloy C, Maréchaux S. Relationship between exercise pressure gradient and haemodynamic progression of aortic stenosis. Arch Cardiovasc Dis 2017; 110:466-474. [PMID: 28395958 DOI: 10.1016/j.acvd.2016.12.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Revised: 07/02/2016] [Accepted: 12/15/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND AIMS We hypothesized that large exercise-induced increases in aortic mean pressure gradient can predict haemodynamic progression during follow-up in asymptomatic patients with aortic stenosis. METHODS We retrospectively identified patients with asymptomatic moderate or severe aortic stenosis (aortic valve area<1.5cm2 or<1cm2) and normal ejection fraction, who underwent an exercise stress echocardiography at baseline with a normal exercise test and a resting echocardiography during follow-up. The relationship between exercise-induced increase in aortic mean pressure gradient and annualised changes in resting mean pressure gradient during follow-up was investigated. RESULTS Fifty-five patients (mean age 66±15 years; 45% severe aortic stenosis) were included. Aortic mean pressure gradient significantly increased from rest to peak exercise (P<0.001). During a median follow-up of 1.6 [1.1-3.2] years, resting mean pressure gradient increased from 35±13mmHg to 48±16mmHg, P<0.0001. Median annualised change in resting mean pressure gradient during follow-up was 5 [2-11] mmHg. Exercise-induced increase in aortic mean pressure gradient did correlate with annualised changes in mean pressure gradient during follow-up (r=0.35, P=0.01). Hemodynamic progression of aortic stenosis was faster in patients with large exercise-induced increase in aortic mean pressure gradient (≥20mmHg) as compared to those with exercise-induced increase in aortic mean pressure gradient<20mmHg (median annualised increase in mean pressure gradient 19 [6-28] vs. 4 [2-10] mmHg/y respectively, P=0.002). Similar results were found in the subgroup of 30 patients with moderate aortic stenosis. CONCLUSION Large exercise-induced increases in aortic mean pressure gradient correlate with haemodynamic progression of stenosis during follow-up in patients with asymptomatic aortic stenosis. Further studies are needed to fully establish the role of ESE in the decision-making process in comparison to other prognostic markers in asymptomatic patients with aortic stenosis.
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Affiliation(s)
- Anne Ringle
- Service de cardiologie, GCS-groupement des hôpitaux de l'institut catholique de Lille, faculté libre de médecine, université catholique de Lille, 59000 Lille, France
| | - Franck Levy
- Service de cardiologie B, CHU d'Amiens, 80054 Amiens, France
| | | | - Caroline Le Goffic
- Service de cardiologie, GCS-groupement des hôpitaux de l'institut catholique de Lille, faculté libre de médecine, université catholique de Lille, 59000 Lille, France
| | - Anne-Laure Castel
- Service de cardiologie, GCS-groupement des hôpitaux de l'institut catholique de Lille, faculté libre de médecine, université catholique de Lille, 59000 Lille, France
| | - François Delelis
- Service de cardiologie, GCS-groupement des hôpitaux de l'institut catholique de Lille, faculté libre de médecine, université catholique de Lille, 59000 Lille, France
| | - Aymeric Menet
- Service de cardiologie, GCS-groupement des hôpitaux de l'institut catholique de Lille, faculté libre de médecine, université catholique de Lille, 59000 Lille, France
| | | | - Pierre Graux
- Service de cardiologie, GCS-groupement des hôpitaux de l'institut catholique de Lille, faculté libre de médecine, université catholique de Lille, 59000 Lille, France
| | | | - Christophe Tribouilloy
- Service de cardiologie B, CHU d'Amiens, 80054 Amiens, France; Inserm U 1088, université de Picardie, 80054 Amiens, France
| | - Sylvestre Maréchaux
- Service de cardiologie, GCS-groupement des hôpitaux de l'institut catholique de Lille, faculté libre de médecine, université catholique de Lille, 59000 Lille, France; Inserm U 1088, université de Picardie, 80054 Amiens, France.
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17
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Vamvakidou A, Chahal N, Senior R. Lack of Stroke Volume Determined Flow Reserve Does Not Always Preclude Assessment of Severity of Aortic Stenosis in Low-Flow Low-Gradient State During Dobutamine Echocardiography. JACC Cardiovasc Imaging 2017; 10:491-493. [DOI: 10.1016/j.jcmg.2016.04.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Revised: 03/18/2016] [Accepted: 04/16/2016] [Indexed: 11/25/2022]
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18
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Recommendations on the Echocardiographic Assessment of Aortic Valve Stenosis: A Focused Update from the European Association of Cardiovascular Imaging and the American Society of Echocardiography. J Am Soc Echocardiogr 2017; 30:372-392. [DOI: 10.1016/j.echo.2017.02.009] [Citation(s) in RCA: 524] [Impact Index Per Article: 74.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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19
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Pérez del Villar C, Yotti R, Espinosa MÁ, Gutiérrez-Ibañes E, Barrio A, Lorenzo MJ, Sánchez Fernández PL, Benito Y, Prieto R, Pérez David E, Martínez-Legazpi P, Fernández-Avilés F, Bermejo J. The Functional Significance of Paradoxical Low-Gradient Aortic Valve Stenosis. JACC Cardiovasc Imaging 2017; 10:29-39. [DOI: 10.1016/j.jcmg.2016.03.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 02/29/2016] [Accepted: 03/03/2016] [Indexed: 10/21/2022]
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20
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Exercise echocardiography in asymptomatic severe aortic stenosis. Int J Cardiovasc Imaging 2015; 31:1561-2. [PMID: 26271199 DOI: 10.1007/s10554-015-0735-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 08/04/2015] [Indexed: 10/23/2022]
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21
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Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA, O’Gara PT, Ruiz CE, Skubas NJ, Sorajja P, Sundt TM, Thomas JD, Anderson JL, Halperin JL, Albert NM, Bozkurt B, Brindis RG, Creager MA, Curtis LH, DeMets D, Guyton RA, Hochman JS, Kovacs RJ, Ohman EM, Pressler SJ, Sellke FW, Shen WK, Stevenson WG, Yancy CW. 2014 AHA/ACC guideline for the management of patients with valvular heart disease. J Thorac Cardiovasc Surg 2014; 148:e1-e132. [DOI: 10.1016/j.jtcvs.2014.05.014] [Citation(s) in RCA: 631] [Impact Index Per Article: 63.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA, O'Gara PT, Ruiz CE, Skubas NJ, Sorajja P, Sundt TM, Thomas JD. 2014 AHA/ACC Guideline 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. Circulation 2014; 129:e521-643. [PMID: 24589853 DOI: 10.1161/cir.0000000000000031] [Citation(s) in RCA: 884] [Impact Index Per Article: 88.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA, O'Gara PT, Ruiz CE, Skubas NJ, Sorajja P, Sundt TM, Thomas JD. 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 129:2440-92. [PMID: 24589852 DOI: 10.1161/cir.0000000000000029] [Citation(s) in RCA: 1041] [Impact Index Per Article: 104.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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24
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Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA, O'Gara PT, Ruiz CE, Skubas NJ, Sorajja P, Sundt TM, Thomas JD. 2014 AHA/ACC guideline 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. J Am Coll Cardiol 2014; 63:2438-88. [PMID: 24603191 DOI: 10.1016/j.jacc.2014.02.537] [Citation(s) in RCA: 1359] [Impact Index Per Article: 135.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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25
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Abstract
Aortic stenosis is the most commonly encountered valvular disease in the elderly, with approximately 2-3% of individuals over 65 years of age afflicted. The most common cause of acquired aortic stenosis is calcific degeneration, characterized by a slowly progressive, asymptomatic period which can last decades. Once symptomatic, the clinical manifestation of aortic stenosis is from functional obstruction of left ventricular outflow and the additional hemodynamic effects on the left ventricle and vasculature. With advances in echocardiography, individuals with aortic stenosis are increasingly diagnosed in the asymptomatic latent period. However, echocardiographic measures alone cannot identify clinically significant outflow obstruction as there is considerable overlap in hemodynamic severity between symptomatic and asymptomatic individuals. Current clinical guidelines predicate the timing of surgical valve replacement on the presence or absence of symptoms. Management for symptomatic, significant stenosis is surgical valve replacement as there are no current medical therapies reliably proven to decrease aortic stenosis severity or improve long-term outcomes. However, recent retrospective studies have demonstrated an association between atherosclerotic disease risk factors, such as hyperlipidemia and aortic stenosis. Given these findings, there are now advocates for prospective primary prevention trials for aortic stenosis in patients with mild or moderate valvular disease. The following paper will discuss etiology, diagnostic evaluation and therapeutic options of acquired aortic stenosis. This review will discuss etiology, diagnostic evaluation, and therapeutic options of acquired aortic stenosis.
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Affiliation(s)
- Rosario V Freeman
- Division of Cardiology, University of Washington, Seattle 98109, USA.
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26
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Dal-Bianco JP, Sengupta PP, Khandheria BK. Role of echocardiography in the diagnosis and management of asymptomatic severe aortic stenosis. Expert Rev Cardiovasc Ther 2014; 6:223-33. [DOI: 10.1586/14779072.6.2.223] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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27
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Lee HF, Hsu LA, Chan YH, Wang CL, Chang CJ, Kuo CT. Prognostic value of global left ventricular strain for conservatively treated patients with symptomatic aortic stenosis. J Cardiol 2013; 62:301-6. [PMID: 23867330 DOI: 10.1016/j.jjcc.2013.05.001] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Revised: 04/23/2013] [Accepted: 05/06/2013] [Indexed: 12/18/2022]
Abstract
AIMS Impaired left ventricular (LV) strain is associated with an increased risk of cardiac events in asymptomatic severe aortic stenosis (AS). We aimed to evaluate the prognostic value of global LV strain in conservatively treated patients with symptomatic AS. METHODS AND RESULTS This cohort study retrospectively reviewed symptomatic AS patients who were treated conservatively or surgically between July 2007 and April 2010. We measured their global longitudinal strain (GLS) and global circumferential strain (GCS). Clinical events were defined as readmission for heart failure or all-cause death for 2 years. GLS and GCS could predict a worse outcome in the conservatively treated group at cut-offs of =-16.5% (77% sensitivity and 67% specificity) and =-22.2% (92% sensitivity and 83% specificity), respectively. By univariate Cox regression analysis, age, logistic EuroSCORE, aortic valve area, GLS, and GCS were significant predictors. When adjusted for age, logistic EuroSCORE, and aortic valve area, impaired GLS and GCS were independently associated with a higher risk of clinical events. CONCLUSION In conservatively treated patients with symptomatic AS, impaired GLS and GCS were associated with an increased risk of cardiac events during a 2-year follow-up. Global LV strain may help to define a higher risk subset; therefore, a larger and prospective observation study would be necessary.
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Affiliation(s)
- Hsin-Fu Lee
- First Division of Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, 5, Fushin Street, Kweishan Hsiang, Taoyuan, Taiwan
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Bhattacharyya S, Khattar R, Chahal N, Moat N, Senior R. Dynamic Assessment of Stenotic Valvular Heart Disease by Stress Echocardiography. Circ Cardiovasc Imaging 2013; 6:583-9. [DOI: 10.1161/circimaging.113.000201] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Sanjeev Bhattacharyya
- From the Department of Cardiology and Echocardiography Laboratory (S.B., R.K., N.C., R.S.), Department of Cardiovascular Surgery (N.M.), Royal Brompton Hospital, London, United Kingdom; and Biomedical Research Unit, National Heart and Lung Institute, Imperial College London, London, United Kingdom (R.S.)
| | - Rajdeep Khattar
- From the Department of Cardiology and Echocardiography Laboratory (S.B., R.K., N.C., R.S.), Department of Cardiovascular Surgery (N.M.), Royal Brompton Hospital, London, United Kingdom; and Biomedical Research Unit, National Heart and Lung Institute, Imperial College London, London, United Kingdom (R.S.)
| | - Nav Chahal
- From the Department of Cardiology and Echocardiography Laboratory (S.B., R.K., N.C., R.S.), Department of Cardiovascular Surgery (N.M.), Royal Brompton Hospital, London, United Kingdom; and Biomedical Research Unit, National Heart and Lung Institute, Imperial College London, London, United Kingdom (R.S.)
| | - Neil Moat
- From the Department of Cardiology and Echocardiography Laboratory (S.B., R.K., N.C., R.S.), Department of Cardiovascular Surgery (N.M.), Royal Brompton Hospital, London, United Kingdom; and Biomedical Research Unit, National Heart and Lung Institute, Imperial College London, London, United Kingdom (R.S.)
| | - Roxy Senior
- From the Department of Cardiology and Echocardiography Laboratory (S.B., R.K., N.C., R.S.), Department of Cardiovascular Surgery (N.M.), Royal Brompton Hospital, London, United Kingdom; and Biomedical Research Unit, National Heart and Lung Institute, Imperial College London, London, United Kingdom (R.S.)
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29
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Svensson LG, Adams DH, Bonow RO, Kouchoukos NT, Miller DC, O'Gara PT, Shahian DM, Schaff HV, Akins CW, Bavaria JE, Blackstone EH, David TE, Desai ND, Dewey TM, D'Agostino RS, Gleason TG, Harrington KB, Kodali S, Kapadia S, Leon MB, Lima B, Lytle BW, Mack MJ, Reardon M, Reece TB, Reiss GR, Roselli EE, Smith CR, Thourani VH, Tuzcu EM, Webb J, Williams MR. Aortic Valve and Ascending Aorta Guidelines for Management and Quality Measures. Ann Thorac Surg 2013; 95:S1-66. [DOI: 10.1016/j.athoracsur.2013.01.083] [Citation(s) in RCA: 160] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2012] [Revised: 12/24/2012] [Accepted: 01/15/2013] [Indexed: 12/31/2022]
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30
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Svensson LG, Adams DH, Bonow RO, Kouchoukos NT, Miller DC, O'Gara PT, Shahian DM, Schaff HV, Akins CW, Bavaria J, Blackstone EH, David TE, Desai ND, Dewey TM, D'Agostino RS, Gleason TG, Harrington KB, Kodali S, Kapadia S, Leon MB, Lima B, Lytle BW, Mack MJ, Reece TB, Reiss GR, Roselli E, Smith CR, Thourani VH, Tuzcu EM, Webb J, Williams MR. Aortic valve and ascending aorta guidelines for management and quality measures: executive summary. Ann Thorac Surg 2013; 95:1491-505. [PMID: 23291103 DOI: 10.1016/j.athoracsur.2012.12.027] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2012] [Revised: 12/24/2012] [Accepted: 12/28/2012] [Indexed: 12/24/2022]
Abstract
The Society of Thoracic Surgeons Clinical Practice Guidelines are intended to assist physicians and other health care providers in clinical decision making by describing a range of generally acceptable approaches for the diagnosis, management, or prevention of specific diseases or conditions. These guidelines should not be considered inclusive of all proper methods of care or exclusive of other methods of care reasonably directed at obtaining the same results. Moreover, these guidelines are subject to change over time, without notice. The ultimate judgment regarding the care of a particular patient must be made by the physician in light of the individual circumstances presented by the patient.
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Affiliation(s)
- Lars G Svensson
- The Cleveland Clinic, 9500 Euclid Ave, Desk F-25 CT Surgery, Cleveland, OH 44195, USA.
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31
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Abstract
Cardiovascular surgery for the repair or replacement of diseased heart valves has continually improved since its introduction in the early 1960s. Despite advances in prosthetic heart valve design, to date there is no valve that is comparable to the native human valve with respect to durability, risk of thrombosis, and overall hemodynamic function. Although bioprosthetic devices are similar to the native valve with respect to thrombogenicity, durability is a significant concern, particularly in younger patients. Approximately 45% of implanted bioprosthetic valves fail at 10 years. In contrast, mechanical prostheses have a significantly lower incidence of structural failure, with an implantation life of greater than 20 years, and are thus more often used for patients under the age of 65. Unfortunately, significant hemodynamic and thrombotic issues have yet to be resolved with the latest generation of mechanical valves. Thus, careful analysis of patient factors and valve-related complications must be considered when treatment of heart valve disease is offered to the patient. The purpose of this review is to discuss the current recommendations for surgical intervention for heart valve disease.
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Affiliation(s)
- Robert P Gallegos
- Division of Cardiovascular and Thoracic Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
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Maréchaux S, Hachicha Z, Bellouin A, Dumesnil JG, Meimoun P, Pasquet A, Bergeron S, Arsenault M, Le Tourneau T, Ennezat PV, Pibarot P. Usefulness of exercise-stress echocardiography for risk stratification of true asymptomatic patients with aortic valve stenosis. Eur Heart J 2010; 31:1390-7. [PMID: 20308041 PMCID: PMC2878968 DOI: 10.1093/eurheartj/ehq076] [Citation(s) in RCA: 179] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Aims Abnormal exercise test defined as the occurrence of exercise limiting symptoms, fall in blood pressure below baseline, or complex ventricular arrhythmias is useful to predict clinical events in asymptomatic patients with aortic stenosis (AS). The purpose of this study was to determine whether exercise-stress echocardiography (ESE) adds any incremental prognostic value to resting echocardiography in patients with AS having a normal exercise response. Methods and results One hundred and eighty-six asymptomatic patients with at least moderate AS and preserved LV ejection fraction (>/=50%) were assessed by Doppler-echocardiography at rest and during a maximum ramp semi-supine bicycle exercise test. Fifty-one (27%) patients had an abnormal exercise test and were excluded from the present analysis. Among the 135 patients with normal exercise test, 67 had an event (aortic valve replacement motivated by symptoms or cardiovascular death) at a mean follow-up of 20 +/- 14 months. The variables independently associated with events were: age >/=65 years [hazard ratio (HR) = 1.96; 95% confidence interval (CI): 1.15-3.47; P = 0.01], diabetes, (HR = 3.20; 95% CI: 1.33-6.87; P = 0.01), LV hypertrophy (HR = 1.96; 95% CI: 1.17-3.27; P = 0.01), resting mean gradient >35 mmHg (HR = 3.60; 95% CI: 2.11-6.37; P < 0.0001), and exercise-induced increase in mean gradient >20 mmHg (HR = 3.83; 95% CI: 2.16-6.67; P < 0.0001). Conclusion The exercise-induced increase in transvalvular gradient may be helpful to improve risk stratification in asymptomatic AS patients with normal exercise response. These results thus suggest that ESE may provide additional prognostic information over that obtained from standard exercise testing and resting echocardiography.
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Affiliation(s)
- Sylvestre Maréchaux
- Centre Hospitalier Régional et Universitaire de Lille, EA2693, Lille F-59019, France
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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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Meta-analysis of prognostic value of stress testing in patients with asymptomatic severe aortic stenosis. Am J Cardiol 2009; 104:972-7. [PMID: 19766766 DOI: 10.1016/j.amjcard.2009.05.044] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2009] [Revised: 05/13/2009] [Accepted: 05/13/2009] [Indexed: 11/21/2022]
Abstract
The management strategy in asymptomatic patients with severe aortic stenosis (AS) is controversial. Aortic valve replacement has significant morbidity and mortality, while there is a risk for sudden cardiac death with conservative management. There is no consensus on the prognostic value of stress testing to stratify management. A pooled analysis of studies in patients with severe AS was performed to assess the prognostic value of stress testing for adverse events, including angina, dyspnea, acute heart failure, sudden death, and symptoms requiring aortic valve replacement. A search of published research was performed using the terms "stress test" and "asymptomatic aortic stenosis." A random-effects model was used to calculate pooled odds ratios and 95% confidence intervals. Data from 7 studies were included (491 patients with asymptomatic severe AS). None of the patients experienced any complications during or after stress testing. There were no sudden deaths in the patients with normal stress test results after 1 year of follow-up, while 5% with abnormal stress test results had sudden cardiac death. Overall, 52 of 253 patients (21%) with normal stress test results had adverse cardiac events, compared with 156 of 238 (66%) with abnormal stress test results (odds ratio 0.12, 95% confidence interval 0.07 to 0.21, p <0.001). In conclusion, stress testing in asymptomatic patients with severe AS is safe and identifies patients at risk for adverse cardiac events and sudden cardiac death. These data suggest that stress tests can be used for risk stratification and for deciding on the timing of aortic valve replacement in asymptomatic patients with severe AS.
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New concepts in valvular hemodynamics: implications for diagnosis and treatment of aortic stenosis. Can J Cardiol 2009; 23 Suppl B:40B-47B. [PMID: 17932586 DOI: 10.1016/s0828-282x(07)71009-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Aortic valve stenosis (AS) is the third-most frequent heart disease after coronary artery disease and arterial hypertension, and it is associated with a high incidence of adverse outcomes. Recent data support the notion that AS is not an isolated disease uniquely limited to the valve. Indeed, AS is frequently associated with abnormalities of the systemic arterial system, and, in particular, with reduced arterial compliance, which may have important consequences for the pathophysiology and clinical outcome of this disease. Moreover, AS may also be associated with left ventricular systolic dysfunction and reduced transvalvular flow rate, which pose important challenges with regards to diagnostic evaluation and clinical decision making in AS patients. Hence, the assessment of AS severity, as well as its therapeutic management, should be conducted with the use of a comprehensive evaluation that includes not only the aortic valve, but also the systemic arterial system and the left ventricle because these three entities are tightly coupled from both a pathophysiological and a hemodynamic standpoint.
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Leurent G, Donal E, de Place C, Chabanne C, Gervais R, Fougerou C, le Helloco A, Daubert JC, Mabo P, Laurent M. Argument for a Doppler echocardiography during exercise in assessing asymptomatic patients with severe aortic stenosis. EUROPEAN JOURNAL OF ECHOCARDIOGRAPHY 2009; 10:69-73. [DOI: 10.1093/ejechocard/jen163] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice. J Am Soc Echocardiogr 2009; 22:1-23; quiz 101-2. [PMID: 19130998 DOI: 10.1016/j.echo.2008.11.029] [Citation(s) in RCA: 1298] [Impact Index Per Article: 86.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Baumgartner H, Hung J, Bermejo J, Chambers JB, Evangelista A, Griffin BP, Iung B, Otto CM, Pellikka PA, Quiñones M. Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice. EUROPEAN JOURNAL OF ECHOCARDIOGRAPHY 2008; 10:1-25. [PMID: 19065003 DOI: 10.1093/ejechocard/jen303] [Citation(s) in RCA: 694] [Impact Index Per Article: 43.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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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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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. 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. Circulation 2008; 118:e523-661. [PMID: 18820172 DOI: 10.1161/circulationaha.108.190748] [Citation(s) in RCA: 698] [Impact Index Per Article: 43.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Sicari R, Nihoyannopoulos P, Evangelista A, Kasprzak J, Lancellotti P, Poldermans D, Voigt JU, Zamorano JL. Stress echocardiography expert consensus statement: European Association of Echocardiography (EAE) (a registered branch of the ESC). EUROPEAN JOURNAL OF ECHOCARDIOGRAPHY 2008; 9:415-37. [PMID: 18579481 DOI: 10.1093/ejechocard/jen175] [Citation(s) in RCA: 395] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Stress echocardiography is the combination of 2D echocardiography with a physical, pharmacological or electrical stress. The diagnostic end point for the detection of myocardial ischemia is the induction of a transient worsening in regional function during stress. Stress echocardiography provides similar diagnostic and prognostic accuracy as radionuclide stress perfusion imaging, but at a substantially lower cost, without environmental impact, and with no biohazards for the patient and the physician. Among different stresses of comparable diagnostic and prognostic accuracy, semisupine exercise is the most used, dobutamine the best test for viability, and dipyridamole the safest and simplest pharmacological stress and the most suitable for combined wall motion coronary flow reserve assessment. The additional clinical benefit of myocardial perfusion contrast echocardiography and myocardial velocity imaging has been inconsistent to date, whereas the potential of adding - coronary flow reserve evaluation of left anterior descending coronary artery by transthoracic Doppler echocardiography adds another potentially important dimension to stress echocardiography. New emerging fields of application taking advantage from the versatility of the technique are Doppler stress echo in valvular heart disease and in dilated cardiomyopathy. In spite of its dependence upon operator's training, stress echocardiography is today the best (most cost-effective and risk-effective) possible imaging choice to achieve the still elusive target of sustainable cardiac imaging in the field of noninvasive diagnosis of coronary artery disease.
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Affiliation(s)
- Rosa Sicari
- Institute of Clinical Physiology, Via G. Moruzzi, 1, 56124 Pisa, Italy.
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Nistri S, Galderisi M, Faggiano P, Antonini-Canterin F, Ansalone G, Dini FL, Di Salvo G, Gallina S, Mele D, Montisci R, Sciomer S, Di Bello V, Mondillo S, Marino PN. Practical echocardiography in aortic valve stenosis. J Cardiovasc Med (Hagerstown) 2008; 9:653-65. [DOI: 10.2459/jcm.0b013e3282f27d49] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Mascherbauer J, Fuchs C, Stoiber M, Schima H, Pernicka E, Maurer G, Baumgartner H. Systemic pressure does not directly affect pressure gradient and valve area estimates in aortic stenosis in vitro. Eur Heart J 2008; 29:2049-57. [PMID: 18502739 DOI: 10.1093/eurheartj/ehn209] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Julia Mascherbauer
- Department of Cardiology, Medical University of Vienna, Vienna General Hospital, Vienna, Austria.
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YEO KHUNGKEONG, LOW REGINALDI. Aortic Stenosis: Assessment of the Patient at Risk. J Interv Cardiol 2007; 20:509-16. [DOI: 10.1111/j.1540-8183.2007.00297.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Peidro R, Brión G, Angelino A. Exercise Testing in Asymptomatic Aortic Stenosis. Cardiology 2006; 108:258-64. [PMID: 17114879 DOI: 10.1159/000096953] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2005] [Accepted: 08/20/2006] [Indexed: 11/19/2022]
Abstract
AIMS To determine the safety of exercise testing (ET) in patients with moderate or severe asymptomatic aortic stenosis (AAS) and its accuracy to predict the need for surgery and mortality. METHODS 106 consecutive patients with AAS performed a maximal ET. RESULTS Follow-up [10.7 (4.9-19.4) months (percentile 25-75)] was completed in 102 patients (96.2%), 63.9 years (+/-15.1), 65 (61.3%) male, peak gradient 82.8 mm Hg (+/-25.4), mean gradient 50.5 mm Hg (+/-16.6), valve area 0.67 cm(2) (+/-0.16); 67 patients (65.7%) had abnormal ET. Among the 35 patients with normal ET, there were no deaths and 10 aortic valve replacements (AVR) (28.5%) were performed. Among the 67 patients with abnormal ET, 37 (55.2%) had events (35 AVR and 2 died) (p <0.0001). There were no complications with ET. CONCLUSION ET may be performed safely in patients with AAS. ET gives additional information to an AVR decision.
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Affiliation(s)
- Roberto Peidro
- Cardiovascular Rehabilitation Department, Favaloro Foundation, Buenos Aires, Argentina.
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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, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Lytle BW, Nishimura R, Page RL, Riegel B. 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) developed in collaboration with the Society of Cardiovascular Anesthesiologists endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. J Am Coll Cardiol 2006; 48:e1-148. [PMID: 16875962 DOI: 10.1016/j.jacc.2006.05.021] [Citation(s) in RCA: 1094] [Impact Index Per Article: 60.8] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Bonow RO, Carabello BA, Kanu C, 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, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Lytle BW, Nishimura R, Page RL, Riegel B. 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): developed in collaboration with the Society of Cardiovascular Anesthesiologists: endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. Circulation 2006; 114:e84-231. [PMID: 16880336 DOI: 10.1161/circulationaha.106.176857] [Citation(s) in RCA: 1391] [Impact Index Per Article: 77.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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ACC/AHA 2006 Practice Guidelines for the Management of Patients With Valvular Heart Disease: Executive Summary. J Am Coll Cardiol 2006. [DOI: 10.1016/j.jacc.2006.05.030] [Citation(s) in RCA: 131] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
Standard echocardiographic evaluation of aortic stenosis (AS) severity includes measurement of aortic velocity, mean transaortic pressure gradient, and continuity equation valve area. Although these measures are adequate for decision making in most patients, there is no single value that defines severe stenosis. Aortic stenosis affects not just the valve, but the entire vascular system, including the left ventricle (LV) and systemic vasculature. More sophisticated measures of disease severity might explain the apparent overlap in hemodynamic severity between symptomatic and asymptomatic patients and might better predict the optimal timing of valve replacement. There have been several approaches to evaluation of stenosis severity based on valve hemodynamics, the ventricular response to increased afterload, ventricular-vascular coupling, or the systemic functional consequences of valve obstruction, such as exercise testing and serum brain natriuretic peptide levels. Aortic valve replacement is indicated when symptoms due to severe AS are present. In most asymptomatic patients, the risk of surgery is greater than the risk of watchful waiting so that management includes patient education, periodic echocardiography, and cardiac risk factor modification. Many adults with AS have comorbid conditions that affect both the diagnosis and management of the valve disease, including aortic regurgitation, aortic root dilation, hypertension, coronary artery disease, LV dysfunction, and atrial fibrillation. Comorbid conditions should be evaluated and treated based on established guidelines, although awareness of the potential effects of therapy in the presence of valve obstruction is needed.
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Affiliation(s)
- Catherine M Otto
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, Washington 98195, USA.
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