1
|
Javadikasgari H, McGurk S, Newell PC, Awtry JA, Sabe AA, Kaneko T. Evolving Concept of Aortic Valve Replacement in Asymptomatic Patients With Severe Aortic Stenosis. Ann Thorac Surg 2024; 117:796-803. [PMID: 37660965 DOI: 10.1016/j.athoracsur.2023.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 08/06/2023] [Accepted: 08/14/2023] [Indexed: 09/05/2023]
Abstract
BACKGROUND Surgical treatment of asymptomatic severe aortic stenosis (AS) has been gaining attention ever since the results of the Early Surgery Versus Conventional Treatment in Very Severe Aortic Stenosis (RECOVERY) and Aortic Valve replacement versus conservative treatment in Asymptomatic seveRe aortic stenosis (AVATAR) trials showed survival benefits with early surgical aortic valve replacement (SAVR). This study analyzed the long-term clinical and echocardiographic outcomes of SAVR in asymptomatic severe AS. METHODS Between 2002 and 2020, 272 patients with asymptomatic severe AS and a left ventricular ejection fraction ≥50% underwent SAVR with or without concomitant aortic surgery and met the study criteria. The median follow-up was 8.5 years (interquartile range, 6-12.8 years), for a total of 2584 patient-years. The time course of the left ventricular mass index (LVMI) and the average E/E' (ratio of the Doppler-derived E wave to the tissue Doppler-derived E' wave) were assessed using 594 postoperative echocardiograms. The association of preoperative LVMI and average E/E' with survival was assessed using Cox proportional hazards. RESULTS There was no operative mortality. On longitudinal analyses, LVMI improved in patients who presented with moderate or severe preoperative left ventricular hypertrophy (LVH). However, after the early decline in average E/E', there was a late increase to greater than upper limit normal, particularly in patients with a preoperative average E/E'≥14. Postoperative survival was 100%, 94%, 84%, and 76% at 1, 5, 10, and 15 years, respectively, comparable to age- and sex-matched expected survival on the basis of the US general population. On adjusted Cox survival analysis, only moderate to severe LVH was associated with a survival penalty (hazard ratio], 2.32; 95% CI, 1.02-5.27; P = .045). CONCLUSIONS In asymptomatic patients with AS, SAVR restores survival and improves LVH, but patients with diastolic dysfunction are left with persistent dysfunction. Presentation with moderate or severe LVH at the time of surgery translated to a survival penalty. This observational study supports early SAVR in this population before development of LVH, although further investigation is needed.
Collapse
Affiliation(s)
- Hoda Javadikasgari
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Siobhan McGurk
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Paige C Newell
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jake A Awtry
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ashraf A Sabe
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Tsuyoshi Kaneko
- Mary Culver Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| |
Collapse
|
2
|
Buonocore M, De Meester P, Brusselmans M, Van Puyvelde T, Verrijcken A, Rega F, Verbelen T. Secondary tricuspid valve regurgitation after isolated aortic valve replacement: outcomes and predictors. Eur J Cardiothorac Surg 2023; 64:ezad275. [PMID: 37551943 DOI: 10.1093/ejcts/ezad275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 07/20/2023] [Accepted: 08/07/2023] [Indexed: 08/09/2023] Open
Abstract
OBJECTIVES We sought to assess the evolution of secondary tricuspid regurgitation (TR) after isolated aortic valve replacement (AVR) and its impact on mortality and to identify possible clinical and echocardiographic predictors of persisting and new-onset TR (TR de novo) after isolated AVR. METHODS Clinical and echocardiographic data of 441 patients, consecutively operated for isolated AVR between January 2017 and January 2020, were retrospectively collected. Four time points were included: preoperative, discharge, 3-6 months and last available follow-up. We followed patients with at least moderate TR (TR ≥2) over time and monitored the impact on survival. Logistic regression analysis was performed to identify possible predictors of persistent TR and TR de novo. RESULTS Median follow-up was 33 months. Incidence of TR ≥2 changed over the time points. Twenty-three percent of patients with preoperative TR ≥2 had persistent TR at 3-6 months follow-up, and this phenomenon was predicted by age at regression analysis. Preoperative TR ≥2 was associated with a 3-fold higher risk to die. At 3- to 6-month follow-up, 12% of patients developed TR de novo. At least moderate preoperative mitral regurgitation (≥2) was predictive of TR de novo. CONCLUSIONS Patients with TR ≥2 undergoing isolated AVR had worse long-term survival, and this was particularly evident in the elderly. Older patients were also more prone to have persistent TR after AVR. Some patients developed TR de novo after isolated AVR, but this did not affect survival.
Collapse
Affiliation(s)
- Marianna Buonocore
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Pieter De Meester
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Marius Brusselmans
- Department of Public Health and Primary Care, Leuven Biostatistics and Statistical Bioinformatics Centre, Catholic University of Leuven, Leuven, Belgium
| | - Tim Van Puyvelde
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | | | - Filip Rega
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Tom Verbelen
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| |
Collapse
|
3
|
Asheghan MM, Javadikasgari H, Attary T, Rouhollahi A, Straughan R, Willi JN, Awal R, Sabe A, de la Cruz KI, Nezami FR. Predicting one-year left ventricular mass index regression following transcatheter aortic valve replacement in patients with severe aortic stenosis: A new era is coming. Front Cardiovasc Med 2023; 10:1130152. [PMID: 37082454 PMCID: PMC10111021 DOI: 10.3389/fcvm.2023.1130152] [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: 12/22/2022] [Accepted: 03/16/2023] [Indexed: 04/22/2023] Open
Abstract
Aortic stenosis (AS) is the most common valvular heart disease in the western world, particularly worrisome with an ever-aging population wherein postoperative outcome for aortic valve replacement is strongly related to the timing of surgery in the natural course of disease. Yet, guidelines for therapy planning overlook insightful, quantified measures from medical imaging to educate clinical decisions. Herein, we leverage statistical shape analysis (SSA) techniques combined with customized machine learning methods to extract latent information from segmented left ventricle (LV) shapes. This enabled us to predict left ventricular mass index (LVMI) regression a year after transcatheter aortic valve replacement (TAVR). LVMI regression is an expected phenomena in patients undergone aortic valve replacement reported to be tightly correlated with survival one and five year after the intervention. In brief, LV geometries were extracted from medical images of a cohort of AS patients using deep learning tools, and then analyzed to create a set of statistical shape models (SSMs). Then, the supervised shape features were extracted to feed a support vector regression (SVR) model to predict the LVMI regression. The average accuracy of the predictions was validated against clinical measurements calculating root mean square error and R 2 score which yielded the satisfactory values of 0.28 and 0.67, respectively, on test data. Our work reveals the promising capability of advanced mathematical and bioinformatics approaches such as SSA and machine learning to improve medical output prediction and treatment planning.
Collapse
Affiliation(s)
- Mohammad Mostafa Asheghan
- Division of Thoracic and Cardiac Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Hoda Javadikasgari
- Division of Thoracic and Cardiac Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Taraneh Attary
- Bio-Intelligence Unit, Sharif Brain Center, Electrical Engineering Department, Sharif University of Technology, Tehran, Iran
| | - Amir Rouhollahi
- Division of Thoracic and Cardiac Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Ross Straughan
- Division of Thoracic and Cardiac Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - James Noel Willi
- Division of Thoracic and Cardiac Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Rabina Awal
- Mechanical Engineering Department, University of Louisiana at Lafayette, Louisiana, LA, United States
| | - Ashraf Sabe
- Division of Thoracic and Cardiac Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Kim I. de la Cruz
- Division of Thoracic and Cardiac Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Farhad R. Nezami
- Division of Thoracic and Cardiac Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
- Correspondence: Farhad R. Nezami
| |
Collapse
|
4
|
Iliuta L, Andronesi AG, Diaconu CC, Panaitescu E, Camburu G. Additional Prognostic Value of Tissue Doppler Evaluation in Patients with Aortic Stenosis and Left-Ventricular Systolic Dysfunction Undergoing Aortic Valve Replacement. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:1410. [PMID: 36295571 PMCID: PMC9610398 DOI: 10.3390/medicina58101410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 09/28/2022] [Accepted: 10/05/2022] [Indexed: 11/21/2022]
Abstract
Background and Objectives: Patients with surgical aortic stenosis (AS) show impaired diastolic filling, which is a risk factor for early and late mortality after aortic valve replacement (AVR). There is a paucity of information concerning the impact of restrictive diastolic filling and the evolution of diastolic dysfunction in the early and medium terms post-AVR. We aimed to determine the prognostic value of the presence of a restrictive left-ventricular (LV) diastolic filling pattern (LVDFP) and dilated left atrium (LA) in patients with AS and LV systolic dysfunction (LVEF < 40%) who underwent AVR, and to define the independent predictors for immediate and long-term prognosis and their value for preoperative risk estimation. Materials and Methods: The study was prospective and included 197 patients with surgical AS and LVEF <40% who underwent AVR. Preoperative echocardiographic examinations were repeated at day 10, at 1, 3 and 6 months, and at 1 and 2 years after surgery, with evaluation of LVEF, diastolic function and LA dimension index (mm/m2). Depending on LV systolic performance, patients were classified as Group A (LVEF: 30−40%) or Group B (LVEF < 30%). Results: The main echographic independent parameters for early and late postoperative death were: restrictive LVDFP, significant pulmonary hypertension, LV end-systolic diameter (LVESD) >55 mm and the presence of second-degree mitral regurgitation. Restrictive LVDFP and LA dimension >30 mm/m2 were independent predictors for fatal outcome (p = 0.0017). Conclusions: Assessment of diastolic function and LA dimension are reliable parameters in predicting fatal outcome and hospitalization for heart failure, having an independent and incremental prognostic value in patients with surgical AS. Complete evaluation of LVDFP with all the echographic measurements (including TDI) should routinely be part of the preoperative assessment of patients with LV systolic dysfunction undergoing AVR.
Collapse
Affiliation(s)
- Luminita Iliuta
- Department of Medical Informatics and Biostatistics, University of Medicine and Pharmacy “Carol Davila”, 050474 Bucharest, Romania
- Cardioclass Clinic for Cardiovascular Disease, 031125 Bucharest, Romania
| | - Andreea Gabriella Andronesi
- Nephrology Department, University of Medicine and Pharmacy “Carol Davila”, 050474 Bucharest, Romania
- Nephrology Department, Fundeni Clinical Institute, 022328 Bucharest, Romania
| | - Camelia Cristina Diaconu
- Internal Medicine Department, University of Medicine and Pharmacy “Carol Davila”, 050474 Bucharest, Romania
- Internal Medicine Clinic, Clinical Emergency Hospital of Bucharest, 014461 Bucharest, Romania
- Academy of Romanian Scientists, 3 Ilfov Street, 050044 Bucharest, Romania
| | - Eugenia Panaitescu
- Department of Medical Informatics and Biostatistics, University of Medicine and Pharmacy “Carol Davila”, 050474 Bucharest, Romania
| | - Georgiana Camburu
- Department of Medical Informatics and Biostatistics, University of Medicine and Pharmacy “Carol Davila”, 050474 Bucharest, Romania
| |
Collapse
|
5
|
Evaluation of left ventricular diastolic function in patients operated for aortic stenosis. PLoS One 2022; 17:e0263824. [PMID: 35213562 PMCID: PMC8880429 DOI: 10.1371/journal.pone.0263824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 01/27/2022] [Indexed: 11/20/2022] Open
Abstract
Background Left ventricular diastolic dysfunction is common in patients with aortic valve stenosis (AS) and reportedly affects prognosis after surgical aortic valve replacement (SAVR). Here we investigated whether and how diastolic function (assessed following the most recent guidelines) was affected by SAVR, and whether preoperative diastolic function affected postoperative outcome. We also examined whether long-term mortality was associated with preoperative NT-proBNP and postoperative heart failure (PHF). Methods We performed a prospective observational study of 273 patients with AS who underwent AVR with or without concomitant coronary artery bypass surgery. Of these patients, 247 were eligible for assessment of left ventricular (LV) filling pressure. Preoperatively and at the 6-month postoperative follow-up, we measured N-terminal pro-B type natriuretic peptide (NT-proBNP) in serum and assessed diastolic function with Doppler echocardiography. PHF was diagnosed using prespecified criteria. Multivariable logistic regression was performed to explore variables associated with high LV filling pressure. Cox regression was performed to explore variables associated with mortality, accounting for timeto-event. Results At the time of surgery, 22% (n = 54) of patients had diastolic dysfunction expressed as high LV filling pressure. Of these 54 patients, 27 (50%) showed postoperative diastolic function improvement. Among the 193 patients with preoperative low LV filling pressure, 24 (12%) showed postoperative diastolic function deterioration. Increased long-term mortality was associated with PHF and high preoperative NT-proBNP, but not with preoperative or postoperative diastolic dysfunction. Cox regression revealed the following independent risk factors for long-term mortality: diabetes, renal dysfunction, preoperative NT-proBNP>960 ng/L, age, and male gender. Conclusions Surgery for aortic stenosis improved diastolic function in patients with high LV filling pressure in 50% of the patients. Our results could not confirm the previously suggested role of diastolic dysfunction as a marker for poor long-term survival after SAVR. Our findings showed that both PHF and high preoperative NT-proBNP were associated with long-term mortality.
Collapse
|
6
|
Panç C, Güler A, Doğan AC, Gülmez R, Güner A, Çelik Ö. Fragmented QRS complex may predict long-term mortality after isolated surgical aortic valve replacement in patients with severe aortic stenosis. Interact Cardiovasc Thorac Surg 2022; 34:26-32. [PMID: 34999796 PMCID: PMC8923387 DOI: 10.1093/icvts/ivab214] [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: 03/02/2021] [Revised: 07/02/2021] [Accepted: 07/07/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Fragmented QRS (fQRS), related to myocardial fibrosis, is an important prognostic marker of cardiovascular events and mortality. Aortic stenosis (AS), the most frequent valvular heart disease in developed countries, causes myocardial fibrosis due to ventricular pressure overload. The current study aimed to investigate whether fQRS is associated with long-term mortality after isolated surgical aortic valve replacement (SAVR) in patients with severe AS. METHODS A total of 289 patients who underwent SAVR for severe AS between May 2009 and January 2020 with interpretable electrocardiogram were included. Patients were divided into 2 groups according to the presence of fQRS. Kaplan-Meier survival analyses were used to detect cumulative survival rates. Univariable and multivariable Cox proportional hazards models were used to determine the predictors of all-cause mortality. RESULTS fQRS occurred in 126 (43.5%) patients. A total of 59 (20.4%) patients died over a follow-up period of 54 ± 32 months. All-cause mortality was higher in the fQRS group (23 [14.1%] vs 36 [28.6], log-rank test P = 0.002) in the long term. The presence of fQRS [hazard ratio (HR): 1.802, confidence interval (CI): 1.035-3.135, P = 0.037], electrocardiographic left ventricular strain (HR: 1.836, CI: 1.036-3.254, P = 0.038) and history of stroke or transient ischaemic attack (HR: 3.130, CI: 1.528-6.412, P = 0.002) were independent predictors of all-cause mortality in the multivariable Cox regression model. CONCLUSIONS fQRS is associated with a 1.8-fold increase in long-term mortality in patients undergoing isolated SAVR for severe AS. Detecting fQRS in electrocardiograms may provide prognostic information about the long-term outcomes.
Collapse
Affiliation(s)
- Cafer Panç
- Department of Cardiology, University of Health Sciences, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, İstanbul, Turkey
| | - Arda Güler
- Department of Cardiology, University of Health Sciences, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, İstanbul, Turkey
| | - Arda Can Doğan
- Department of Cardiology, University of Health Sciences, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, İstanbul, Turkey
| | - Recep Gülmez
- Department of Cardiology, University of Health Sciences, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, İstanbul, Turkey
| | - Ahmet Güner
- Department of Cardiology, University of Health Sciences, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, İstanbul, Turkey
| | - Ömer Çelik
- Department of Cardiology, University of Health Sciences, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, İstanbul, Turkey
| |
Collapse
|
7
|
Carter-Storch R, Mortensen NSB, Ali M, Laursen K, Pellikka PA, Møller JE, Dahl JS. Assessment of diastolic function in aortic stenosis: A comparison between 2009 and 2016 guidelines. Echocardiography 2021; 38:2006-2015. [PMID: 34921437 DOI: 10.1111/echo.15230] [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: 03/10/2021] [Revised: 09/17/2021] [Accepted: 10/04/2021] [Indexed: 12/01/2022] Open
Abstract
AIMS New diastolic dysfunction (DD) guidelines were introduced in 2016 to replace the 2009 guidelines, but have not yet been evaluated in aortic stenosis (AS). We aimed to compare the 2009 and 2016 DD guidelines in severe AS patients in terms of association with left ventricular (LV) and left atrial (LA) remodeling, with pulmonary capillary wedge pressure (PCWP) at rest and exercise, and with prognosis. METHODS AND RESULTS We included 212 patients with severe AS (112 undergoing AVR, 100 asymptomatic). Echocardiography, magnetic resonance imaging, and brain natriuretic peptides (BNP) were performed/measured. Thirty-nine asymptomatic patients had PCWP measured during rest and maximal exertion. Asymptomatic patients were followed for 3.1 years for the combined endpoint of death, AVR or admission with heart failure. The 2009 and 2016 DD guidelines agreed poorly with each other (Cohens' κ = .15). 2009 guidelines showed many ambiguous DD findings. With the 2016 guidelines, 20% of patients had indeterminate DD. DD grade 2 according to 2016 guidelines showed stronger association with symptom status, BNP, global longitudinal strain (GLS) and peak exercise PCWP than 2009 guidelines. For indeterminate DD patients according to 2009 guidelines, GLS above the median was associated with event-free survival (HR .11 (95% CI .02-.53)). For neither guideline was DD associated with the combined endpoint in asymptomatic patients. CONCLUSION The 2016 guidelines show a stronger association with BNP, GLS, and exercise PCWP than the 2009 guidelines. The 2016 guidelines result in 20% of patients with indeterminate DD; however, these patients may possibly be stratified according to GLS.
Collapse
Affiliation(s)
- Rasmus Carter-Storch
- Department of Cardiology, Odense University Hospital, Odense, Denmark.,OPEN Odense Patient data Explorative Network, Odense, Denmark
| | | | - Mulham Ali
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Kristian Laursen
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Patricia A Pellikka
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jacob E Møller
- Department of Cardiology, Odense University Hospital, Odense, Denmark.,OPEN Odense Patient data Explorative Network, Odense, Denmark
| | - Jordi S Dahl
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| |
Collapse
|
8
|
Sabbah M, Joshi FR, Minkkinen M, Holmvang L, Tilsted HH, Pedersen F, Ahtarovski K, Sørensen R, Thue Olsen N, Søndergaard L, De Backer O, Engstrøm T, Lønborg J. Long-Term Changes in Invasive Physiological Pressure Indices of Stenosis Severity Following Transcatheter Aortic Valve Implantation. Circ Cardiovasc Interv 2021; 15:e011331. [PMID: 34809440 DOI: 10.1161/circinterventions.121.011331] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Patients with severe aortic stenosis frequently have coexisting coronary artery disease. Invasive hyperemic and nonhyperemic pressure indices are used to assess coronary artery disease severity but have not been evaluated in the context of severe aortic stenosis. METHODS We compared lesion reclassification rates of fractional flow reserve (FFR) and resting full-cycle ratio (RFR) measured before and 6 months after transcatheter aortic valve implantation using the conventional clinical cutoffs of ≤0.80 for FFR and ≤0.89 for RFR. This was a substudy of the ongoing NOTION-3 trial (Third Nordic Aortic Valve Intervention). Two-dimensional quantitative coronary analysis was used to assess changes in angiographic lesion severity. RESULTS Forty patients were included contributing 50 lesions in which FFR was measured. In 32 patients (36 lesions), RFR was also measured. There was no significant change in diameter stenosis from baseline to follow-up, 49.8% (42.9%-57.1%) versus 52.3% (43.2%-57.8%), P=0.50. RFR improved significantly from 0.88 (0.83%-0.93) at baseline to 0.92 (0.83-0.95) at follow-up, P=0.003, whereas FFR remained unchanged, 0.84 (0.81-0.89) versus 0.86 (0.78-0.90), P=0.72. At baseline, 11 out of 50 (22%) lesions were FFR-positive, whereas 15 out of 50 (30%) were positive at follow-up, P=0.219. Corresponding numbers for RFR were 23 out of 36 (64%) at baseline and 12 out of 36 (33%) at follow-up, P=0.003. CONCLUSIONS In patients with severe aortic stenosis, physiological assessment of coronary lesions with FFR before transcatheter aortic valve implantation leads to lower reclassification rate at 6-month follow-up, compared with RFR.
Collapse
Affiliation(s)
- Muhammad Sabbah
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark (M.S., F.R.J., M.M., L.H., H.-H.T., F.P., K.A., R.S., L.S., O.D.B., T.E., J.L.)
| | - Francis R Joshi
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark (M.S., F.R.J., M.M., L.H., H.-H.T., F.P., K.A., R.S., L.S., O.D.B., T.E., J.L.)
| | - Mikko Minkkinen
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark (M.S., F.R.J., M.M., L.H., H.-H.T., F.P., K.A., R.S., L.S., O.D.B., T.E., J.L.)
| | - Lene Holmvang
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark (M.S., F.R.J., M.M., L.H., H.-H.T., F.P., K.A., R.S., L.S., O.D.B., T.E., J.L.)
| | - Hans-Henrik Tilsted
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark (M.S., F.R.J., M.M., L.H., H.-H.T., F.P., K.A., R.S., L.S., O.D.B., T.E., J.L.)
| | - Frants Pedersen
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark (M.S., F.R.J., M.M., L.H., H.-H.T., F.P., K.A., R.S., L.S., O.D.B., T.E., J.L.)
| | - Kiril Ahtarovski
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark (M.S., F.R.J., M.M., L.H., H.-H.T., F.P., K.A., R.S., L.S., O.D.B., T.E., J.L.)
| | - Rikke Sørensen
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark (M.S., F.R.J., M.M., L.H., H.-H.T., F.P., K.A., R.S., L.S., O.D.B., T.E., J.L.)
| | - Niels Thue Olsen
- Department of Cardiology, Copenhagen University Hospital, Herlev and Gentofte, Denmark (N.T.O.).,Department of Clinical Medicine, University of Copenhagen, Denmark (N.T.O., L.S., T.E.)
| | - Lars Søndergaard
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark (M.S., F.R.J., M.M., L.H., H.-H.T., F.P., K.A., R.S., L.S., O.D.B., T.E., J.L.).,Department of Clinical Medicine, University of Copenhagen, Denmark (N.T.O., L.S., T.E.)
| | - Ole De Backer
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark (M.S., F.R.J., M.M., L.H., H.-H.T., F.P., K.A., R.S., L.S., O.D.B., T.E., J.L.)
| | - Thomas Engstrøm
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark (M.S., F.R.J., M.M., L.H., H.-H.T., F.P., K.A., R.S., L.S., O.D.B., T.E., J.L.).,Department of Clinical Medicine, University of Copenhagen, Denmark (N.T.O., L.S., T.E.)
| | - Jacob Lønborg
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark (M.S., F.R.J., M.M., L.H., H.-H.T., F.P., K.A., R.S., L.S., O.D.B., T.E., J.L.)
| |
Collapse
|
9
|
Issa IF, Dahl JS, Poulsen SH, Waziri F, Pedersen CT, Riber L, Søgaard P, Møller JE. The relation of structural valve deterioration to adverse remodelling and outcome in patients with biological heart valve prostheses. Eur Heart J Cardiovasc Imaging 2021; 22:82-91. [PMID: 31942609 DOI: 10.1093/ehjci/jez317] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 09/03/2019] [Accepted: 12/16/2019] [Indexed: 11/14/2022] Open
Abstract
AIMS Native valve aortic stenosis is associated with adverse remodelling of the left ventricle and remodelling is stopped or even reversed with aortic valve replacement (AVR). However, the degeneration of bioprostheses and development of structural valve deterioration (SVD) may affect this. METHODS AND RESULTS To assess the association with SVD, remodelling and outcome 451 patients from a single surgical centre who had undergone AVR with a Mitroflow pericardial bioprosthesis were studied. All patients were assessed in 2014 and a subgroup of patients (N = 327) were re-exanimated again after at least 18 months [median time of 27 (interquartile range, IQR 26-33) months] including echocardiography, measurements of N-terminal pro-brain natriuretic peptide, and assessment of functional status. SVD was based on echocardiography. Moderate SVD was present in 63 patients (14%) and severe SVD in 19 (4%), in the subgroup with follow-up echocardiography 48 patients (15%) patients had moderate to severe SVD at first examination. Patients with SVD had significantly greater increase in left ventricular (LV) mass index [21.6 g/m2 (IQR 5.7-48.3 g/m2) vs. 9.1 g/m2 (-8.6 to 27.3 g/m2), P = 0.01]. Further, patients with SVD had lower LV ejection fraction [55% (IQR 51-62%) vs. 60% (IQR 54-63%), P = 0.01] at follow-up. During follow-up, 94 patients (21%) met the composite endpoint of death or reoperation due to SVD and 41 patient readmitted for heart failure. In multivariable Cox regression analysis, severe SVD [hazard ratio (HR) 2.64 (1.37-5.07), P = 0.004] was associated with composite endpoint, and readmission for heart failure [HR 3.82 (1.53-9.51), P = 0.004]. CONCLUSION SVD in aortic bioprostheses is associated with adverse LV remodelling and adverse outcome.
Collapse
Affiliation(s)
- Issa Farah Issa
- Department of Cardiology, OPEN-Odense Patient Data Explorative Network, Odense University Hospital and University of Southern Denmark, J. B. Winsløwsvej 4, DK-5000 Odense, Denmark
| | - Jordi Sanchez Dahl
- Department of Cardiology, OPEN-Odense Patient Data Explorative Network, Odense University Hospital and University of Southern Denmark, J. B. Winsløwsvej 4, DK-5000 Odense, Denmark
| | - Steen Hvitfeldt Poulsen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Blvd. 99, DK-8200 Aarhus, Denmark
| | - Farhad Waziri
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Palle Juul-Jensens Blvd. 99, DK-8200 Aarhus, Denmark
| | - Christian Torp Pedersen
- Department of Cardiology, Aalborg University Hospital, Hobrovej 18-22, DK- 9000 Aalborg, Denmark.,Department of Cardiothoracic and Vascular Surgery, Aalborg University Hospital, Hobrovej 18-22, DK- 9000 Aalborg, Denmark
| | - Lars Riber
- Department of Cardiothoracic and Vascular Surgery, OPEN-Odense Patient Data Explorative Network, Odense University Hospital and University of Southern Denmark, J. B. Winsløwsvej 4, DK-5000 Odense, Denmark
| | - Peter Søgaard
- Department of Cardiology, Aalborg University Hospital, Hobrovej 18-22, DK- 9000 Aalborg, Denmark.,Department of Cardiothoracic and Vascular Surgery, Aalborg University Hospital, Hobrovej 18-22, DK- 9000 Aalborg, Denmark
| | - Jacob Eifer Møller
- Department of Cardiology, OPEN-Odense Patient Data Explorative Network, Odense University Hospital and University of Southern Denmark, J. B. Winsløwsvej 4, DK-5000 Odense, Denmark
| |
Collapse
|
10
|
Incomplete structural reverse remodeling from late-stage left ventricular hypertrophy impedes the recovery of diastolic but not systolic dysfunction in rats. J Hypertens 2020; 37:1200-1212. [PMID: 31026245 DOI: 10.1097/hjh.0000000000002042] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Pressure overload-induced left ventricular myocardial hypertrophy (LVH) regresses after pressure unloading. However, distinct structural alterations become less reversible during the progression of LVH, which might influence the restoration of cardiac function. Here, we investigated how a reverse remodeling process from early versus late-stage LVH affects different aspects of left ventricular function. METHODS Pressure overload was induced in rats for 6, 12 and 18 weeks. Sham-operated animals were used as controls. Pressure unloading was evoked by removing the aortic constriction at week 6 (early-debanded) and week 12 (late-debanded). Echocardiography and histological analyses were carried out to detect structural alterations. Pressure-volume analysis was performed to assess left ventricular function. Molecular alterations were analyzed by quantitative real-time-PCR, and western blot. RESULTS Myocardial hypertrophy regressed to a similar degree in early and late-debanded groups. Accordingly, no differences were detected in the extent of regression regarding left ventricular mass, cardiomyocyte diameter, heart weight-to-tibial length ratio and beta-to-alpha myosin heavy chain expression. In contrast, resorption of interstitial and perivascular myocardial fibrosis was only detected in the early-debanded group, whereas it persisted in the late-debanded group. Removing the aortic constriction normalized ventriculo-arterial coupling and increased systolic performance in both debanded groups. However, the residual dysfunction in active relaxation and passive stiffness was more severe in the late-debanded compared to the early-debanded group. CONCLUSION Early debanding led to complete structural reverse remodeling (reduced hypertrophy and fibrosis) and full restoration of left ventricular function. In contrast, myocardial fibrosis persisted after late debanding, which impeded the normalization of diastolic but not systolic function.
Collapse
|
11
|
Calin A, Mateescu AD, Popescu AC, Bing R, Dweck MR, Popescu BA. Role of advanced left ventricular imaging in adults with aortic stenosis. Heart 2020; 106:962-969. [PMID: 32179586 PMCID: PMC7306876 DOI: 10.1136/heartjnl-2019-315211] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 01/17/2020] [Accepted: 02/17/2020] [Indexed: 12/23/2022] Open
Abstract
This review focuses on the available data regarding the utility of advanced left ventricular (LV) imaging in aortic stenosis (AS) and its potential impact for optimising the timing of aortic valve replacement. Ejection fraction is currently the only LV parameter recommended to guide intervention in AS. The cut-off value of 50%, recommended for decision-making in asymptomatic patients with AS, is currently under debate. Several imaging parameters have emerged as predictors of disease progression and clinical outcomes in this setting. Global longitudinal LV strain by speckle tracking echocardiography is useful for risk stratification of asymptomatic patients with severe AS and preserved LV ejection fraction. Its prognostic value was demonstrated in these patients, but further work is required to define the best thresholds to aid the decision-making process. The assessment of myocardial fibrosis is the most studied application of cardiac magnetic resonance in AS. The detection of replacement fibrosis by late gadolinium enhancement offers incremental prognostic information in these patients. Clinical implementation of this technique to optimise the timing of aortic valve intervention in asymptomatic patients is currently tested in a randomised trial. The use of T1 mapping techniques can provide an assessment of interstitial myocardial fibrosis and represents an expanding field of interest. However, convincing data in patients with AS is still lacking. All these imaging parameters have substantial potential to influence the management decision in patients with AS in the future, but data from randomised clinical trials are awaited to define their utility in daily practice.
Collapse
Affiliation(s)
- Andreea Calin
- Department of Cardiology, Euroecolab, University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania.,Department of Cardiology, Emergency Institute for Cardiovascular Diseases "Prof Dr C C Iliescu", Bucharest, Romania
| | - Anca D Mateescu
- Department of Cardiology, Euroecolab, University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania.,Department of Cardiology, Emergency Institute for Cardiovascular Diseases "Prof Dr C C Iliescu", Bucharest, Romania
| | - Andreea C Popescu
- Department of Cardiology, Euroecolab, University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania.,Department of Cardiology, Emergency University Hospital Elias, Bucharest, Romania
| | - Rong Bing
- BHF Centre for Cardiovascular Science, The University of Edinburgh, Edinburgh, EH16 4SB, United Kingdom
| | - Marc R Dweck
- BHF Centre for Cardiovascular Science, The University of Edinburgh, Edinburgh, EH16 4SB, United Kingdom
| | - Bogdan A Popescu
- Department of Cardiology, Euroecolab, University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania .,Department of Cardiology, Emergency Institute for Cardiovascular Diseases "Prof Dr C C Iliescu", Bucharest, Romania
| |
Collapse
|
12
|
Malik AO, Omer M, Pflederer MC, Almomani A, Gosch KL, Jones PG, Peri-Okonny PA, Al Badarin F, Brandt HA, Arnold SV, Main ML, Cohen DJ, Spertus JA, Chhatriwalla AK. Association Between Diastolic Dysfunction and Health Status Outcomes in Patients Undergoing Transcatheter Aortic Valve Replacement. JACC Cardiovasc Interv 2019; 12:2476-2484. [PMID: 31786216 DOI: 10.1016/j.jcin.2019.08.036] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 08/16/2019] [Accepted: 08/20/2019] [Indexed: 11/15/2022]
Abstract
OBJECTIVES The aim of this study was to assess the association of baseline left ventricular diastolic dysfunction (LVDD) with health status outcomes of patients undergoing transcatheter aortic valve replacement (TAVR). BACKGROUND Although LVDD in patients with aortic stenosis is associated with higher mortality after TAVR, it is unknown if it is also associated with health status recovery. METHODS In a cohort of 304 patients with interpretable echocardiograms, undergoing TAVR, LVDD was categorized at baseline as absent (grade 0), mild (grade 1), moderate (grade 2), or severe (grade 3). Disease-specific health status was assessed using the 12-item Kansas City Cardiomyopathy Questionnaire overall summary score (KCCQ-OS) at baseline and at 1-month and 12-month follow-up. Association of baseline LVDD with health status at baseline and follow-up after TAVR was assessed using a linear trend test, and association with health status recovery (change in KCCQ-OS) was examined using a linear mixed model adjusting for baseline KCCQ-OS. RESULTS Twenty-four (7.9%), 54 (17.8%), 186 (61.2%), and 40 (13.2%) patients had LVDD grades of 0, 1, 2, and 3, respectively. Baseline KCCQ-OS was 61.3 ± 22.7, 51.0 ± 26.1, 44.7 ± 25.7, and 44.4 ± 21.9 (p = 0.004) in patients with LVDD grades of 0, 1,2 and 3. At 1 and 12 months after TAVR, LVDD was not associated with KCCQ-OS. Recovery in KCCQ-OS after TAVR was substantial and similar in patients across all severities of LVDD. CONCLUSIONS Although LVDD is associated with health status prior to TAVR, patients across all severities of LVDD have similar recovery in health status after TAVR.
Collapse
Affiliation(s)
- Ali O Malik
- University of Missouri-Kansas City, Kansas City, Missouri; Saint Luke's Mid America Heart Institute, Kansas City, Missouri.
| | - Mohamed Omer
- University of Missouri-Kansas City, Kansas City, Missouri; Saint Luke's Mid America Heart Institute, Kansas City, Missouri
| | - Mathew C Pflederer
- University of Missouri-Kansas City, Kansas City, Missouri; Saint Luke's Mid America Heart Institute, Kansas City, Missouri
| | - Ahmed Almomani
- University of Missouri-Kansas City, Kansas City, Missouri; Saint Luke's Mid America Heart Institute, Kansas City, Missouri
| | - Kensey L Gosch
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri
| | - Philip G Jones
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri
| | - Poghni A Peri-Okonny
- University of Missouri-Kansas City, Kansas City, Missouri; Saint Luke's Mid America Heart Institute, Kansas City, Missouri
| | - Firas Al Badarin
- University of Missouri-Kansas City, Kansas City, Missouri; Saint Luke's Mid America Heart Institute, Kansas City, Missouri
| | - Hunter A Brandt
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri
| | - Suzanne V Arnold
- University of Missouri-Kansas City, Kansas City, Missouri; Saint Luke's Mid America Heart Institute, Kansas City, Missouri
| | - Michael L Main
- University of Missouri-Kansas City, Kansas City, Missouri; Saint Luke's Mid America Heart Institute, Kansas City, Missouri
| | - David J Cohen
- University of Missouri-Kansas City, Kansas City, Missouri; Saint Luke's Mid America Heart Institute, Kansas City, Missouri
| | - John A Spertus
- University of Missouri-Kansas City, Kansas City, Missouri; Saint Luke's Mid America Heart Institute, Kansas City, Missouri
| | - Adnan K Chhatriwalla
- University of Missouri-Kansas City, Kansas City, Missouri; Saint Luke's Mid America Heart Institute, Kansas City, Missouri
| |
Collapse
|
13
|
Ngiam JN, Chew N, Teng R, Kochav JD, Kochav SM, Tan BYQ, Sim HW, Sia CH, Kong WKF, Tay ELW, Yeo TC, Poh KK. Clinical and echocardiographic features of paradoxical low-flow and normal-flow severe aortic stenosis patients with concomitant mitral regurgitation. Int J Cardiovasc Imaging 2019; 36:441-446. [PMID: 31773341 DOI: 10.1007/s10554-019-01735-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 11/14/2019] [Indexed: 11/25/2022]
Abstract
Mitral regurgitation (MR) coexists in a significant proportion of patients with severe aortic stenosis (AS), and portends inferior therapeutic outcomes. In severe AS, MR is thought to contribute to a low-flow state by decreasing forward stroke volume. We investigated concomitant MR on the clinical and echocardiographic features of patients with "paradoxical" low-flow (PLF) and normal-flow (NF) severe AS. Clinical and echocardiographic profiles of 886 consecutive patients with index echocardiographic diagnosis of severe AS (AVA < 1.0 cm2) were analysed retrospectively. All patients had preserved ejection fraction (LVEF ≥ 50%, n = 645), and were divided into PLF (stroke volume index, SVI < 35 mL/m2) and NF AS. They were then further subdivided based on the presence or absence of moderate-or-severe MR (msMR). A higher prevalence of concomitant msMR was observed in patients with PLF AS (14.9%; n = 33/221) compared to those with NF AS (8.0%; n = 34/424). Concomitant msMR was associated with echocardiographic features of increased diastolic dysfunction in both PLF AS and NF AS patients, as evidenced by increased LA diameter (PLF AS 52.9 ± 12.5 to 43.9 ± 8.9 mm; NF AS 29.6 ± 10.8 to 42.4 ± 8.8 mm; p < 0.001) and increased transmitral E/A ratio (PLF AS 1.26 ± 0.56 to 0.92 ± 0.43; NF AS 1.19 ± 0.63 to 0.94 ± 0.45; p = 0.004). Amongst patients with NF AS, msMR was additionally associated with increased E:e' ratio (25.5 ± 15.1 vs 19.3 ± 10.8; p = 0.025). Concomitant MR was more common in PLF AS compared to NF. Although possibly related to the MR, patients severe AS and MR appeared to have more severe diastolic dysfunction. Further studies are warranted to evaluate prognosis and guide management.
Collapse
Affiliation(s)
| | - Nicholas Chew
- Department of Medicine, National University Health System, Singapore, Singapore
| | - Rebecca Teng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Jonathan D Kochav
- Department of Cardiology, Massachusetts General Hospital, Boston, USA
| | | | | | - Hui Wen Sim
- Department of Cardiology, National University Heart Centre, National University Health System, 1E Kent Ridge Rd, NUHS Tower Block, Level 9, Singapore, 119228, Singapore
| | - Ching-Hui Sia
- Department of Cardiology, National University Heart Centre, National University Health System, 1E Kent Ridge Rd, NUHS Tower Block, Level 9, Singapore, 119228, Singapore
| | - William K F Kong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Cardiology, National University Heart Centre, National University Health System, 1E Kent Ridge Rd, NUHS Tower Block, Level 9, Singapore, 119228, Singapore
| | - Edgar Lik Wui Tay
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Cardiology, National University Heart Centre, National University Health System, 1E Kent Ridge Rd, NUHS Tower Block, Level 9, Singapore, 119228, Singapore
| | - Tiong-Cheng Yeo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Cardiology, National University Heart Centre, National University Health System, 1E Kent Ridge Rd, NUHS Tower Block, Level 9, Singapore, 119228, Singapore
| | - Kian-Keong Poh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
- Department of Cardiology, National University Heart Centre, National University Health System, 1E Kent Ridge Rd, NUHS Tower Block, Level 9, Singapore, 119228, Singapore.
| |
Collapse
|
14
|
Aortic Stenosis: What Risks Do the Stresses of Noncardiac Surgery or Pregnancy Pose and How Should They Be Managed? Cardiol Clin 2019; 38:139-148. [PMID: 31753173 DOI: 10.1016/j.ccl.2019.09.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Studies suggest that patients with aortic stenosis have increased risk in pregnancy and delivery and during anesthesia and surgery, although there are significant degrees of uncertainty as to the exact risks and best way to manage such patients. This article reviews current literature regarding impact of aortic stenosis on pregnancy and anesthesia during noncardiac surgery. There are shortcomings in the scientific evidence. Most of the available studies are observational and often retrospective and therefore there is a great deal of bias. This leads to difficulty in drawing conclusions in terms of how to apply the published information to clinical management.
Collapse
|
15
|
Affiliation(s)
- Julian Yeoh
- King's College Hospital National Health Service Foundation Trust London United Kingdom
| | - Philip MacCarthy
- King's College Hospital National Health Service Foundation Trust London United Kingdom
| |
Collapse
|
16
|
Benfari G, Noni M, Onorati F, Cerrito L, Pernigo M, Vinco G, Cameli M, Mandoli G, Borio G, Geremia G, Zivelonghi C, Abbasciano R, Mazzali G, Zamboni M, Faggian G, Rossi A, Ribichini F. Effects of Aortic Valve Replacement on Left Ventricular Diastolic Function in Patients With Aortic Valve Stenosis. Am J Cardiol 2019; 124:409-415. [PMID: 31186115 DOI: 10.1016/j.amjcard.2019.04.046] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 04/13/2019] [Accepted: 04/23/2019] [Indexed: 10/26/2022]
Abstract
The afterload increase imposed by severe aortic valve stenosis (AS) creates concentric left ventricular (LV) remodeling and diastolic dysfunction (DD), which are both markers of poor clinical outcome. Ideally, a correctly timed surgery for isolated AS can reverse the LV remodeling. However, data on LV DD after aortic valve replacement (AVR) are sparse and contrasting. Aims of the study are to define the markers of a favorable evolution of the DD at follow-up. Patients with severe isolated AS, scheduled for AVR were prospectively enrolled. Transthoracic echocardiography with DD assessment was performed before surgery, and at 12 months after surgery. Global LV longitudinal and circumferential strain, peak atrial longitudinal and contraction strain (PALS, PACS) were obtained at baseline. LV septal biopsy to assess fibrosis was performed at the time of AVR. Sixty-seven patients were enrolled, age 72 ± 8 years, 66% female, ejection fraction 61 ± 8%, E/e' 13 ± 6, PALS 23 ± 7%. Normal estimated left atrial pressure was detected in 19/67 (28%) versus 43/67 (64%) at follow-up (p <0.0001). In the 37 patients with biopsy available, fibrosis was 24 ± 12%. PALS and AS severity were correlated with LV fibrosis (R2 = 0.19; p = 0.006, and R2 = 0.15; p = 0.02, respectively). PALS (odds ratio: 1.19 [1.05 to 1.41], p = 0.02) and PACS (odds ratio: 1.24 [1.06 to 1.50], p = 0.006) were the only baseline noninvasive parameters independently associated with normal left atrial pressure at follow-up. Mean follow-up time was 791 ± 245 days, and 8 (12%) patients had cardiovascular events (death, hospital admission due to heart failure or ischemic disease, and onset of atrial fibrillation). Myocardial fibrosis (p = 0.05), baseline PALS (p = 0.004), and PACS (p = 0.03) were associated with cardiovascular events. In conclusion, LV diastolic function generally improves after AVR for severe AS. Baseline PALS, PACS, and LV fibrosis were related to the DD and clinical outcome at follow-up; these parameters might cue a better diastolic response to the afterload correction.
Collapse
|
17
|
Miranda-Silva D, Gonçalves-Rodrigues P, Almeida-Coelho J, Hamdani N, Lima T, Conceição G, Sousa-Mendes C, Cláudia-Moura, González A, Díez J, Linke WA, Leite-Moreira A, Falcão-Pires I. Characterization of biventricular alterations in myocardial (reverse) remodelling in aortic banding-induced chronic pressure overload. Sci Rep 2019; 9:2956. [PMID: 30814653 PMCID: PMC6393473 DOI: 10.1038/s41598-019-39581-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 01/18/2019] [Indexed: 01/03/2023] Open
Abstract
Aortic Stenosis (AS) is the most frequent valvulopathy in the western world. Traditionally aortic valve replacement (AVR) has been recommended immediately after the onset of heart failure (HF) symptoms. However, recent evidence suggests that AVR outcome can be improved if performed earlier. After AVR, the process of left ventricle (LV) reverse remodelling (RR) is variable and frequently incomplete. In this study, we aimed at detecting mechanism underlying the process of LV RR regarding myocardial structural, functional and molecular changes before the onset of HF symptoms. Wistar-Han rats were subjected to 7-weeks of ascending aortic-banding followed by a 2-week period of debanding to resemble AS-induced LV remodelling and the early events of AVR-induced RR, respectively. This resulted in 3 groups: Sham (n = 10), Banding (Ba, n = 15) and Debanding (Deb, n = 10). Concentric hypertrophy and diastolic dysfunction (DD) were patent in the Ba group. Aortic-debanding induced RR, which promoted LV functional recovery, while cardiac structure did not normalise. Cardiac parameters of RV dysfunction, assessed by echocardiography and at the cardiomyocyte level prevailed altered after debanding. After debanding, these alterations were accompanied by persistent changes in pathways associated to myocardial hypertrophy, fibrosis and LV inflammation. Aortic banding induced pulmonary arterial wall thickness to increase and correlates negatively with effort intolerance and positively with E/e′ and left atrial area. We described dysregulated pathways in LV and RV remodelling and RR after AVR. Importantly we showed important RV-side effects of aortic constriction, highlighting the impact that LV-reverse remodelling has on both ventricles.
Collapse
Affiliation(s)
| | | | | | - Nazha Hamdani
- Department of Systems Physiology, Ruhr University, Bochum, Germany
| | - Tânia Lima
- Department of Surgery and Physiology, University of Porto, Porto, Portugal
| | - Glória Conceição
- Department of Surgery and Physiology, University of Porto, Porto, Portugal
| | | | - Cláudia-Moura
- Department of Surgery and Physiology, University of Porto, Porto, Portugal
| | - Arantxa González
- Program of Cardiovascular Diseases, Centre for Applied Medical Research, University of Navarra and CIBERCV, Pamplona, Spain.,Department of Cardiology and Cardiac Surgery and Department of Nephrology, University of Navarra Clinic, Pamplona, Spain
| | - Javier Díez
- Program of Cardiovascular Diseases, Centre for Applied Medical Research, University of Navarra and CIBERCV, Pamplona, Spain.,Department of Cardiology and Cardiac Surgery and Department of Nephrology, University of Navarra Clinic, Pamplona, Spain
| | - Wolfgang A Linke
- Institute of Physiology II, University of Muenster, Muenster, Germany
| | | | - Inês Falcão-Pires
- Department of Surgery and Physiology, University of Porto, Porto, Portugal.
| |
Collapse
|
18
|
Left Ventricular Diastolic Function After Aortic Valve Replacement for Chronic Aortic Regurgitation. Ann Thorac Surg 2018; 106:24-29. [DOI: 10.1016/j.athoracsur.2018.03.034] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 12/23/2017] [Accepted: 03/11/2018] [Indexed: 11/19/2022]
|
19
|
Prognostic Impact of Low-Flow Severe Aortic Stenosis in Small-Body Patients Undergoing TAVR: The OCEAN-TAVI Registry. JACC Cardiovasc Imaging 2017; 11:659-669. [PMID: 28528156 DOI: 10.1016/j.jcmg.2016.12.028] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 12/01/2016] [Accepted: 12/22/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVES This study aimed to analyze the prognostic impact of low-flow (LF) severe aortic stenosis in small-body patients undergoing transcatheter aortic valve replacement (TAVR). BACKGROUND Western literature demonstrates a poor prognosis with paradoxical LF and low-flow low-gradient (LF-LG) severe aortic stenosis (AS), as defined by stroke volume index (SVi) <35 ml/m2 and mean pressure gradient <40 mm Hg with preserved left ventricular ejection fraction (LVEF). However, this poor prognosis is contested in Japan owing to the smaller body size of Japanese patients relative to that of Western patients. Additionally, there are no reports of the prognostic implication of paradoxical LF or LF-LG severe AS in small-body patients undergoing TAVR. METHODS This was a retrospective analysis of 723 consecutive Japanese patients (median age 85 years; 32.6% male; median body surface area 1.4 m2) who underwent TAVR for severe AS at 9 sites in Japan. The primary and secondary endpoints were cumulative all-cause and cardiovascular mortality after TAVR, respectively. RESULTS Ninety-seven (13.4%) patients had paradoxical LF severe AS whereas 38 (5.3%) had paradoxical LF-LG with severe AS. PLF was associated with a significant increase in all-cause (hazard ratio [HR]: 3.00; 95% confidence interval [CI]: 1.34 to 6.72; p < 0.001) and cardiovascular mortality (HR: 5.58; 95% CI: 1.19 to 26.2; p < 0.01), as compared with patients' normal flow and preserved LVEF. PLF-LG was associated with a significant increase in all-cause mortality (HR: 3.76; 95% CI: 1.09 to 13.73; p < 0.01), as compared with normal flow high gradient with preserved LVEF. SVi was an independent predictor of cardiovascular mortality on multivariate analysis after adjustments for age, sex, clinically relevant variables, and other echocardiographic parameters (HR: 1.96; 95% CI: 1.19 to 3.23; p < 0.01). CONCLUSIONS Among Japanese small-body patients with severe AS, both paradoxical LF and LF-LG severe AS were associated with poor outcomes following TAVR. SVi was an independent predictor of cardiovascular mortality after TAVR. (Optimised Transcatheter Valvular Intervention registry [OCEAN-TAVI]; UMIN000020423).
Collapse
|
20
|
Associations of residual left ventricular and left atrial remodeling with clinical outcomes in patients after aortic valve replacement for severe aortic stenosis. J Cardiol 2016; 68:241-7. [DOI: 10.1016/j.jjcc.2015.09.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Revised: 09/08/2015] [Accepted: 09/24/2015] [Indexed: 12/22/2022]
|
21
|
Zhu Y, Roselli EE, Idrees JJ, Wojnarski CM, Griffin B, Kalahasti V, Pettersson G, Svensson LG. Outcomes After Operations for Unicuspid Aortic Valve With or Without Ascending Repair in Adults. Ann Thorac Surg 2015; 101:613-9. [PMID: 26453423 DOI: 10.1016/j.athoracsur.2015.07.058] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Revised: 07/19/2015] [Accepted: 07/22/2015] [Indexed: 12/19/2022]
Abstract
BACKGROUND Unicuspid aortic valve is an important subset of bicuspid aortic valve, and knowledge regarding its aortopathy pattern and surgical outcomes is limited. Our objectives were to characterize unicuspid aortic valve patients, associated aortopathy, and surgical outcomes. METHODS From January 1990 to May 2013, 149 adult unicuspid aortic valve patients underwent aortic valve replacement or repair for aortic stenosis (n = 13), regurgitation (n = 13), or both (n = 123), and in 91 (61%) the aortic valve operation was combined with aortic repair. Data were obtained from the Cardiovascular Information Registry and medical record review. Three-dimensional imaging analysis was performed from preoperative computed tomography and magnetic resonance imaging scans. The Kaplan-Meier method was used for survival analysis. RESULTS Patients had a mean maximum aortic diameter of 44 ± 8 mm and variably involved the aortic root, ascending, or arch, or both. Patients with valve operations alone were more likely to be hypertensive (p = 0.01) and to have severe aortic stenosis (p = 0.07) than those who underwent concurrent aortic operations. There were no operative deaths, strokes, or myocardial infarctions. Patients undergoing aortic repair had better long-term survival. Estimated survival at 1, 5, and 10 years was 100%, 100%, and 100% after combined operations and was 100%, 88%, and 88% after valve operations alone (p = 0.01). CONCLUSIONS Patients with a dysfunctional unicuspid aortic valve frequently present with an ascending aneurysm that requires repair. Combined aortic valve operations and aortic repair was associated with significantly better long-term survival than a valve operation alone. Further study of this association may direct decisions about timing of surgical intervention.
Collapse
Affiliation(s)
- Yuanjia Zhu
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland, Ohio; Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland, Ohio; Aortic Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, Ohio.
| | - Jay J Idrees
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland, Ohio; Aortic Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Charles M Wojnarski
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland, Ohio; Aortic Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Brian Griffin
- Department of Cardiology, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Aortic Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Vidyasagar Kalahasti
- Department of Cardiology, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Aortic Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Gosta Pettersson
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland, Ohio; Aortic Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Lars G Svensson
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland, Ohio; Aortic Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, Ohio
| |
Collapse
|
22
|
Călin A, Roşca M, Beladan CC, Enache R, Mateescu AD, Ginghină C, Popescu BA. The left ventricle in aortic stenosis--imaging assessment and clinical implications. Cardiovasc Ultrasound 2015; 13:22. [PMID: 25928763 PMCID: PMC4425891 DOI: 10.1186/s12947-015-0017-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 04/21/2015] [Indexed: 01/07/2023] Open
Abstract
Aortic stenosis has an increasing prevalence in the context of aging population. In these patients non-invasive imaging allows not only the grading of valve stenosis severity, but also the assessment of left ventricular function. These two goals play a key role in clinical decision-making. Although left ventricular ejection fraction is currently the only left ventricular function parameter that guides intervention, current imaging techniques are able to detect early changes in LV structure and function even in asymptomatic patients with significant aortic stenosis and preserved ejection fraction. Moreover, new imaging parameters emerged as predictors of disease progression in patients with aortic stenosis. Although proper standardization and confirmatory data from large prospective studies are needed, these novel parameters have the potential of becoming useful tools in guiding intervention in asymptomatic patients with aortic stenosis and stratify risk in symptomatic patients undergoing aortic valve replacement. This review focuses on the mechanisms of transition from compensatory left ventricular hypertrophy to left ventricular dysfunction and heart failure in aortic stenosis and the role of non-invasive imaging assessment of the left ventricular geometry and function in these patients.
Collapse
Affiliation(s)
- Andreea Călin
- Department of Cardiology, University of Medicine and Pharmacy "Carol Davila", Euroecolab, Bucharest, Romania.
| | - Monica Roşca
- Department of Cardiology, University of Medicine and Pharmacy "Carol Davila", Euroecolab, Bucharest, Romania.
| | - Carmen Cristiana Beladan
- Department of Cardiology, University of Medicine and Pharmacy "Carol Davila", Euroecolab, Bucharest, Romania. .,Institute of Cardiovascular Diseases "Prof. Dr. C. C. Iliescu", Sos Fundeni 258 sector 2, 022328, Bucharest, Romania.
| | - Roxana Enache
- Department of Cardiology, University of Medicine and Pharmacy "Carol Davila", Euroecolab, Bucharest, Romania. .,Institute of Cardiovascular Diseases "Prof. Dr. C. C. Iliescu", Sos Fundeni 258 sector 2, 022328, Bucharest, Romania.
| | - Anca Doina Mateescu
- Department of Cardiology, University of Medicine and Pharmacy "Carol Davila", Euroecolab, Bucharest, Romania.
| | - Carmen Ginghină
- Department of Cardiology, University of Medicine and Pharmacy "Carol Davila", Euroecolab, Bucharest, Romania. .,Institute of Cardiovascular Diseases "Prof. Dr. C. C. Iliescu", Sos Fundeni 258 sector 2, 022328, Bucharest, Romania.
| | - Bogdan Alexandru Popescu
- Department of Cardiology, University of Medicine and Pharmacy "Carol Davila", Euroecolab, Bucharest, Romania. .,Institute of Cardiovascular Diseases "Prof. Dr. C. C. Iliescu", Sos Fundeni 258 sector 2, 022328, Bucharest, Romania.
| |
Collapse
|
23
|
Lee M, Choi JO, Park SJ, Kim EY, Park P, Oh JK, Jeon ES. N-terminal pro-B-type natriuretic peptide measurement is useful in predicting left ventricular hypertrophy regression after aortic valve replacement in patients with severe aortic stenosis. HEART ASIA 2015; 7:23-8. [PMID: 27326209 DOI: 10.1136/heartasia-2014-010593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Revised: 03/17/2015] [Accepted: 03/28/2015] [Indexed: 11/03/2022]
Abstract
BACKGROUND The predictive factors for early left ventricular hypertrophy (LVH) regression after aortic valve replacement (AVR) have not been fully elucidated. This study was conducted to investigate which preoperative parameters predict early LVH regression after AVR. METHODS AND RESULTS 87 consecutive patients who underwent AVR due to isolated severe aortic stenosis (AS) were analysed. Patients with ejection fraction <50% or concomitant coronary artery disease were excluded from the analysis. Preoperative evaluation including echocardiography and N-terminal pro-B-type natriuretic peptide (NT-proBNP) measurement was performed and midterm follow-up echocardiography was done at a median of 9 months after AVR. The presence of complete regression of LVH at the midterm follow-up was determined. In multivariate analysis, including preoperative echocardiographic parameters, only E/e' ratio was associated with midterm LVH regression (OR 1.11, 95% CI 1.01 to 1.22; p=0.035). When preoperative NT-proBNP was added to the analysis, logNT-proBNP was found to be the single significant predictor of midterm LVH regression (OR 2.00, 95% CI 1.08 to 3.71; p=0.028). By receiver operating characteristic curve analysis, a cut-off value of 440 pg/mL for NT-proBNP yielded a sensitivity of 72% and a specificity of 77% for the prediction of LVH regression after AVR. CONCLUSIONS Preoperative NT-proBNP was an independent predictor for early LVH regression after AVR in patients with isolated severe AS.
Collapse
Affiliation(s)
- Mirae Lee
- Division of Cardiology , Samsung Changwon Hospital, Sungkyunkwan University School of Medicine , Changwon , Korea
| | - Jin-Oh Choi
- Division of Cardiology , Samsung Medical Center, Sungkyunkwan University School of Medicine , Seoul , Korea
| | - Sung-Ji Park
- Division of Cardiology , Samsung Medical Center, Sungkyunkwan University School of Medicine , Seoul , Korea
| | - Eun Young Kim
- Division of Cardiology , Samsung Medical Center, Sungkyunkwan University School of Medicine , Seoul , Korea
| | - PyoWon Park
- Department of Thoracic and Cardiovascular Surgery , Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine , Seoul , Korea
| | - Jae K Oh
- Division of Cardiovascular Diseases , Mayo Clinic College of Medicine , Rochester, Minnesota , USA
| | - Eun-Seok Jeon
- Division of Cardiology , Samsung Medical Center, Sungkyunkwan University School of Medicine , Seoul , Korea
| |
Collapse
|
24
|
Elahi MM, Chuang A, Ewing MJ, Choi CH, Grant PW, Matata BM. One problem two issues! Left ventricular systolic and diastolic dysfunction in aortic stenosis. ANNALS OF TRANSLATIONAL MEDICINE 2014; 2:10. [PMID: 25332986 DOI: 10.3978/j.issn.2305-5839.2013.06.05] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Accepted: 06/19/2013] [Indexed: 01/19/2023]
Abstract
Reports suggested that immediate post-aortic valve replacement (AVR); left ventricular (LV) dysfunction may be an important risk for morbidity and mortality in patients requiring positive inotropic support. Several factors have been identified as significant prognostic factors i.e., LV systolic dysfunction, LV diastolic dysfunction (LV-DD), heart failure and myocardial infarction (MI). Specific to pathophysiological changes associated with AS, markers of systolic LV function (e.g., LVEF) have been extensively studied in management, yet only a few studies have analysed the association between LV-DD and immediate post-operative LV dysfunction This review brings together the current body of evidence on this issue.
Collapse
Affiliation(s)
- Maqsood M Elahi
- 1 Division of Cardiothoracic Surgery, Department of Surgery, Texas A & M Health Science Center at Scott & White Memorial Hospital, Temple, TX, USA ; 2 Division of Cardiothoracic Surgery, Prince of Wales & Sydney Children's Hospital, Barker Street, Randwick, Sydney, NSW, Australia ; 3 Liverpool Heart and Chest Hospital, NHS Foundation Trust, Liverpool, UK
| | - Anthony Chuang
- 1 Division of Cardiothoracic Surgery, Department of Surgery, Texas A & M Health Science Center at Scott & White Memorial Hospital, Temple, TX, USA ; 2 Division of Cardiothoracic Surgery, Prince of Wales & Sydney Children's Hospital, Barker Street, Randwick, Sydney, NSW, Australia ; 3 Liverpool Heart and Chest Hospital, NHS Foundation Trust, Liverpool, UK
| | - Michael J Ewing
- 1 Division of Cardiothoracic Surgery, Department of Surgery, Texas A & M Health Science Center at Scott & White Memorial Hospital, Temple, TX, USA ; 2 Division of Cardiothoracic Surgery, Prince of Wales & Sydney Children's Hospital, Barker Street, Randwick, Sydney, NSW, Australia ; 3 Liverpool Heart and Chest Hospital, NHS Foundation Trust, Liverpool, UK
| | - Charles H Choi
- 1 Division of Cardiothoracic Surgery, Department of Surgery, Texas A & M Health Science Center at Scott & White Memorial Hospital, Temple, TX, USA ; 2 Division of Cardiothoracic Surgery, Prince of Wales & Sydney Children's Hospital, Barker Street, Randwick, Sydney, NSW, Australia ; 3 Liverpool Heart and Chest Hospital, NHS Foundation Trust, Liverpool, UK
| | - Peter W Grant
- 1 Division of Cardiothoracic Surgery, Department of Surgery, Texas A & M Health Science Center at Scott & White Memorial Hospital, Temple, TX, USA ; 2 Division of Cardiothoracic Surgery, Prince of Wales & Sydney Children's Hospital, Barker Street, Randwick, Sydney, NSW, Australia ; 3 Liverpool Heart and Chest Hospital, NHS Foundation Trust, Liverpool, UK
| | - Bashir M Matata
- 1 Division of Cardiothoracic Surgery, Department of Surgery, Texas A & M Health Science Center at Scott & White Memorial Hospital, Temple, TX, USA ; 2 Division of Cardiothoracic Surgery, Prince of Wales & Sydney Children's Hospital, Barker Street, Randwick, Sydney, NSW, Australia ; 3 Liverpool Heart and Chest Hospital, NHS Foundation Trust, Liverpool, UK
| |
Collapse
|
25
|
Jeong DS, Sung K, Kim WS, Lee YT, Yang JH, Jun TG, Park PW. Fate of functional tricuspid regurgitation in aortic stenosis after aortic valve replacement. J Thorac Cardiovasc Surg 2014; 148:1328-1333.e1. [DOI: 10.1016/j.jtcvs.2013.10.056] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Revised: 09/29/2013] [Accepted: 10/29/2013] [Indexed: 11/17/2022]
|
26
|
Coronary artery disease and outcomes of aortic valve replacement for severe aortic stenosis. J Am Coll Cardiol 2013; 61:837-48. [PMID: 23428216 DOI: 10.1016/j.jacc.2012.10.049] [Citation(s) in RCA: 114] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2012] [Revised: 09/18/2012] [Accepted: 10/16/2012] [Indexed: 01/06/2023]
Abstract
OBJECTIVES The study sought to contrast risk profiles and compare outcomes of patients with severe aortic stenosis (AS) and coronary artery disease (CAD) who underwent aortic valve replacement (AVR) and coronary artery bypass grafting (AS+CABG) with those of patients with isolated AS who underwent AVR alone. BACKGROUND In patients with severe AS, CAD is often an incidental finding with underappreciated survival implications. METHODS From October 1991 to July 2010, 2,286 patients underwent AVR+CABG and 1,637 AVR alone. A propensity score was developed and used for matched comparisons of outcomes (1,082 patient pairs). Analyses of long-term mortality were performed for each group, then combined to identify common and unique risk factors. RESULTS Patients with AS+CAD versus isolated AS were older, more symptomatic, and more likely to be hypertensive, and had lower ejection fraction and greater arteriosclerotic burden but less severe AS. Hospital morbidity and long-term survival were poorer (43% vs. 59% at 10 years). Both groups shared many mortality risk factors; however, early risk among AS+CAD patients reflected effects of CAD; late risk reflected diastolic left ventricular dysfunction expressed as ventricular hypertrophy and left atrial enlargement. Patients with isolated AS and few comorbidities had the best outcome, those with CAD without myocardial damage had intermediate outcome equivalent to propensity-matched isolated AS patients, and those with CAD, myocardial damage, and advanced comorbidities had the worst outcome. CONCLUSIONS Cardiovascular risk factors and comorbidities must be considered in managing patients with severe AS. Patients with severe AS and CAD risk factors should undergo early diagnostics and AVR+CABG before ischemic myocardial damage occurs.
Collapse
|
27
|
Mannacio V, Antignano A, De Amicis V, Di Tommaso L, Giordano R, Iannelli G, Vosa C. B-type natriuretic peptide as a biochemical marker of left ventricular diastolic function: assessment in asymptomatic patients 1 year after valve replacement for aortic stenosis. Interact Cardiovasc Thorac Surg 2013; 17:371-7. [PMID: 23656924 DOI: 10.1093/icvts/ivt186] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES Left ventricular (LV) diastolic dysfunction after aortic valve replacement (AVR) carries a substantial risk of development of heart failure and reduced survival. In addition to echocardiography, B-type natriuretic peptide (BNP) provides a powerful incremental assessment of diastolic function. This study evaluates BNP as a marker of LV diastolic dysfunction in a cohort of patients with preserved LV ejection fraction who underwent AVR for pure aortic stenosis and the relationship between BNP values and the grade of LV diastolic dysfunction. METHODS A total of 113 patients were included in the study. Echocardiographic evaluation was performed preoperatively, 5 days postoperatively and at 12-month follow-up, to assess LV dimensional and functional parameters. Diastolic function was labelled as normal, mild, moderate or severe dysfunction. Concomitantly, BNP levels were evaluated. RESULTS Mild to severe diastolic dysfunction occurred preoperatively in all patients. At 12-month follow-up, 65 (62.5%) patients had mild and 25 (24.1%) moderate to severe diastolic dysfunction. BNP values, categorized for quartile distribution, correlated with diastolic dysfunction grade (P<0.001 for each comparison). At receiver operating characteristic analysis, the BNP level of 120 pg/ml was 91% sensitive and 85% specific for diastolic disease, while 300 pg/ml was 80% sensitive and 91% specific for moderate or severe diastolic dysfunction. Twelve months after AVR, BNP values were strongly correlated with the significant echocardiographic parameters suggestive of diastolic dysfunction (P≤0.006 in all cases). CONCLUSIONS The BNP level following AVR is related to diastolic disease severity and may complement echocardiographic evaluation when symptoms are unclear and LV function is difficult to interpret.
Collapse
Affiliation(s)
- Vito Mannacio
- Department of Cardiac Surgery, University of Naples Federico II, Naples, Italy.
| | | | | | | | | | | | | |
Collapse
|
28
|
Friedman KG, McElhinney DB, Rhodes J, Powell AJ, Colan SD, Lock JE, Brown DW. Left ventricular diastolic function in children and young adults with congenital aortic valve disease. Am J Cardiol 2013; 111:243-9. [PMID: 23102884 DOI: 10.1016/j.amjcard.2012.09.026] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2012] [Revised: 09/05/2012] [Accepted: 09/05/2012] [Indexed: 12/31/2022]
Abstract
Young patients with congenital aortic valve disease are at risk of left ventricular (LV) diastolic dysfunction (DD). We evaluated LV remodeling and the prevalence of, and risk factors for, DD in patients with aortic stenosis (AS), pure aortic regurgitation (AR), and AS+AR. Patients aged 8 to 39 years with congenital AS (n = 103), AR (n = 36), or AS+AR (n = 107) were identified. Cross-sectional assessment of the LV remodeling pattern and diastolic function was performed. A diastolic function score (DFS; range 0 to 4) was assigned to each patient, with 1 point for an abnormal value in each of 4 categories: mitral inflow (E/A and E-wave deceleration time), tissue Doppler E', E/E', and left atrial volume. Patients with a DFS of ≥2 were compared to those with a DFS <2. Concentric hypertrophy was the most common remodeling pattern in those with AS (51%), mixed/physiologic hypertrophy in those with AS+AR (48%) and eccentric hypertrophy in those with AR (49%) predominated. In the entire cohort, 91 patients (37%) had a DFS of ≥2. Patients with AS or AS+AR had greater DFS than those with pure AR (p <0.001). On multivariate analysis, a greater LV mass z-score and previous aortic valve balloon dilation were associated with a DFS of ≥2. In patients with catheterization data (n = 65), E/E' correlated with LV end-diastolic pressure. Those with a DFS of ≥2 had a greater LV end-diastolic pressure and mean pulmonary artery pressure than those with a DFS <2. In conclusion, DD is common in young patients with AS and AS+AR but not in those with pure AR. A greater LV mass and previous aortic valve dilation were associated with DD.
Collapse
Affiliation(s)
- Kevin G Friedman
- Department of Cardiology, Children's Hospital Boston and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.
| | | | | | | | | | | | | |
Collapse
|
29
|
Beach JM, Mihaljevic T, Rajeswaran J, Marwick T, Edwards ST, Nowicki ER, Thomas J, Svensson LG, Griffin B, Gillinov AM, Blackstone EH. Ventricular hypertrophy and left atrial dilatation persist and are associated with reduced survival after valve replacement for aortic stenosis. J Thorac Cardiovasc Surg 2013; 147:362-369.e8. [PMID: 23312984 DOI: 10.1016/j.jtcvs.2012.12.016] [Citation(s) in RCA: 113] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2012] [Revised: 11/07/2012] [Accepted: 12/05/2012] [Indexed: 12/28/2022]
Abstract
OBJECTIVES We sought to understand the factors modulating left heart reverse remodeling after aortic valve replacement, the relationship between the preoperative symptoms and modulators of left heart remodeling, and their influence on long-term survival. METHODS From October 1991 to January 2008, 4264 patients underwent primary aortic valve replacement for aortic stenosis. Changes in the time course of left ventricular reverse remodeling were assessed using 5740 postoperative transthoracic echocardiograms from 3841 patients. RESULTS Left ventricular hypertrophy rapidly declined after surgery, from 137 ± 42 g/m(2) preoperatively to 115 ± 27 by 2 years and remained relatively constant but greater than the upper limit of normal. The most important risk factor for residual left ventricular hypertrophy was greater preoperative left ventricular hypertrophy (P < .0001). Other factors included a greater left atrial diameter (reflecting diastolic dysfunction), a lower ejection fraction, and male gender. An increased postoperative transprosthesis gradient was associated with greater residual left ventricular hypertrophy; however, its effect was minimal. Preoperative severe left ventricular hypertrophy and left atrial dilatation reduced long-term survival, independent of symptom status. CONCLUSIONS Severe left ventricular hypertrophy with left atrial dilatation can develop from severe aortic stenosis, even without symptoms. These changes can persist, are associated with decreased long-term survival even after successful aortic valve replacement, and could be indications for early aortic valve replacement if supported by findings from an appropriate prospective study.
Collapse
Affiliation(s)
- Jocelyn M Beach
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Tomislav Mihaljevic
- Heart and Vascular Institute, Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates.
| | - Jeevanantham Rajeswaran
- Research Institute, Department of Quantitative Health Sciences, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Thomas Marwick
- Heart and Vascular Institute, Department of Cardiovascular Medicine, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Samuel T Edwards
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Edward R Nowicki
- Heart and Vascular Institute, Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - James Thomas
- Heart and Vascular Institute, Department of Cardiovascular Medicine, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Lars G Svensson
- Heart and Vascular Institute, Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Brian Griffin
- Heart and Vascular Institute, Department of Cardiovascular Medicine, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - A Marc Gillinov
- Heart and Vascular Institute, Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Eugene H Blackstone
- Heart and Vascular Institute, Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates; Research Institute, Department of Quantitative Health Sciences, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| |
Collapse
|
30
|
Vizzardi E, D’Aloia A, Fiorina C, Bugatti S, Parrinello G, De Carlo M, Giannini C, Di Bello V, Petronio AS, Curello S, Ettori F, Dei Cas L. Early Regression of Left Ventricular Mass Associated with Diastolic Improvement after Transcatheter Aortic Valve Implantation. J Am Soc Echocardiogr 2012; 25:1091-8. [DOI: 10.1016/j.echo.2012.06.010] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2012] [Indexed: 01/29/2023]
|
31
|
Friedman KG, McElhinney DB, Colan SD, Porras D, Powell AJ, Lock JE, Brown DW. Left ventricular remodeling and improvement in diastolic function after balloon aortic valvuloplasty for congenital aortic stenosis. Circ Cardiovasc Interv 2012; 5:549-54. [PMID: 22739787 DOI: 10.1161/circinterventions.112.968958] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND In congenital aortic stenosis, chronic pressure load has detrimental effects on left ventricular (LV) systolic and diastolic function. Reduction in LV pressure load with balloon aortic valvuloplasty (BAVP) may improve diastolic function. METHODS AND RESULTS Echocardiographic and catheterization data for 25 consecutive patients undergoing BAVP for congenital aortic stenosis were retrospectively analyzed. Median age at BAVP was 11.5 years (3.2-40.1). LV end-diastolic pressure was elevated (≥15 mm Hg) in 72% of patients, with a median of 17 mm Hg (range, 9-24). With BAVP, median aortic stenosis gradient was reduced from 63 mm Hg (range, 44-105) to 30 mm Hg (range, 10-43). Aortic regurgitation increased from trivial (none to mild) to mild (trivial to moderate). Pre-BAVP early diastolic mitral inflow velocity/tissue Doppler early diastolic velocity (E/E´) correlated with LV end-diastolic pressure (r=0.52, P=0.007). On follow-up echocardiography (median, 11 months after BAVP), aortic stenosis gradient was lower (P<0.001) and degree of AR was higher (P=0.01) compared with pre-BAVP echocardiograms. LV end-diastolic volume z-score increased (P=0.02), LV mass was unchanged, and LV mass:volume decreased (P=0.002). Mitral annular and septal E´ (P<0.001) were higher and E/E´ was lower after dilation (10.8 versus 14.2, P<0.001). Lower pre-BAVP E/E´ and lower pre-BAVP LV mass z-score were associated with lower post-BAVP E/E. CONCLUSION After BAVP, LV remodeling characterized by an increase in EDV and decrease in LV mass:volume occurs and echocardiographic measures of diastolic function and LV end-diastolic pressure improve in most patients. Risk factors for persistent diastolic dysfunction include higher pre-BAVP LV mass z-score and worse pre-BAVP diastolic function.
Collapse
Affiliation(s)
- Kevin G Friedman
- Department of Cardiology, Children's Hospital Boston and Harvard Medical School, Boston, MA 02115, USA.
| | | | | | | | | | | | | |
Collapse
|
32
|
|
33
|
Tzikas A, Geleijnse ML, Van Mieghem NM, Schultz CJ, Nuis RJ, van Dalen BM, Sarno G, van Domburg RT, Serruys PW, de Jaegere PPT. Left ventricular mass regression one year after transcatheter aortic valve implantation. Ann Thorac Surg 2011; 91:685-91. [PMID: 21352980 DOI: 10.1016/j.athoracsur.2010.09.037] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2010] [Revised: 09/15/2010] [Accepted: 09/17/2010] [Indexed: 12/16/2022]
Abstract
BACKGROUND Left ventricular (LV) hypertrophy is associated with LV diastolic dysfunction and constitutes a risk factor for cardiac morbidity and mortality. The objective of this study was to investigate the degree of LV mass regression and the changes of LV diastolic function one year after transcatheter aortic valve implantation (TAVI). METHODS Echocardiography was performed at baseline, before discharge, and at one-year follow-up in 63 consecutive patients with severe aortic stenosis who underwent TAVI with the Medtronic CoreValve System (Medtronic Inc, Minneapolis, MN). The LV mass was calculated using the Devereux formula and indexed to body surface area. RESULTS One-year all-cause mortality was 29%. The LV mass index decreased from 126 ± 42 g/m(2) at baseline to 110 ± 30 g/m(2) at one-year follow-up (p < 0.001). Left ventricular ejection fraction and LV diastolic function did not change significantly. Mean transaortic gradient decreased from 47 ± 19 mm Hg at baseline to 9 ± 5 mm Hg at discharge and 9 ± 4 mm Hg at one year (p < 0.001), and was accompanied by significant clinical improvement. More than mild paravalvular aortic regurgitation was found in 24% and 15% of patients at discharge and one-year follow-up, respectively. CONCLUSIONS A significant regression in LV mass was found one year after TAVI. However, regression was incomplete and was not accompanied by an improvement in LV diastolic function.
Collapse
Affiliation(s)
- Apostolos Tzikas
- Department of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | | | | | | | | | | | | | | | | |
Collapse
|
34
|
Kardassis D, Bech-Hanssen O, Schönander M, Sjöström L, Petzold M, Karason K. Impact of body composition, fat distribution and sustained weight loss on cardiac function in obesity. Int J Cardiol 2011; 159:128-33. [PMID: 21367473 DOI: 10.1016/j.ijcard.2011.02.036] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2010] [Revised: 12/07/2010] [Accepted: 02/10/2011] [Indexed: 12/19/2022]
Abstract
BACKGROUND Obesity is associated with alterations in left ventricular function varying along with the degree of fatness, but the mechanisms underlying this co-variation are not clear. In a case-control study we examined how sustained weight losses affect cardiac function and report on how body composition and fat distribution relate to the left ventricular performance. METHODS At the 10-year follow-up of the Swedish obese subjects (SOS) study cohort we identified 44 patients with sustained weight losses after bariatric surgery (surgery group) and 44 matched obese control patients who remained weight stable (obese group). We also recruited 44 matched normal weight subjects (lean group). Dual-energy X-ray absorptiometry, computed tomography and echocardiography were performed to evaluate body composition, fat distribution and cardiac function. RESULTS BMI was 42.5 kg/m(2), 31.5 kg/m(2) and 24.4 kg/m(2) for the obese, surgery and lean groups respectively. Increasing degree of obesity was associated with larger left ventricular volumes (p < 0.001), higher cardiac output (p < 0.001), reduced systolic myocardial velocity (p<0.001) and impaired ventricular relaxation (p = 0.015). In multivariate analyses, left ventricular volume, stroke volume and cardiac output primarily associated with lean body mass, whereas blood pressure, heart rate and variables reflecting cardiac dysfunction were more related to total body fat and visceral adiposity. CONCLUSION Obesity is associated with discrete but distinct disturbances in the left ventricular performance appearing to be related to both the total amount of body fat and degree of visceral adiposity. Patients with sustained weight losses display superior left ventricular systolic and diastolic functions as compared with their obese counterparts remaining weight stable.
Collapse
Affiliation(s)
- Dimitris Kardassis
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden.
| | | | | | | | | | | |
Collapse
|
35
|
Noninvasive assessment of filling pressure and left atrial pressure overload in severe aortic valve stenosis: relation to ventricular remodeling and clinical outcome after aortic valve replacement. J Thorac Cardiovasc Surg 2011; 142:e77-83. [PMID: 21353251 DOI: 10.1016/j.jtcvs.2011.01.032] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2010] [Revised: 06/05/2010] [Accepted: 01/19/2011] [Indexed: 01/08/2023]
Abstract
OBJECTIVE One of the hemodynamic consequences of aortic valve stenosis is pressure overload leading to left atrial dilatation. Left atrial size is a known risk factor providing prognostic information in several cardiac conditions. It is not known if this is also the case in patients with aortic valve stenosis after aortic valve replacement. METHODS A total of 119 patients with severe aortic valve stenosis scheduled for aortic valve replacement were evaluated preoperatively and divided into 2 groups according to left atrial volume index (≥40 mL/m(2)). Echocardiography was repeated 12 months after surgery. Patients were followed up for 24 months. The primary end point was the composite end point overall mortality and hospitalization due to congestive heart failure. RESULTS Preoperative left atrial dilation was associated with left ventricular hypertrophy and increased filling pressure. Preoperative left atrial volume index was associated with persistent abnormalities in left ventricular filling pressure and left ventricular mass index at 1 year after surgery. Event-free survival in patients with left atrial volume index of 40 mL/m(2) or more at 1 year was 71% compared with 88% in patients with left atrial volume index less than 40 mL/m(2) (P = .002). Patients with preoperative increased E/e' ratio and left ventricular hypertrophy were at increased risk. In Cox regression analysis after correcting for standard risk factors, left atrial volume index was found to be the only significant predictor of the composite end point. In a forward conditional multivariable model, left atrial volume index 40 mL/m(2) or greater (hazard ratio, 4.2 [1.6-10.7]; P = .003) remained an independent predictor, whereas E/e' was borderline significant (P = .06). CONCLUSIONS In patients with symptomatic severe aortic valve stenosis undergoing aortic valve replacement, left atrial volume provides important prognostic information beyond standard risk factors.
Collapse
|
36
|
Bech-Hanssen O, Aljassim O, Houltz E, Svensson G. The relative contribution of prosthetic gradients, systemic arterial pressure, and pulse pressure to the left ventricular pressure in patients with aortic prosthetic valves. EUROPEAN JOURNAL OF ECHOCARDIOGRAPHY 2010; 12:37-45. [DOI: 10.1093/ejechocard/jeq101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
37
|
Bauer F, Lemercier M, Zajarias A, Tron C, Eltchaninoff H, Cribier A. Immediate and Long-Term Echocardiographic Findings after Transcatheter Aortic Valve Implantation for the Treatment of Aortic Stenosis: The Cribier-Edwards/Edwards-Sapien Valve Experience. J Am Soc Echocardiogr 2010; 23:370-6. [DOI: 10.1016/j.echo.2010.01.020] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2009] [Indexed: 11/28/2022]
|
38
|
Brown J, Shah P, Stanton T, Marwick TH. Interaction and prognostic effects of left ventricular diastolic dysfunction and patient-prosthesis mismatch as determinants of outcome after isolated aortic valve replacement. Am J Cardiol 2009; 104:707-12. [PMID: 19699349 DOI: 10.1016/j.amjcard.2009.04.035] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2009] [Revised: 04/21/2009] [Accepted: 04/21/2009] [Indexed: 11/25/2022]
Abstract
There are variable reported effects of patient-prosthesis mismatch (P-PM) on outcome. It was hypothesized that the adverse effect attributed to P-PM is actually due to left ventricular diastolic dysfunction (DD) in patients with small hearts. The aim of this study was therefore to determine the association among P-PM, DD, and outcomes. Doppler echocardiography was performed in 156 patients after aortic valve replacement. In vivo effective orifice areas for each prosthesis type and size were obtained from published references values of normally functioning prostheses. P-PM was identified from the predicted indexed orifice area, obtained by dividing the effective orifice area by body surface area. DD was classed as normal, delayed relaxation (prolonged deceleration time for age), or increased left atrial pressure (increased E/E' ratio, left atrial enlargement, short deceleration time). Events (cardiac-related hospitalizations and all-cause mortality after aortic valve replacement) were determined over a median follow-up periods of 3.5 years (interquartile range 2.1 to 5.7). P-PM was found in 91 patients (58%). Of the patients with P-PM, no DD was present on postoperative echocardiography in 15 patients (16%), delayed relaxation in 35 (39%), and increased left atrial pressure in 41 (45%). There were 61 total events (18 deaths and 43 hospitalizations): 4 (7%) in the no-DD group, 26 (42%) in the delayed relaxation group, and 31 (51%) in the increased left atrial pressure group. DD (p = 0.034) but not age (p = 0.09), the left ventricular ejection fraction (p = 0.60), or the presence of mismatch (p = 0.20) was associated with events. In conclusion, P-PM was associated with 14% mortality and a 39% composite event rate over 2-year follow-up. Events were significantly associated with DD.
Collapse
|
39
|
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]
|
40
|
Influence of Prosthesis–Patient Mismatch on Diastolic Heart Failure After Aortic Valve Replacement. Ann Thorac Surg 2008; 85:1310-7. [DOI: 10.1016/j.athoracsur.2007.12.069] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2007] [Revised: 12/22/2007] [Accepted: 12/27/2007] [Indexed: 11/20/2022]
|
41
|
Aortic stenosis. ACTA ACUST UNITED AC 2008; 33:174-83. [PMID: 18025609 DOI: 10.1007/s12019-007-8021-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2007] [Revised: 11/30/1999] [Accepted: 07/16/2007] [Indexed: 10/22/2022]
Abstract
Patients with aortic stenosis (AS) have an increased prevalence of coronary risk factors, coronary artery disease, and other atherosclerotic vascular disease and an increased incidence of coronary events and death. Statins may reduce the progression of AS. Angina pectoris, syncope or near syncope, and heart failure are the three classic manifestations of severe AS. Prolonged duration and late peaking of an aortic systolic ejection murmur best differentiate severe AS from mild AS on physical examination. Doppler echocardiography is used to diagnose the presence and severity of AS. Once symptoms develop, aortic valve replacement (AVR) should be performed in patients with severe or moderate AS. Warfarin should be administered indefinitely after AVR in patients with a mechanical aortic valve and in patients with a bioprosthetic aortic valve who have either atrial fibrillation, prior thromboembolism, left ventricular systolic dysfunction, or a hypercoagulable condition. Patients with a bioprosthetic aortic valve without any of these four risk factors should be treated with aspirin 75-100 mg daily.
Collapse
|
42
|
Abstract
Elderly patients with valvular aortic stenosis have an increased prevalence of coronary risk factors, of coronary artery disease, and evidence of other atherosclerotic vascular diseases. Statins may reduce the progression of aortic stenosis (AS). Angina pectoris, syncope or near syncope, and congestive heart failure are the 3 classic manifestations of severe AS. Prolonged duration and late peaking of an aortic systolic ejection murmur best differentiate severe AS from mild AS on physical examination. Doppler echocardiography is used to diagnose the prevalence and severity of AS. The indications for cardiac catheterization and the medical management of AS are discussed. Once symptoms develop, aortic valve replacement (AVR) should be performed in patients with severe or moderate AS. Other indications for AVR are discussed. Warfarin should be administered indefinitely after AVR in patients with a mechanical aortic valve and in patients with a bioprosthetic aortic valve who have either atrial fibrillation, prior thromboembolism, left ventricular systolic dysfunction, or a hypercoagulable condition. Patients with a bioprosthetic aortic valve without any of these 4 risk factors should be treated with aspirin 75-100 mg daily.
Collapse
Affiliation(s)
- Wilbert S Aronow
- Cardiology Division, Department of Medicine, New York Medical College, Valhalla, New York 10595, USA.
| |
Collapse
|
43
|
Barbetseas J, Brili S, Stamatopoulos I, Aggeli C, Metallinos G, Chrysohoou C, Stefanadis C. Pitfalls Leading to Misdiagnosis of a Normally Functioning Prosthetic Aortic Valve as Stenotic. Echocardiography 2007; 24:773-9. [PMID: 17651110 DOI: 10.1111/j.1540-8175.2007.00465.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- John Barbetseas
- First Department of Cardiology, Athens Medical School, Hippokratio Hospital, Athens, Greece
| | | | | | | | | | | | | |
Collapse
|
44
|
Villa E, Troise G, Cirillo M, Brunelli F, Tomba MD, Mhagna Z, Tasca G, Quaini E. Factors affecting left ventricular remodeling after valve replacement for aortic stenosis. An overview. Cardiovasc Ultrasound 2006; 4:25. [PMID: 16803632 PMCID: PMC1524988 DOI: 10.1186/1476-7120-4-25] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2005] [Accepted: 06/27/2006] [Indexed: 01/19/2023] Open
Abstract
Although a small percentage of patients with critical aortic stenosis do not develop left ventricle hypertrophy, increased ventricular mass is widely observed in conditions of increased afterload. There is growing epidemiological evidence that hypertrophy is associated with excess cardiac mortality and morbidity not only in patients with arterial hypertension, but also in those undergoing aortic valve replacement. Valve replacement surgery relieves the aortic obstruction and prolongs the life of many patients, but favorable or adverse left ventricular remodeling is affected by a large number of factors whose specific roles are still a subject of debate. Age, gender, hemodynamic factors, prosthetic valve types, myocyte alterations, interstitial structures, blood pressure control and ethnicity can all influence the process of left ventricle mass regression, and myocardial metabolism and coronary artery circulation are also involved in the changes occurring after aortic valve replacement. The aim of this overview is to analyze these factors in the light of our experience, elucidate the important question of prosthesis-patient mismatch by considering the method of effective orifice area, and discuss surgical timings and techniques that can improve the management of patients with aortic valve stenosis and maximize the probability of mass regression.
Collapse
Affiliation(s)
- Emmanuel Villa
- Cardiac Surgery Unit, Cardiovascular Dept. Poliambulanza Foundation Hospital, Brescia, Italy
- University of Milan, Milan, Italy
| | - Giovanni Troise
- Cardiac Surgery Unit, Cardiovascular Dept. Poliambulanza Foundation Hospital, Brescia, Italy
| | - Marco Cirillo
- Cardiac Surgery Unit, Cardiovascular Dept. Poliambulanza Foundation Hospital, Brescia, Italy
| | - Federico Brunelli
- Cardiac Surgery Unit, Cardiovascular Dept. Poliambulanza Foundation Hospital, Brescia, Italy
| | - Margherita Dalla Tomba
- Cardiac Surgery Unit, Cardiovascular Dept. Poliambulanza Foundation Hospital, Brescia, Italy
| | - Zen Mhagna
- Cardiac Surgery Unit, Cardiovascular Dept. Poliambulanza Foundation Hospital, Brescia, Italy
| | - Giordano Tasca
- Cardiac Surgery Unit, Cardiovascular Dept. Poliambulanza Foundation Hospital, Brescia, Italy
| | - Eugenio Quaini
- Cardiac Surgery Unit, Cardiovascular Dept. Poliambulanza Foundation Hospital, Brescia, Italy
| |
Collapse
|