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Hariri EH, El Halabi J, Kassis N, Al Hammoud MM, Badwan OZ, Layoun H, Kassab J, Al Shuab W, Bansal A, Farwati M, Harb SC, Popović ZB, Svensson L, Menon V, Kapadia SR. Sex Differences in the Progression and Long-Term Outcomes of Native Mild to Moderate Aortic Stenosis. JACC Cardiovasc Imaging 2024; 17:1-12. [PMID: 37498256 DOI: 10.1016/j.jcmg.2023.06.006] [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: 03/01/2023] [Revised: 06/01/2023] [Accepted: 06/02/2023] [Indexed: 07/28/2023]
Abstract
BACKGROUND There are limited data on the sex differences in the hemodynamic progression and outcomes of early-stage aortic stenosis (AS). OBJECTIVES The authors sought to determine sex differences in hemodynamic progression and outcomes of mild to moderate native AS. METHODS This was a retrospective observational cohort study including patients with mild to moderate native tricuspid AS from the Cleveland Clinic echocardiographic database between 2008 and 2016 and followed until 2018. All-cause mortality, aortic valve replacement (AVR), and disease progression assessed by annualized changes in echocardiographic parameters were analyzed based on sex. RESULTS The authors included 2,549 patients (mean age, 74 ± 7 years and 42.5% women) followed over a median duration of 5.7 years. There was no difference in all-cause mortality between sexes irrespective of age, baseline disease severity, progression to severe AS, and receipt of AVR. Relative to men, women had similar all-cause mortality but lower risk of AVR (adjusted HR: 0.81 [95% CI: 0.67-0.91]; P = 0.009) at 10 years. On 1:1 propensity-matched analysis, men had a significantly faster disease progression represented by greater increases in the median of annualized change in mean gradient (2.10 vs 1.15 mm Hg/y, respectively, P < 0.001), maximum transvalvular velocity (0.42 vs 0.28 m/s/y), left ventricular end-diastolic diameters (0.15 vs 0.048 mm/m2.7/y) (P = 0.014). Women have significantly higher left ventricular ejection fraction, filling pressures, and left ventricular septum thickness over time on follow-up echocardiograms compared with men. CONCLUSIONS Women with mild to moderate AS had slower hemodynamic progression of AS, were more likely to have preserved left ventricular ejection fraction and concentric left ventricular hypertrophy in addition to lower incidence of AVR compared with men despite similar mortality. These findings provide further evidence that there are distinct sex-specific longitudinal echocardiographic and clinical profiles in patients with AS.
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Affiliation(s)
- Essa H Hariri
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Jessica El Halabi
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Nicholas Kassis
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Mazen M Al Hammoud
- Gilbert and Rose-Marie Chagoury School of Medicine, Lebanese American University, Byblos, Lebanon
| | - Osamah Z Badwan
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Habib Layoun
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Joseph Kassab
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Wael Al Shuab
- New York Institute of Technology College of Osteopathic Medicine, Old Westbury, New York
| | - Agam Bansal
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio; Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Medhat Farwati
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio; Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Serge C Harb
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Zoran B Popović
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Lars Svensson
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Venu Menon
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Samir R Kapadia
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio.
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Rymer JA, Sun JL, Chiswell K, Cohen D, Vilain K, Wang A, Samad Z, Wang TY, Douglas PS. Variation in resource utilization and mortality among patients with varying MR type and severity. Am Heart J 2023; 260:44-57. [PMID: 36792001 DOI: 10.1016/j.ahj.2023.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 12/24/2022] [Accepted: 01/08/2023] [Indexed: 05/07/2023]
Abstract
BACKGROUND Limited data exists regarding the relationships between resource use and outcomes in patients with mitral regurgitation (MR). We examined resource utilization and outcomes across MR type and severity. METHODS Using the Duke Echocardiography Laboratory Database, we identified patients with an index echo demonstrating moderate or severe MR (2000-2016) and examined 5-year cumulative rates of resources (ie, TTE, TEE, cardiac catheterization, cardiology/CTS referral, MV surgery/TEER, hospitalizations) by severity and type. We performed a multivariable landmark analysis of resource use during a 6 to 12 month period and 5-year mortality; and a multivariable analysis of the association between MR type and 5-year hospitalization costs. RESULTS Among 4,511 patients with moderate or severe MR, 84.7% had moderate MR and 42.2% had secondary ischemic MR. The median age was 70 years-moderate, 66 years-severe. The mean 5-year cumulative resource utilization rate was 11.1 encounters/patients. Among patients with moderate or severe MR, there was significant variation in utilization of each resource by MR type (all P < .05). For severe MR, the performance of cardiac catheterization or MV surgery during the landmark period was associated with significantly lower mortality; for moderate MR, CTS referral during the landmark was associated with significantly lower mortality (P < .05). Patients with secondary ischemic and non-ischemic MR had significantly higher 5-year hospitalization costs compared with primary myxomatous MR (P < .05). CONCLUSIONS Resource utilization and outcomes vary by MR type and severity. Utilization of resources, such as TTE, during guideline-recommended surveillance periods was not associated with a reduction in mortality while other care (catheterization or surgery) was associated with improved survival.
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Affiliation(s)
- Jennifer A Rymer
- Division of Cardiology, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Durham, NC.
| | | | | | - David Cohen
- Cardiovascular Research Foundation, New York, NY; Division of Cardiology, St. Francis Hospital and Heart Center, Roslyn, NY
| | - Kate Vilain
- Department of Cardiovascular Medicine, Mid America Heart Institute, Kansas City, MO
| | - Andrew Wang
- Duke Clinical Research Institute, Durham, NC
| | - Zainab Samad
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Tracy Y Wang
- Division of Cardiology, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Durham, NC
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Cho I, Kim WD, Kim S, Ko KY, Seong Y, Kim DY, Seo J, Shim CY, Ha JW, Mori M, Gupta A, You SC, Hong GR, Krumholz HM. Reclassification of moderate aortic stenosis based on data-driven phenotyping of hemodynamic progression. Sci Rep 2023; 13:6694. [PMID: 37095171 PMCID: PMC10125992 DOI: 10.1038/s41598-023-33683-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Accepted: 04/17/2023] [Indexed: 04/26/2023] Open
Abstract
The management and follow-up of moderate aortic stenosis (AS) lacks consensus as the progression patterns are not well understood. This study aimed to identify the hemodynamic progression of AS, and associated risk factors and outcomes. We included patients with moderate AS with at least three transthoracic echocardiography (TTE) studies performed between 2010 and 2021. Latent class trajectory modeling was used to classify AS groups with distinctive hemodynamic trajectories, which were determined by serial systolic mean pressure gradient (MPG) measurements. Outcomes were defined as all-cause mortality and aortic valve replacement (AVR). A total of 686 patients with 3093 TTE studies were included in the analysis. Latent class model identified two distinct AS trajectory groups based on their MPG: a slow progression group (44.6%) and a rapid progression group (55.4%). Initial MPG was significantly higher in the rapid progression group (28.2 ± 5.6 mmHg vs. 22.9 ± 2.8 mmHg, P < 0.001). The prevalence of atrial fibrillation was higher in the slow progression group; there was no significant between-group difference in the prevalence of other comorbidities. The rapid progression group had a significantly higher AVR rate (HR 3.4 [2.4-4.8], P < 0.001); there was no between-group difference in mortality (HR 0.7 [0.5-1.0]; P = 0.079). Leveraging longitudinal echocardiographic data, we identified two distinct groups of patients with moderate AS: slow and rapid progression. A higher initial MPG (≥ 24 mmHg) was associated with more rapid progression of AS and higher rates of AVR, thus indicating the predictive value of MPG in management of the disease.
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Affiliation(s)
- Iksung Cho
- Division of Cardiology, Department of Internal Medicine, Severance Hospital, Yonsei University, 50-1, Yonsei-ro, Seodaemun-gu, Seoul, 03722, Korea
| | - William D Kim
- Chung-Ang University College of Medicine, Seoul, Korea
| | - Subin Kim
- Division of Cardiology, Department of Internal Medicine, Severance Hospital, Yonsei University, 50-1, Yonsei-ro, Seodaemun-gu, Seoul, 03722, Korea
- Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul, Korea
- Institute for Innovation in Digital Healthcare, Yonsei University, 50-1, Yonsei-ro, Seodaemun-gu, Seoul, 03722, Korea
| | - Kyu-Yong Ko
- Division of Cardiology, Department of Internal Medicine, Severance Hospital, Yonsei University, 50-1, Yonsei-ro, Seodaemun-gu, Seoul, 03722, Korea
| | - Yeonchan Seong
- Division of Cardiology, Department of Internal Medicine, Severance Hospital, Yonsei University, 50-1, Yonsei-ro, Seodaemun-gu, Seoul, 03722, Korea
| | - Dae-Young Kim
- Division of Cardiology, Department of Internal Medicine, Severance Hospital, Yonsei University, 50-1, Yonsei-ro, Seodaemun-gu, Seoul, 03722, Korea
| | - Jiwon Seo
- Division of Cardiology, Department of Internal Medicine, Severance Hospital, Yonsei University, 50-1, Yonsei-ro, Seodaemun-gu, Seoul, 03722, Korea
| | - Chi Young Shim
- Division of Cardiology, Department of Internal Medicine, Severance Hospital, Yonsei University, 50-1, Yonsei-ro, Seodaemun-gu, Seoul, 03722, Korea
| | - Jong-Won Ha
- Division of Cardiology, Department of Internal Medicine, Severance Hospital, Yonsei University, 50-1, Yonsei-ro, Seodaemun-gu, Seoul, 03722, Korea
| | - Makoto Mori
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT, USA
| | - Aakriti Gupta
- Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Seng Chan You
- Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul, Korea.
- Institute for Innovation in Digital Healthcare, Yonsei University, 50-1, Yonsei-ro, Seodaemun-gu, Seoul, 03722, Korea.
| | - Geu-Ru Hong
- Division of Cardiology, Department of Internal Medicine, Severance Hospital, Yonsei University, 50-1, Yonsei-ro, Seodaemun-gu, Seoul, 03722, Korea.
| | - Harlan M Krumholz
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT, USA
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA
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4
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All Aortic Valve Diseases Taken Together Are Not Associated With Obesity. Crit Pathw Cardiol 2022; 21:191-193. [PMID: 36413398 DOI: 10.1097/hpc.0000000000000298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Obesity is a risk factor for cardiovascular disease. The goal of this study was to evaluate any association between aortic valve disease and obesity using a very large database. METHODS The Nationwide Inpatient Sample database was utilized for statistical analysis using ICD-9 codes for aortic valve disease and obesity in the United States from 2003 to 2007. A 25% random sample of nonobese patients was used for comparison of aortic valve disease prevalence during the same 5-year period. RESULTS A total of 1,971,812 patients with obesity were identified from 2003 to 2007. Comparing this population with a random sample of nonobese patients during the same years, there was no significant difference between obese and nonobese patients in regards to the prevalence of aortic valve disease (1.1-1.2% in 2003 and 2004, 1.2% in 2005-2007, P = NS). After adjusting for age, gender, and race, obesity was associated with lower prevalence of aortic valve disease in 2003-2007 (odds ratio 0.81-0.86, P < 0.01). CONCLUSIONS Using a very large database, we found a decrease in the prevalence of aortic valve disease in the obese population. This suggests that obesity alone does not pathologically affect the aortic valve.
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Pinto G, Fragasso G. Aortic valve stenosis: drivers of disease progression and drug targets for therapeutic opportunities. Expert Opin Ther Targets 2022; 26:633-644. [DOI: 10.1080/14728222.2022.2118576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Giuseppe Pinto
- Departmen of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- IRCCS Humanitas Research Hospital, Rozzano-Milan, Italy
| | - Gabriele Fragasso
- Department of Clinical Cardiology, Heart Failure Clinic, IRCCS San Raffaele Scientific Institute, Milano
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Dayawansa NH, Baratchi S, Peter K. Uncoupling the Vicious Cycle of Mechanical Stress and Inflammation in Calcific Aortic Valve Disease. Front Cardiovasc Med 2022; 9:783543. [PMID: 35355968 PMCID: PMC8959593 DOI: 10.3389/fcvm.2022.783543] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 02/15/2022] [Indexed: 12/24/2022] Open
Abstract
Calcific aortic valve disease (CAVD) is a common acquired valvulopathy, which carries a high burden of mortality. Chronic inflammation has been postulated as the predominant pathophysiological process underlying CAVD. So far, no effective medical therapies exist to halt the progression of CAVD. This review aims to outline the known pathways of inflammation and calcification in CAVD, focussing on the critical roles of mechanical stress and mechanosensing in the perpetuation of valvular inflammation. Following initiation of valvular inflammation, dysregulation of proinflammatory and osteoregulatory signalling pathways stimulates endothelial-mesenchymal transition of valvular endothelial cells (VECs) and differentiation of valvular interstitial cells (VICs) into active myofibroblastic and osteoblastic phenotypes, which in turn mediate valvular extracellular matrix remodelling and calcification. Mechanosensitive signalling pathways convert mechanical forces experienced by valve leaflets and circulating cells into biochemical signals and may provide the positive feedback loop that promotes acceleration of disease progression in the advanced stages of CAVD. Mechanosensing is implicated in multiple aspects of CAVD pathophysiology. The mechanosensitive RhoA/ROCK and YAP/TAZ systems are implicated in aortic valve leaflet mineralisation in response to increased substrate stiffness. Exposure of aortic valve leaflets, endothelial cells and platelets to high shear stress results in increased expression of mediators of VIC differentiation. Upregulation of the Piezo1 mechanoreceptor has been demonstrated to promote inflammation in CAVD, which normalises following transcatheter valve replacement. Genetic variants and inhibition of Notch signalling accentuate VIC responses to altered mechanical stresses. The study of mechanosensing pathways has revealed promising insights into the mechanisms that perpetuate inflammation and calcification in CAVD. Mechanotransduction of altered mechanical stresses may provide the sought-after coupling link that drives a vicious cycle of chronic inflammation in CAVD. Mechanosensing pathways may yield promising targets for therapeutic interventions and prognostic biomarkers with the potential to improve the management of CAVD.
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Affiliation(s)
- Nalin H. Dayawansa
- Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
- Department of Cardiology, Alfred Hospital, Melbourne, VIC, Australia
- Department of Medicine, Monash University, Melbourne, VIC, Australia
| | - Sara Baratchi
- Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
- School of Health and Biomedical Sciences, RMIT University, Melbourne, VIC, Australia
- Department of Cardiometabolic Health, The University of Melbourne, Melbourne, VIC, Australia
| | - Karlheinz Peter
- Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
- Department of Cardiology, Alfred Hospital, Melbourne, VIC, Australia
- Department of Medicine, Monash University, Melbourne, VIC, Australia
- Department of Cardiometabolic Health, The University of Melbourne, Melbourne, VIC, Australia
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7
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Evaluating Medical Therapy for Calcific Aortic Stenosis: JACC State-of-the-Art Review. J Am Coll Cardiol 2021; 78:2354-2376. [PMID: 34857095 DOI: 10.1016/j.jacc.2021.09.1367] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 09/08/2021] [Accepted: 09/27/2021] [Indexed: 12/23/2022]
Abstract
Despite numerous promising therapeutic targets, there are no proven medical treatments for calcific aortic stenosis (AS). Multiple stakeholders need to come together and several scientific, operational, and trial design challenges must be addressed to capitalize on the recent and emerging mechanistic insights into this prevalent heart valve disease. This review briefly discusses the pathobiology and most promising pharmacologic targets, screening, diagnosis and progression of AS, identification of subgroups that should be targeted in clinical trials, and the need to elicit the patient voice earlier rather than later in clinical trial design and implementation. Potential trial end points and tools for assessment and approaches to implementation and design of clinical trials are reviewed. The efficiencies and advantages offered by a clinical trial network and platform trial approach are highlighted. The objective is to provide practical guidance that will facilitate a series of trials to identify effective medical therapies for AS resulting in expansion of therapeutic options to complement mechanical solutions for late-stage disease.
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8
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Shen M, Tastet L, Capoulade R, Arsenault M, Bédard É, Clavel MA, Pibarot P. Effect of bicuspid aortic valve phenotype on progression of aortic stenosis. Eur Heart J Cardiovasc Imaging 2021; 21:727-734. [PMID: 32386199 DOI: 10.1093/ehjci/jeaa068] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 02/12/2020] [Accepted: 03/25/2020] [Indexed: 11/14/2022] Open
Abstract
AIMS To compare the progression of aortic stenosis (AS) in patients with bicuspid aortic valve (BAV) or tricuspid aortic valve (TAV). METHODS AND RESULTS One hundred and forty-one patients with mild-to-moderate AS, recruited prospectively in the PROGRESSA study, were included in this sub-analysis. Baseline clinical, Doppler echocardiography and multidetector computed tomography characteristics were compared between BAV (n = 32) and TAV (n = 109) patients. The 2-year haemodynamic [i.e. peak aortic jet velocity (Vpeak) and mean transvalvular gradient (MG)] and anatomic [i.e. aortic valve calcification density (AVCd) and aortic valve calcification density ratio (AVCd ratio)] progression of AS were compared between the two valve phenotypes. The 2-year progression rate of Vpeak was: 16 (-0 to 40) vs. 17 (3-35) cm/s, P = 0.95; of MG was: 1.8 (-0.7 to 5.8) vs. 2.6 (0.4-4.8) mmHg, P = 0.56; of AVCd was 32 (2-109) vs. 52 (25-85) AU/cm2, P = 0.15; and of AVCd ratio was: 0.08 (0.01-0.23) vs. 0.12 (0.06-0.18), P = 0.16 in patients with BAV vs. TAV. In univariable analyses, BAV was not associated with AS progression (all, P ≥ 0.26). However, with further adjustment for age, AS baseline severity, and several risk factors (i.e. sex, history of hypertension, creatinine level, diabetes, metabolic syndrome), BAV was independently associated with faster haemodynamic (Vpeak: β = 0.31, P = 0.02) and anatomic (AVCd: β = 0.26, P = 0.03 and AVCd ratio: β = 0.26, P = 0.03) progression of AS. CONCLUSION In patients with mild-to-moderate AS, patients with BAV have faster haemodynamic and anatomic progression of AS when compared to TAV patients with similar age and risk profile. This study highlights the importance and necessity to closely monitor patients with BAV and to adequately control and treat their risk factors. CLINICAL TRIAL REGISTRATION https://clinicaltrials.gov Unique identifier: NCT01679431.
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Affiliation(s)
- Mylène Shen
- Department of Medicine, Institut universitaire de cardiologie et de pneumologie de Québec-Université Laval/Quebec Heart & Lung Institute-Laval University, 2725 Chemin Sainte-Foy, Quebec City, Quebec G1V 4G5, Canada
| | - Lionel Tastet
- Department of Medicine, Institut universitaire de cardiologie et de pneumologie de Québec-Université Laval/Quebec Heart & Lung Institute-Laval University, 2725 Chemin Sainte-Foy, Quebec City, Quebec G1V 4G5, Canada
| | - Romain Capoulade
- Inserm UMR 1087/CNRS UMR 6291, IRS-UN, L'institut du thorax, CHU Nantes, UNIV Nantes, 8 quai Moncousu, BP 70721, 44007 Nantes Cedex 1, France
| | - Marie Arsenault
- Department of Medicine, Institut universitaire de cardiologie et de pneumologie de Québec-Université Laval/Quebec Heart & Lung Institute-Laval University, 2725 Chemin Sainte-Foy, Quebec City, Quebec G1V 4G5, Canada
| | - Élisabeth Bédard
- Department of Medicine, Institut universitaire de cardiologie et de pneumologie de Québec-Université Laval/Quebec Heart & Lung Institute-Laval University, 2725 Chemin Sainte-Foy, Quebec City, Quebec G1V 4G5, Canada
| | - Marie-Annick Clavel
- Department of Medicine, Institut universitaire de cardiologie et de pneumologie de Québec-Université Laval/Quebec Heart & Lung Institute-Laval University, 2725 Chemin Sainte-Foy, Quebec City, Quebec G1V 4G5, Canada
| | - Philippe Pibarot
- Department of Medicine, Institut universitaire de cardiologie et de pneumologie de Québec-Université Laval/Quebec Heart & Lung Institute-Laval University, 2725 Chemin Sainte-Foy, Quebec City, Quebec G1V 4G5, Canada
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9
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Myasoedova VA, Saccu C, Chiesa M, Songia P, Alfieri V, Massaiu I, Valerio V, Moschetta D, Gripari P, Naliato M, Cavallotti L, Spirito R, Trabattoni P, Poggio P. Aortic Valve Sclerosis as an Important Predictor of Long-Term Mortality in Patients With Carotid Atheromatous Plaque Requiring Carotid Endarterectomy. Front Cardiovasc Med 2021; 8:653991. [PMID: 34124193 PMCID: PMC8193358 DOI: 10.3389/fcvm.2021.653991] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 04/26/2021] [Indexed: 12/27/2022] Open
Abstract
Background: A strong association between aortic valve sclerosis (AVSc), the earliest manifestation of calcific aortic valve disease, and atherosclerosis exists. The aim of the study was to evaluate the predictive capabilities of AVSc on long-term all-cause mortality, in patients requiring carotid endarterectomy (CEA). Methods and Results: 806 consecutive CEA patients were enrolled. Preoperative echocardiography was used to assess AVSc. Computed tomography angiography was applied for plaque characterization. Kaplan-Meier curves, Cox linear regression, and area under the receiving operator characteristic (AUC) curve analyses were used to evaluate the predictive capability of AVSc. Overall, 348 of 541 patients had AVSc (64%). Age, diabetes, and estimated glomerular filtration rate (eGFR) were associated with AVSc. In the 5-year follow-up, AVSc group had a mortality rate of 16.7% while in no-AVSc group was 7.8%. Independent predictors of all-cause mortality were age, sex, eGFR, left ventricular ejection fraction, and AVSc. After adjustments, AVSc was associated with a significant increase in all-cause mortality risk (hazard ratio, HR = 1.9; 95%CI: 1.04–3.54; p = 0.038). We stratify our cohort based on carotid atheromatous plaque-type: soft, calcified, and mixed-fibrotic. In patients with mixed-fibrotic plaques, the mortality rate of AVSc patients was 15.5% compared to 2.4% in no-AVSc patients. In this group, AVSc was associated with an increased long-term all-cause mortality risk with an adjusted HR of 12.8 (95%CI: 1.71–96.35; p = 0.013), and the AUC, combing eGFR and AVSc was 0.77 (p < 0.001). Conclusions: Our findings indicate that AVSc together with eGFR may be used to improve long-term risk stratification of patients undergoing CEA surgery.
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Affiliation(s)
- Veronika A Myasoedova
- Unità per lo Studio delle Patologie Aortiche, Valvolari e Coronariche, Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Claudio Saccu
- Dipartimento di Chirurgia Cardiovascolare, Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Mattia Chiesa
- Bioinformatics and Artificial Intelligence Facility, Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Paola Songia
- Unità per lo Studio delle Patologie Aortiche, Valvolari e Coronariche, Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Valentina Alfieri
- Unità per lo Studio delle Patologie Aortiche, Valvolari e Coronariche, Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Ilaria Massaiu
- Unità per lo Studio delle Patologie Aortiche, Valvolari e Coronariche, Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Vincenza Valerio
- Unità per lo Studio delle Patologie Aortiche, Valvolari e Coronariche, Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy.,Università degli Studi di Napoli Federico II, Dipartimento di Medicina Clinica e Chirurgia, Napoli, Italy
| | - Donato Moschetta
- Unità per lo Studio delle Patologie Aortiche, Valvolari e Coronariche, Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy.,Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy
| | - Paola Gripari
- Dipartimento di Imaging Cardiovascolare, Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Moreno Naliato
- Dipartimento di Chirurgia Cardiovascolare, Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Laura Cavallotti
- Dipartimento di Chirurgia Cardiovascolare, Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Rita Spirito
- Dipartimento di Chirurgia Cardiovascolare, Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Piero Trabattoni
- Dipartimento di Chirurgia Cardiovascolare, Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Paolo Poggio
- Unità per lo Studio delle Patologie Aortiche, Valvolari e Coronariche, Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
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Yankey GS, Jackson LR, Marts C, Chiswell K, Wu A, Ugowe F, Wilson J, Vemulapalli S, Samad Z, Thomas KL. African American-Caucasian American differences in aortic valve replacement in patients with severe aortic stenosis. Am Heart J 2021; 234:111-121. [PMID: 33453161 PMCID: PMC9899489 DOI: 10.1016/j.ahj.2021.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 01/08/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Among patients with severe aortic stenosis (AS), there are limited data on aortic valve replacement (AVR), reasons for nonreceipt and mortality by race. METHODS Utilizing the Duke Echocardiography Laboratory Database, we analyzed data from 110,711 patients who underwent echocardiography at Duke University Medical Center between 1999 and 2013. We identified 1,111 patients with severe AS who met ≥1 of 3 criteria for AVR: ejection fraction ≤50%, diagnosis of heart failure, or need for coronary artery bypass surgery. Logistic regression models were used to assess the association between race, AVR and 1-year mortality. χ2 testing was used to assess potential racial differences in reasons for AVR nonreceipt. RESULTS Among the 1,111 patients (143 AA and 968 CA) eligible for AVR, AA were more often women, had more diabetes, renal insufficiency, aortic regurgitation and left ventricular hypertrophy. CA were more often smokers, had more ischemic heart disease, hyperlipidemia and higher median income levels. There were no racial differences in surgical risk utilizing logistic euroSCORES. Relative to CA, AA had lower rates of AVR (adjusted odds ratio 0.46, 95% CI 0.3-0.71, P < .001) yet similar 1-year mortality (aHR 0.81, 95% CI 0.57-1.17, P = .262). There were no significant differences in reasons for AVR nonreceipt. CONCLUSIONS We identified 143 African Americans (AA) and 968 Caucasian Americans(CA) with severe AS who met prespecified criteria for AVR.. AA relative to CA were more often women, had more diabetes, renal insufficiency, and left ventricular hypertrophy, however had less tobacco use, ischemic heart disease, hyperlipidemia and lower median income levels. Among patients with severe AS, AA relative to CA had lower rates of AVR (adjusted odds ratio 0.46, 95% CI 0.3-0.71, P < .001) without significant differences in reasons for AVR nonreceipt and similar 1-year mortality.
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Affiliation(s)
| | - Larry R Jackson
- Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Durham, NC
| | - Colin Marts
- Duke University School of Medicine, Durham, NC
| | | | - Angie Wu
- Duke Clinical Research Institute, Durham, NC
| | | | | | - Sreekanth Vemulapalli
- Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Durham, NC
| | | | - Kevin L Thomas
- Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Durham, NC.
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Markers of Elevated Left Ventricular Filling Pressure Are Associated with Increased Mortality in Nonsevere Aortic Stenosis. J Am Soc Echocardiogr 2021; 34:465-471. [PMID: 33388447 DOI: 10.1016/j.echo.2020.12.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 12/21/2020] [Accepted: 12/21/2020] [Indexed: 01/20/2023]
Abstract
BACKGROUND Echocardiographic measures of elevated left ventricular filling pressures are associated with an adverse prognosis. The aim of this study was to determine the relationship between acute (ratio of early transmitral flow to mitral annular velocity [E/e']) and chronic (indexed left atrial volume) markers of left ventricular filling pressure and mortality in patients with nonsevere aortic stenosis (AS), within the National Echo Database Australia cohort, testing the hypothesis that they would reflect the early hemodynamic consequences of AS and be associated with increased mortality in this setting. METHODS The first record for patients ≥18 years of age showing hemodynamically significant but nonsevere (mild or moderate) AS (mean pressure gradient ≥ 10 to <40 mm Hg and aortic valve area > 1 cm2) was analyzed. Baseline demographics and echocardiographic variables were compared with those among patients without AS (mean pressure gradient < 10 mm Hg). Mortality linkage data were available for all patients. RESULTS Of 78,886 patients with aortic valve mean pressure gradients < 40 mm Hg and aortic valve areas > 1 cm2, 13,768 (17%) were identified with nonsevere AS (aortic valve mean pressure gradient 10-40 mm Hg), of whom 57% were men (mean age, 73 ± 13.4 years) with a median follow-up of 3.4 years (interquartile range, 1.7-6.1 years). In unadjusted time-varying coefficient models, nonsevere AS and indexed left atrial volume > 34 mL/m2 (hazard ratio [HR], 2.29; 95% CI, 2.03-2.58), E/e' ratio > 14 (HR, 2.27; 95% CI, 2.08-2.49), left ventricular ejection fraction < 50% (HR, 2.82; 95% CI, 2.50-3.19), and tricuspid regurgitation peak velocity > 280 cm/sec (HR, 2.54; 95% CI, 2.30-2.80) were associated with increased mortality hazard at the time of echocardiography. All markers were significant when combined in a multivariate model. CONCLUSIONS Indices of elevated left ventricular filling pressure are independently associated with death in patients with nonsevere AS. Risk stratification models incorporating these variables may identify patients at risk for complications, warranting closer surveillance and possibly earlier intervention.
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Predicting the Development of Reduced Left Ventricular Ejection Fraction in Patients With Left Bundle Branch Block. Am J Cardiol 2020; 137:39-44. [PMID: 32998010 DOI: 10.1016/j.amjcard.2020.09.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 09/13/2020] [Accepted: 09/15/2020] [Indexed: 01/24/2023]
Abstract
Left bundle branch block (LBBB) increases the likelihood of developing reduced left ventricular (LV) ejection fraction (EF) but predicting which patients with LBBB and normal LVEF will develop decreased LVEF remains challenging. Fifty patients with LBBB and normal LVEF were retrospectively identified. Clinical, electrocardiographic, and echocardiographic variables were compared between patients who developed a decreased LVEF and those who did not. A total of 16 of 50 patients developed reduced LVEF after 4.3 (SD = 2.8) years of follow-up. Baseline patient and electrocardiographic variables were similar between patients who did and did not develop decreased LVEF. Baseline LVEF was lower in patients who developed decreased LVEF than in those who did not (51.9% [SD = 2.2%] vs 54.9% [SD = 4.4%], p <0.01). Diastolic filling time (DFT) accounted for a significantly smaller percentage of the cardiac cycle in patients who developed decreased LVEF than in those who did not (35.9%, [SD = 6.9%] vs 44.4% [SD = 4.5%] p <0.01). In univariable logistic regression, DFT had a C-statistic of 0.86 (p <0.0001) for prediction of development of decreased LVEF. In conclusion, patients in whom DFT accounted for <38% of the cardiac cycle had a relative risk of developing decreased LVEF of 7.0 (95% confidence interval 3.0 to 16.0) compared to patients with DFT accounting for ≥38% of the cardiac cycle.
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13
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Vollema EM, Prihadi EA, Ng ACT, Gegenava T, Ajmone Marsan N, Bax JJ, Delgado V. Prognostic Implications of Renal Dysfunction in Patients With Aortic Stenosis. Am J Cardiol 2020; 125:1108-1114. [PMID: 31982104 DOI: 10.1016/j.amjcard.2019.12.040] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 12/23/2019] [Accepted: 12/30/2019] [Indexed: 01/22/2023]
Abstract
Aortic stenosis (AS) and renal dysfunction share risk factors and often occur simultaneously. The influence of renal dysfunction on the prognosis of patients with various grades of AS has not been extensively described. The present study aimed to assess the prognostic implications of renal dysfunction in a large cohort of patients with aortic sclerosis and patients with various grades of AS. Patients diagnosed with various grades of AS by transthoracic echocardiography were assessed and divided according to renal function by estimated glomerular filtration rate (eGFR). The occurrence of all-cause mortality (primary end point) and aortic valve replacement (AVR) was noted. Of 1,178 patients (mean age 70 ± 13 years, 60% male), 327 (28%) had aortic sclerosis, 86 (7%) had mild AS, 285 (24%) had moderate AS, and 480 (41%) had severe AS. Renal dysfunction (eGFR <60 ml/min/1.73 m2) was present in 440 (37%) patients, and moderate to severe AS was observed more often in these patients compared to patients without (70 vs 62%, respectively; p = 0.008). After a median follow-up of 95 [31 to 149] months, 626 (53%) patients underwent AVR and 549 (47%) patients died. Severely impaired renal function (eGFR <30 ml/min/1.73 m2) and AVR were independently associated with all-cause mortality after correcting for AS severity. In conclusion, renal dysfunction is highly prevalent in patients with various grades of AS. After correcting for AS severity and AVR, severely impaired renal function (eGFR <30 ml/min/1.73 m2) was independently associated with all-cause mortality. Independent of renal function, AVR was associated with improved survival.
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Affiliation(s)
- E Mara Vollema
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Edgard A Prihadi
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands; Antwerp Cardiovascular Center, ZNA Middelheim, Antwerp, Belgium
| | - Arnold C T Ng
- Department of Cardiology, Princess Alexandra Hospital, University of Queensland, Brisbane, Australia
| | - Tea Gegenava
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Nina Ajmone Marsan
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Victoria Delgado
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands.
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Samad Z, Shaw LK, Phelan M, Glower DD, Ersboll M, Toptine JH, Alexander JH, Kisslo JA, Wang A, Mark DB, Velazquez EJ. Long-term outcomes of mitral regurgitation by type and severity. Am Heart J 2018; 203:39-48. [PMID: 30015067 DOI: 10.1016/j.ahj.2018.05.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 05/04/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND We aimed to determine the association of MR severity and type with all-cause death in a large, real-world, clinical setting. METHODS We reviewed full echocardiography studies at Duke Echocardiography Laboratory (01/01/1995-12/31/2010), classifying MR based on valve morphology, presence of coronary artery disease, and left ventricular size and function. Survival was compared among patients stratified by MR type and baseline severity. RESULTS Of 93,007 qualifying patients, 32,137 (34.6%) had ≥mild MR. A total of 8094 (8.7%) had moderate/severe MR, which was primary myxomatous (14.1%), primary non-myxomatous (6.2%), secondary non-ischemic (17.0%), and secondary ischemic (49.4%). At 10 years, patients with primary myxomatous MR or MR due to indeterminate cause had survival rates of >60%; primary non-myxomatous, secondary ischemic, and non-ischemic MR had survival rates <50%. While mild (HR 1.06, 95% CI 1.03-1.09), moderate (HR 1.31, 95% CI 1.27-1.37), and severe (HR 1.55, 95% CI 1.46-1.65) MR were independently associated with all-cause death, the relationship of increasing MR severity with mortality varied across MR types (P ≤ .001 for interaction); the highest risk associated with worsening severity was seen in primary myxomatous MR followed by secondary ischemic MR and primary non-myxomatous MR. CONCLUSIONS Although MR severity is independently associated with increased all-cause death risk for most forms of MR, the absolute mortality rates associated with worse MR severity are much higher for primary myxomatous, non-myxomatous, and secondary ischemic MR. The findings from this study support carefully defining MR by type and severity.
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15
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Comparison of Incidence of Left Ventricular Systolic Dysfunction Among Patients With Left Bundle Branch Block Versus Those With Normal QRS Duration. Am J Cardiol 2017; 120:1990-1997. [PMID: 28958452 DOI: 10.1016/j.amjcard.2017.08.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 08/07/2017] [Accepted: 08/08/2017] [Indexed: 11/20/2022]
Abstract
We compared the incidence of left ventricular systolic dysfunction (LVSD) among patients with left bundle branch block (LBBB) to a matched cohort of patients with a narrow QRS duration <120 ms (NQRS). We hypothesized patients with preserved ejection fraction (EF) ≥50% and LBBB would have higher incidence of LVSD compared with a matched population of NQRS patients. Patients with LBBB on electrocardiogram within 30 days of a baseline echocardiogram with EF ≥50%, who had at least 1 follow-up echocardiogram ≥6 months later, were matched 1:1 on risk factors for cardiomyopathy to patients with NQRS. Incident LVSD was defined as a decline in EF to ≤45% on follow-up echocardiogram, or heart transplant, receipt of a cardiac device for LVSD (defibrillator or biventricular pacemaker), or implantation of a left ventricular assist device ≥6 months post baseline echocardiogram. Relative risk was calculated using conditional Poisson regression techniques. The final study cohort consisted of 188 patients, 94 with LBBB and 94 with NQRS. On follow-up, progression to LVSD was noted in 36% of LBBB patients and 10% of NQRS patients. The relative risk for LVSD in patients with LBBB was 3.78 (95% confidence interval = 1.98 to 7.19). In conclusion, there is a strong association between LBBB and the subsequent development of LVSD independent of common risk factors for cardiomyopathy.
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16
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Samad Z, Sivak JA, Phelan M, Schulte PJ, Patel U, Velazquez EJ. Prevalence and Outcomes of Left-Sided Valvular Heart Disease Associated With Chronic Kidney Disease. J Am Heart Assoc 2017; 6:e006044. [PMID: 29021274 PMCID: PMC5721834 DOI: 10.1161/jaha.117.006044] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 08/04/2017] [Indexed: 01/13/2023]
Abstract
BACKGROUND Chronic kidney disease (CKD) is an adverse prognostic marker for valve intervention patients; however, the prevalence and related outcomes of valvular heart disease in CKD patients is unknown. METHODS AND RESULTS Included patients underwent echocardiography (1999-2013), had serum creatinine values within 6 months before index echocardiogram, and had no history of valve surgery. CKD was defined as diagnosis based on the International Classification of Diseases, Ninth Revision or an estimated glomerular filtration rate <60 mL/min per 1.73 m2. Qualitative assessment determined left heart stenotic and regurgitant valve lesions. Cox models assessed CKD and aortic stenosis (AS) interaction for subsequent mortality; analyses were repeated for mitral regurgitation (MR). Among 78 059 patients, 23 727 (30%) had CKD; of these, 1326 were on hemodialysis. CKD patients were older; female; had a higher prevalence of hypertension, hyperlipidemia, diabetes, history of coronary artery bypass grafting/percutaneous coronary intervention, atrial fibrillation, and heart failure ≥mild AS; and ≥mild MR (all P<0.001). Five-year survival estimates of mild, moderate, and severe AS for CKD patients were 40%, 34%, and 42%, respectively, and 69%, 54%, and 67% for non-CKD patients. Five-year survival estimates of mild, moderate, and severe MR for CKD patients were 51%, 38%, and 37%, respectively, and 75%, 66%, and 65% for non-CKD patients. Significant interaction occurred among CKD, AS/MR severity, and mortality in adjusted analyses; the CKD hazard ratio increased from 1.8 (non-AS patients) to 2.0 (severe AS) and from 1.7 (non-MR patients) to 2.6 (severe MR). CONCLUSIONS Prevalence of at least mild AS and MR is substantially higher and is associated with significantly lower survival among patients with versus without CKD. There is significant interaction among CKD, AS/MR severity, and mortality, with increasingly worse outcomes for CKD patients with increasing AS/MR severity.
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Affiliation(s)
- Zainab Samad
- Division of Cardiology, Department of Medicine, Duke University, Durham, NC
| | - Joseph A Sivak
- Division of Cardiology, Department of Medicine, Duke University, Durham, NC
| | - Matthew Phelan
- Duke Clinical Research Institute, Duke University, Durham, NC
| | | | - Uptal Patel
- Duke Clinical Research Institute, Duke University, Durham, NC
- Duke O'Brien Center for Kidney Diseases, Duke University, Durham, NC
| | - Eric J Velazquez
- Division of Cardiology, Department of Medicine, Duke University, Durham, NC
- Duke Clinical Research Institute, Duke University, Durham, NC
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17
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Improving on the diagnostic characteristics of echocardiography for pulmonary hypertension. Int J Cardiovasc Imaging 2017; 33:1341-1349. [PMID: 28337558 DOI: 10.1007/s10554-017-1114-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 03/09/2017] [Indexed: 10/19/2022]
Abstract
This retrospective study evaluated the diagnostic characteristics of a combination of echocardiographic parameters for pulmonary hypertension (PH). Right ventricular systolic pressure (RVSP) estimation by echocardiography (echo) is used to screen for PH. However, the sensitivity of this method is suboptimal. We hypothesized that RVSP estimation in conjunction with other echo parameters would improve the value of echo for PH. The Duke Echo database was queried for adult patients with known or suspected PH who had undergone both echo and right heart catheterization (RHC) within a 24 h period between 1/1/2008 and 12/31/2013. Patients with complex congenital heart disease, heart transplantation, ventricular assist device, or on mechanical ventilation at time of study were excluded. Diagnostic characteristics of several echo parameters (right atrial enlargement, pulmonary artery (PA) enlargement, RV enlargement, RV dysfunction, and RVSP) for PH (mean PA pressure 25 mmHg on RHC) were evaluated among 1007 patients. RVSP ≥40 had a sensitivity of 77% (accuracy 77), while RVSP ≥35 had the highest sensitivity at 88% (81% accuracy). PA enlargement had the lowest sensitivity at 17%. The area under the curve (AUC) for RVSP was 0.844. A model including RVSP, RA, PA, RV enlargement and RV dysfunction had a higher AUC (AUC = 0.87) than RVSP alone. The value of echo as a screening test for PH is improved by a model incorporating a lower RVSP in addition to other right heart parameters. These findings need to be validated in prospective cohorts.
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18
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Sivak JA, Vora AN, Navar AM, Schulte PJ, Crowley AL, Kisslo J, Corey GR, Liao L, Wang A, Velazquez EJ, Samad Z. An Approach to Improve the Negative Predictive Value and Clinical Utility of Transthoracic Echocardiography in Suspected Native Valve Infective Endocarditis. J Am Soc Echocardiogr 2016; 29:315-22. [PMID: 26850679 PMCID: PMC6052444 DOI: 10.1016/j.echo.2015.12.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Indexed: 11/20/2022]
Abstract
BACKGROUND In patients with suspected native valve infective endocarditis, current guidelines recommend initial transthoracic echocardiography (TTE) followed by transesophageal echocardiography (TEE) if clinical suspicion remains. The guidelines do not account for the quality of initial TTE or other findings that may alter the study's diagnostic characteristics. This may lead to unnecessary TEE when initial TTE was sufficient to rule out vegetation. METHODS The objective of this study was to determine if the use of a strict definition of negative results on TTE would improve the performance characteristics of TTE sufficiently to exclude vegetation. A retrospective analysis of patients at a single institution with suspected native valve endocarditis who underwent TTE followed by TEE within 7 days between January 1, 2007, and February 28, 2014, was performed. Negative results on TTE for vegetation were defined by either the standard approach (no evidence of vegetation seen on TTE) or by applying a set of strict negative criteria incorporating other findings on TTE. Using TEE as the gold standard for the presence of vegetation, the diagnostic performance of the two transthoracic approaches was compared. RESULTS In total, 790 pairs of TTE and TEE were identified. With the standard approach, 661 of the transthoracic studies had negative findings (no vegetation seen), compared with 104 studies with negative findings using the strict negative approach (meeting all strict negative criteria). The sensitivity and negative predictive value of TTE for detecting vegetation were substantially improved using the strict negative approach (sensitivity, 98% [95% CI, 95%-99%] vs 43% [95% CI, 36%-51%]; negative predictive value, 97% [95% CI, 92%-99%] vs 87% [95% CI, 84%-89%]). CONCLUSIONS The ability of TTE to exclude vegetation in patients is excellent when strict criteria for negative results are applied. In patients at low to intermediate risk with strict negative results on TTE, follow-up TEE may be unnecessary.
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Affiliation(s)
- Joseph A Sivak
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Amit N Vora
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
| | - Ann Marie Navar
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | | | - Anna Lisa Crowley
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Joseph Kisslo
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - G Ralph Corey
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
| | - Lawrence Liao
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Andrew Wang
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Eric J Velazquez
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
| | - Zainab Samad
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina.
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19
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Samad Z, Vora AN, Dunning A, Schulte PJ, Shaw LK, Al-Enezi F, Ersboll M, McGarrah RW, Vavalle JP, Shah SH, Kisslo J, Glower D, Harrison JK, Velazquez EJ. Aortic valve surgery and survival in patients with moderate or severe aortic stenosis and left ventricular dysfunction. Eur Heart J 2016; 37:2276-86. [PMID: 26787441 DOI: 10.1093/eurheartj/ehv701] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 12/01/2015] [Indexed: 11/14/2022] Open
Abstract
AIMS We aimed to determine the frequency of aortic valve surgery (AVR) with or without coronary artery bypass grafting (CABG), among patients with moderate/severe aortic stenosis (AS) and left ventricular systolic dysfunction (LVSD), and its relationship with survival. METHODS AND RESULTS The Duke Echocardiographic Database (N = 132 804) was queried for patients with mean gradient ≥25 mmHg and/or peak velocity ≥3 m/s and LVSD (left ventricular ejection fraction ≤50%) from 1 January 1995-28 February 2014. For analyses purposes, AS was defined both by mean gradient and calculated aortic valve area (AVA) criteria. Time-dependent indicators of AVR in multivariable Cox models were used to assess the relationship of AVR and all-cause mortality. A total of 1634 patients had moderate (N = 1090, 67%) or severe (N = 544, 33%) AS by mean gradient criteria. Overall, 287 (26%) patients with moderate AS and 263 (48%) patients with severe AS underwent AVR within 5 years of the qualifying echo. There were 863 (53%) deaths observed up to 5 years following index echo. After multivariable adjustment in an inverse probability weighted regression model, AVR was associated with higher 5-year survival amongst patients with moderate AS and severe AS whether classified by AVA or mean gradient criteria. Over all, AVR ± CABG compared with medical therapy was associated with significantly lower mortality [hazard ratio, HR = 0.49 (0.38, 0.62), P < 0.0001]. Compared with CABG alone, CABG + AVR was associated with better survival [HR = 0.18 (0.12, 0.27), P < 0.0001]. CONCLUSIONS In patients with moderate/severe AS and LVSD, mortality is substantial and amongst those selected for surgery, AVR with or without CABG is associated with higher survival. Research is required to understand factors contributing to current practice patterns and the possible utility of transcatheter approaches in this high-risk cohort.
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Affiliation(s)
- Zainab Samad
- Division of Cardiology, Duke Medicine, Duke University, PO Box 3254, Rm 3347A Duke South, 200 Trent Drive, Durham, NC, USA
| | - Amit N Vora
- Division of Cardiology, Duke Medicine, Duke University, PO Box 3254, Rm 3347A Duke South, 200 Trent Drive, Durham, NC, USA Duke Clinical Research Institute, Durham, NC, USA
| | | | | | - Linda K Shaw
- Duke Clinical Research Institute, Durham, NC, USA
| | - Fawaz Al-Enezi
- Division of Cardiology, Duke Medicine, Duke University, PO Box 3254, Rm 3347A Duke South, 200 Trent Drive, Durham, NC, USA
| | - Mads Ersboll
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Robert W McGarrah
- Division of Cardiology, Duke Medicine, Duke University, PO Box 3254, Rm 3347A Duke South, 200 Trent Drive, Durham, NC, USA
| | - John P Vavalle
- Division of Cardiology, Duke Medicine, Duke University, PO Box 3254, Rm 3347A Duke South, 200 Trent Drive, Durham, NC, USA
| | - Svati H Shah
- Division of Cardiology, Duke Medicine, Duke University, PO Box 3254, Rm 3347A Duke South, 200 Trent Drive, Durham, NC, USA Duke Clinical Research Institute, Durham, NC, USA Duke Molecular Physiology Institute, Durham, NC, USA
| | - Joseph Kisslo
- Division of Cardiology, Duke Medicine, Duke University, PO Box 3254, Rm 3347A Duke South, 200 Trent Drive, Durham, NC, USA
| | - Donald Glower
- Division of Cardiology, Duke Medicine, Duke University, PO Box 3254, Rm 3347A Duke South, 200 Trent Drive, Durham, NC, USA Department of Surgery, Duke University, Durham, NC, USA
| | - J Kevin Harrison
- Division of Cardiology, Duke Medicine, Duke University, PO Box 3254, Rm 3347A Duke South, 200 Trent Drive, Durham, NC, USA
| | - Eric J Velazquez
- Division of Cardiology, Duke Medicine, Duke University, PO Box 3254, Rm 3347A Duke South, 200 Trent Drive, Durham, NC, USA Duke Clinical Research Institute, Durham, NC, USA
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