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Cavalcante PN, Kanhouche G, Rosa VEE, Campos CM, Lopes MP, Lopes MAAADM, Sampaio RO, de Brito Júnior FS, Tarasoutchi F, Abizaid AAC. B-type natriuretic peptide and N-terminal Pro-B-type natriuretic peptide in severe aortic stenosis: a comprehensive literature review. Front Cardiovasc Med 2023; 10:1182530. [PMID: 37727304 PMCID: PMC10506406 DOI: 10.3389/fcvm.2023.1182530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 08/11/2023] [Indexed: 09/21/2023] Open
Abstract
B-type natriuretic peptide (BNP) and N-terminal pro-BNP (NT-pro BNP) are cardiac biomarkers that are released in response to increased ventricular and atrial wall stress. Aortic stenosis (AS) leads to hemodynamic changes and left ventricular hypertrophy and may be associated with natriuretic peptide levels. Several studies have shown that increased natriuretic peptide levels are correlated with AS severity and can predict the need for intervention. It can be useful in risk stratification, monitoring follow-up, and predicting cardiovascular outcomes of patients with severe AS. This paper aims to summarize the evidence of the role of BNP and NT-pro BNP in AS, before and after intervention.
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Affiliation(s)
- Pâmela Nogueira Cavalcante
- Instituto do Coracao (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Gabriel Kanhouche
- Instituto do Coracao (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Vitor Emer Egypto Rosa
- Instituto do Coracao (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Carlos M. Campos
- Instituto do Coracao (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
- Departament of Hemodynamic, Instituto Prevent Senior, Sao Paulo, Brazil
| | - Mariana Pezzute Lopes
- Instituto do Coracao (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | | | - Roney Orismar Sampaio
- Instituto do Coracao (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Fábio Sândoli de Brito Júnior
- Instituto do Coracao (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Flavio Tarasoutchi
- Instituto do Coracao (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Alexandre Antonio Cunha Abizaid
- Instituto do Coracao (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
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Pedersen ALD, Povlsen JA, Rasmussen VG, Frederiksen CA, Christiansen EH, Terkelsen CJ, Vase H, Poulsen SH. Prognostic implications of residual left ventricular hypertrophy and systolic dysfunction in aortic stenosis following transcatheter aortic valve replacement. Int J Cardiovasc Imaging 2023; 39:13-22. [PMID: 36598683 DOI: 10.1007/s10554-022-02688-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 07/01/2022] [Indexed: 01/07/2023]
Abstract
The impact of left ventricle (LV) hypertrophy (LVH) regression on contractility-associated measures, the extent of residual cardiac dysfunction and prognostic implications after the initial remodeling process after transcatheter aortic valve replacement (TAVR) has not been investigated. We aimed to assess whether greater LV mass regression from pre-TAVR to 12-months after TAVR was associated with increased systolic function; and assess the prognostic value of residual LVH, systolic function and contractility-associated measures 12-months after TAVR. A total of 439 symptomatic patients were included and examined by echocardiography. LVH regression was assessed as percentage change in LV mass index (LVMi) from baseline to 12-months after TAVR. Midwall fractional shortening (mFS) and stress-corrected (SC-mFS) were used as contractility-associated measures. Primary outcome was all-cause mortality. SC-mFS increased from 0.94 (0.7) at baseline (BS) to 1.22 (0.7) (p < 0.05) 12-months after TAVR for patients with the most LVH regression, compared to patients with no LV regression (BS 1.06 (0.7) to 1.04 (0.5), NS). At 12-months after TAVR, multivariate analysis showed independent prognostic value of LVEF < 50% or GLS < 15% (HR 1.59, p = 0.049) and mFS < 14% (HR 1.99, p = 0.002) for future all cause death. LVH regression in AS after TAVR is associated with significant improvements of LV systolic function in contrast to patients without LV regression. Residual LVH and subsequent LV systolic dysfunction is substantial 12 months after TAVR and are associated with reduced survival. Impaired mFS and the combination of abnormal LVEF or GLS independently predicted all-cause mortality beyond 12 months after TAVR.
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Affiliation(s)
| | - Jonas Agerlund Povlsen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Vibeke Guldbrand Rasmussen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | | | - Evald Høj Christiansen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Christian Juhl Terkelsen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Henrik Vase
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Steen Hvitfeldt Poulsen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
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Bi X, Yeung DF, Thaden JJ, Nhola LF, Schaff HV, Pislaru SV, Pellikka PA, Pochettino A, Greason KL, Nkomo VT, Villarraga HR. Characterization of myocardial mechanics and its prognostic significance in patients with severe aortic stenosis undergoing aortic valve replacement. EUROPEAN HEART JOURNAL OPEN 2022; 2:oeac074. [PMID: 36540107 PMCID: PMC9760549 DOI: 10.1093/ehjopen/oeac074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 10/25/2022] [Accepted: 11/02/2022] [Indexed: 06/17/2023]
Abstract
AIMS Aortic stenosis (AS) induces characteristic changes in left ventricular (LV) mechanics that can be reversed after aortic valve replacement (AVR). We aimed to comprehensively characterize LV mechanics before and after AVR in patients with severe AS and identify predictors of short-term functional recovery and long-term survival. METHODS AND RESULTS We prospectively performed comprehensive strain analysis by 2D speckle-tracking echocardiography in 88 patients with severe AS and LV ejection fraction ≥50% (mean age 71 ± 12 years, 42% female) prior to and within 7 days after AVR. Patients were followed for up to 5.2 years until death from any cause or last encounter. Within days after AVR, we observed an absolute increase in global longitudinal strain (GLS) (-16.0 ± 2.0% vs. -18.5 ± 2.1%, P<0.0001) and a decrease in apical rotation (10.5 ± 4.0° vs. 8.3 ± 2.8°, P = 0.0002) and peak systolic twist (18.2 ± 5.0° vs. 15.5 ± 3.8°, P = 0.0008). A baseline GLS is less negative than -16.2% was 90% sensitive and 67% specific in predicting a ≥ 20% relative increase in GLS. During a median follow-up of 3.8 years, a global circumferential systolic strain rate (GCSRs) less negative than -1.9% independently predicted lower survival. CONCLUSION In patients with severe AS, a reversal in GLS, apical rotation, and peak systolic twist abnormalities towards normal occurs within days of AVR. Baseline GLS is the strongest predictor of GLS recovery but neither was associated with long-term survival. In contrast, abnormal baseline GCSRs are associated with worse outcomes.
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Affiliation(s)
| | | | - Jeremy J Thaden
- Department of Cardiovascular Diseases, Mayo Clinic, 200 First St SW, Rochester, Rochester, MN 55905, USA
| | - Lara F Nhola
- Department of Cardiovascular Diseases, Mayo Clinic, 200 First St SW, Rochester, Rochester, MN 55905, USA
| | - Hartzell V Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, 200 First St SW, Rochester, Rochester, MN 55905, USA
| | - Sorin V Pislaru
- Department of Cardiovascular Diseases, Mayo Clinic, 200 First St SW, Rochester, Rochester, MN 55905, USA
| | - Patricia A Pellikka
- Department of Cardiovascular Diseases, Mayo Clinic, 200 First St SW, Rochester, Rochester, MN 55905, USA
| | - Alberto Pochettino
- Department of Cardiovascular Surgery, Mayo Clinic, 200 First St SW, Rochester, Rochester, MN 55905, USA
| | - Kevin L Greason
- Department of Cardiovascular Surgery, Mayo Clinic, 200 First St SW, Rochester, Rochester, MN 55905, USA
| | - Vuyisile T Nkomo
- Department of Cardiovascular Diseases, Mayo Clinic, 200 First St SW, Rochester, Rochester, MN 55905, USA
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Incremental Prognostic Value of Left Ventricular Global Longitudinal Strain in Patients with Preserved Ejection Fraction Undergoing Transcatheter Aortic Valve Implantation. J Am Soc Echocardiogr 2022; 35:947-955.e7. [DOI: 10.1016/j.echo.2022.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 04/19/2022] [Accepted: 04/24/2022] [Indexed: 11/18/2022]
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Role of myocardial strain and rotation for predicting prosthetic aortic valve stenosis. Int J Cardiovasc Imaging 2021; 38:551-560. [PMID: 34626295 DOI: 10.1007/s10554-021-02431-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 09/30/2021] [Indexed: 10/20/2022]
Abstract
Pressure overload due to aortic stenosis leads to subclinical left ventricular (LV) dysfunction and global longitudinal strain (GLS) impairment even if ejection fraction is preserved. However, little is known about LV mechanics in aortic prosthetic valve (APV) stenosis. The study aimed to determine the role of myocardial strain and rotation in predicting prosthetic valve stenosis in mechanical APV patients. 60 patients with mechanical APV and 30 healthy individuals were evaluated. APV patients were analyzed in two groups; aortic valve mean gradient < 20 mmHg (27 normal gradient patients) and ≥ 20 mmHg (33 high gradient patients). Strain, rotation, and twist values were assessed using the speckle tracking method, and brain natriuretic peptide (BNP) levels were measured. Four-chamber (p < 0.001) and two-chamber (p = 0.008) longitudinal strain (LS) were higher in the control group. GLS was lower in the high gradient group than control and normal gradient groups (p < 0.001, p = 0.022). LS of lateral wall's basal and mid segments were lower in normal and high gradient groups than the control group (p = 0.003, p = 0.008). While basal rotation was lower in the high gradient group than the control group (p = 0.048), there was no difference between the groups in terms of apical rotation, and twist. BNP levels were significantly different between the groups (p = 0.048). No correlation was found between aortic valve mean gradient and GLS, basal rotation, and BNP. In conclusions, LV GLS and basal rotation are depressed in high APV gradient patients; however, these parameters are not independent predictors of gradient increment.
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6
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Miranda-Silva D, Lima T, Rodrigues P, Leite-Moreira A, Falcão-Pires I. Mechanisms underlying the pathophysiology of heart failure with preserved ejection fraction: the tip of the iceberg. Heart Fail Rev 2021; 26:453-478. [PMID: 33411091 DOI: 10.1007/s10741-020-10042-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/15/2020] [Indexed: 12/18/2022]
Abstract
Heart failure with preserved ejection fraction (HFpEF) is a multifaceted syndrome with a complex aetiology often associated with several comorbidities, such as left ventricle pressure overload, diabetes mellitus, obesity, and kidney disease. Its pathophysiology remains obscure mainly due to the complex phenotype induced by all these associated comorbidities and to the scarcity of animal models that adequately mimic HFpEF. Increased oxidative stress, inflammation, and endothelial dysfunction are currently accepted as key players in HFpEF pathophysiology. However, we have just started to unveil HFpEF complexity and the role of calcium handling, energetic metabolism, and mitochondrial function remain to clarify. Indeed, the enlightenment of such cellular and molecular mechanisms represents an opportunity to develop novel therapeutic approaches and thus to improve HFpEF treatment options. In the last decades, the number of research groups dedicated to studying HFpEF has increased, denoting the importance and the magnitude achieved by this syndrome. In the current technological and web world, the amount of information is overwhelming, driving us not only to compile the most relevant information about the theme but also to explore beyond the tip of the iceberg. Thus, this review aims to encompass the most recent knowledge related to HFpEF or HFpEF-associated comorbidities, focusing mainly on myocardial metabolism, oxidative stress, and energetic pathways.
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Affiliation(s)
- Daniela Miranda-Silva
- Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal.
| | - Tânia Lima
- Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Patrícia Rodrigues
- Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Adelino Leite-Moreira
- Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Inês Falcão-Pires
- Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal
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7
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Maceira AM, Guardiola S, Ripoll C, Cosin-Sales J, Belloch V, Salazar J. Detection of subclinical myocardial dysfunction in cocaine addicts with feature tracking cardiovascular magnetic resonance. J Cardiovasc Magn Reson 2020; 22:70. [PMID: 32981526 PMCID: PMC7520970 DOI: 10.1186/s12968-020-00663-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 08/25/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Cocaine is an addictive, sympathomimetic drug with potentially lethal effects. We have previously shown with cardiovascular magnetic resonance (CMR) the presence of cardiovascular involvement in a significant percentage of consecutive asymptomatic cocaine addicts. CMR with feature-tracking analysis (CMR-FT) allows for the quantification of myocardial deformation which may detect preclinical involvement. Therefore, we aimed to assess the effects of cocaine on the left ventricular myocardium in a group of asymptomatic cocaine users with CMR-FT. METHODS In a cohort of asymptomatic cocaine addicts (CA) who had been submitted to CMR at 3 T, we used CMR-FT to measure strain, strain rate and dyssynchrony index in CA with mildly decreased left ventricular ejection fraction (CA-LVEFd) and in CA with preserved ejection fraction (CA-LVEFp). We also measured these parameters in 30 age-matched healthy subjects. RESULTS There were no differences according to age. Significant differences were seen in global longitudinal, radial and circumferential strain, in global longitudinal and radial strain rate and in radial and circumferential dyssynchrony index among the groups, with the lowest values in CA-LVEFd and intermediate values in CA-LVEFp. Longitudinal, radial and circumferential strain values were significantly lower in CA-LVEFp with respect to controls. CONCLUSIONS CA-LVEFp show decreased systolic strain and strain rate values, with intermediate values between healthy controls and CA-LVEFd. Signs suggestive of dyssynchrony were also detected. In CA, CMR-FT based strain analysis can detect early subclinical myocardial involvement.
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Affiliation(s)
- Alicia M. Maceira
- Cardiovascular Unit, Ascires Biomedical Grup, C/ Marques de San Juan Nº6, 46015, Valencia, Spain
- Department of Medicine, Health Sciences School, CEU-Cardenal Herrera University, C/ Santiago Ramón y Cajal, s/n, 46115 Alfara del Patriarca, Moncada-Valencia, Spain
| | - Sara Guardiola
- Cardiovascular Unit, Ascires Biomedical Grup, C/ Marques de San Juan Nº6, 46015, Valencia, Spain
| | - Carmen Ripoll
- Addictions Treatment Unit of Campanar, La Fe Hospital, Valencia, Spain
| | - Juan Cosin-Sales
- Department of Cardiology, Hospital Arnau de Vilanova, Valencia, Spain
| | - Vicente Belloch
- Cardiovascular Unit, Ascires Biomedical Grup, C/ Marques de San Juan Nº6, 46015, Valencia, Spain
| | - Jose Salazar
- Department of Psychiatry, Hospital General Universitario, Valencia, Spain
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8
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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.
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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
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9
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van Zalen J, Badiani S, Hart LM, Marshall AJ, Beale L, Brickley G, Bhattacharyya S, Patel NR, Lloyd GW. The importance of contractile reserve in predicting exercise tolerance in asymptomatic patients with severe aortic stenosis. Echo Res Pract 2019; 6:43-52. [PMID: 31100718 PMCID: PMC6589858 DOI: 10.1530/erp-19-0005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 05/16/2019] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Mortality dramatically rises with the onset of symptoms in patients with severe aortic stenosis (AS). Surgery is indicated when symptoms become apparent or when there is ventricular decompensation. Cardiopulmonary exercise testing (CPET) in combination with exercise echocardiography can unmask symptoms and provides valuable information regarding contractile reserve. The aim of the present study was to determine the prevalence of reduced exercise tolerance and the parameters predicting adverse cardiovascular events. METHODS Thirty-two patients with asymptomatic severe AS were included in this study. Patients were followed up as part of an enhanced surveillance clinic. RESULTS Age was 69 ± 15.7 years, 75% of patients were male. Patients had a raised NT-ProBNP of 301 pg/mL. VO2peak was 19.5 ± 6.2 mL/kg/min. Forty-one percent of patients had a reduced %VO2peak and this predicted unplanned cardiac hospitalisation (P = 0.005). Exercise systolic longitudinal velocity (S') and age were the strongest independent predictors for VO2peak (R 2 = 0.76; P < 0.0001). Exercise S' was the strongest independent predictor for NT-ProBNP (R 2 = 0.48; P = 0.001). CONCLUSION A large proportion of patients had a lower than predicted VO2peak. The major determinant of exercise and NT-ProBNP is the ability of the left ventricle (LV) to augment S' on exercise rather than the severity of aortic valve obstruction or resting structural remodelling of the LV. Reduced exercise tolerance and more adverse remodelling, rather than valve obstruction predicted unplanned hospitalisation. This study demonstrates that for those patients, in whom a watchful waiting is an agreed strategy, a detailed assessment should be undertaken including CPET, exercise echocardiography and biomarkers to ensure those with exercise limitation and risk of decompensation are detected early and treated appropriately.
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Affiliation(s)
- Jet van Zalen
- Department of Cardiology, Eastbourne District General Hospital, Eastbourne, UK
- University of Brighton, Centre for Sport and Exercise Science and Medicine (SESAME), Eastbourne, UK
- St. Bartholomew’s Hospital, Barts Heart Centre, London, UK
| | - Sveeta Badiani
- St. Bartholomew’s Hospital, Barts Heart Centre, London, UK
| | - Lesley M Hart
- Department of Cardiology, Eastbourne District General Hospital, Eastbourne, UK
| | - Andrew J Marshall
- Department of Cardiology, Eastbourne District General Hospital, Eastbourne, UK
| | - Louisa Beale
- University of Brighton, Centre for Sport and Exercise Science and Medicine (SESAME), Eastbourne, UK
| | - Gary Brickley
- University of Brighton, Centre for Sport and Exercise Science and Medicine (SESAME), Eastbourne, UK
| | | | - Nikhil R Patel
- Department of Cardiology, Eastbourne District General Hospital, Eastbourne, UK
| | - Guy W Lloyd
- St. Bartholomew’s Hospital, Barts Heart Centre, London, UK
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10
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Suzuki-Eguchi N, Murata M, Itabashi Y, Shirakawa K, Fukuda M, Endo J, Tsuruta H, Arai T, Hayashida K, Shimizu H, Fukuda K. Prognostic value of pre-procedural left ventricular strain for clinical events after transcatheter aortic valve implantation. PLoS One 2018; 13:e0205190. [PMID: 30308001 PMCID: PMC6181329 DOI: 10.1371/journal.pone.0205190] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2018] [Accepted: 08/28/2018] [Indexed: 12/04/2022] Open
Abstract
Background Transcatheter aortic valve implantation (TAVI) is an alternative therapy for surgically high-risk patients with severe aortic stenosis (AS). Although TAVI improves survival of patients with severe AS, the mechanism of this effect remains to be clarified. We investigated the effects of TAVI on left ventricular (LV) function and identified the predictive parameters for cardiac events after TAVI. Methods and results We studied 128 patients with severe symptomatic AS who underwent TAVI. Echocardiographic assessments were performed before and after TAVI. In addition to the conventional echocardiographic parameters such as LV ejection fraction (LVEF) and LV mass index (LVMI), the LV global longitudinal strain (GLS) and early diastolic peak strain rate (SR_E) using two-dimensional speckle tracking echocardiography were also evaluated. All patients were assessed for clinical events including major adverse cardiac events and stroke according to Valve Academic Research Consortium-2 criteria. GLS, early diastolic peak velocity (eʹ), aortic regurgitation (AR) severity, and SR_E were significantly improved after TAVI. Thirteen patients had an event during the observational period of 591 days (median). Patients with events had higher LVMI, more severe AR, and worse GLS compared to those without events. Furthermore, receiver-operating curve analysis revealed that GLS was the strongest predictor for clinical events (p = 0.009; area under the curve, 0.73). Conclusion Preoperative LV geometric deformation and dysfunction, as a consequence of the cumulative burden of pressure overload, improved after TAVI and could predict cardiac events after TAVI.
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Affiliation(s)
| | - Mitsushige Murata
- Center for Preventive Medicine, Keio University Hospital, Tokyo, Japan
- * E-mail:
| | - Yuji Itabashi
- Department of Laboratory Medicine, School of Medicine, Keio University, Tokyo, Japan
| | - Kousuke Shirakawa
- Department of Cardiology, School of Medicine, Keio University, Tokyo, Japan
| | - Memori Fukuda
- Department of Cardiology, School of Medicine, Keio University, Tokyo, Japan
| | - Jin Endo
- Department of Cardiology, School of Medicine, Keio University, Tokyo, Japan
| | - Hikaru Tsuruta
- Department of Cardiology, School of Medicine, Keio University, Tokyo, Japan
| | - Takahide Arai
- Department of Cardiology, School of Medicine, Keio University, Tokyo, Japan
| | - Kentaro Hayashida
- Department of Cardiology, School of Medicine, Keio University, Tokyo, Japan
| | - Hideyuki Shimizu
- Cardiovascular Surgery, School of Medicine, Keio University, Tokyo, Japan
| | - Keiichi Fukuda
- Department of Cardiology, School of Medicine, Keio University, Tokyo, Japan
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11
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Osteoprotegerin and Myocardial Fibrosis in Patients with Aortic Stenosis. Sci Rep 2018; 8:14550. [PMID: 30266917 PMCID: PMC6162228 DOI: 10.1038/s41598-018-32738-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 09/09/2018] [Indexed: 01/18/2023] Open
Abstract
Left ventricular myocardial fibrosis in patients with aortic stenosis (AS) confers worse prognosis. Plasma osteoprotegerin (OPG), a cytokine from the TNF receptor family, correlates with the degree of valve calcification in AS, reflecting the activity of the tissue RANKL/RANK/OPG (receptor activator of nuclear factor κΒ ligand/RANK/osteoprotegerin) axis, and is associated with poorer outcomes in AS. Its association with myocardial fibrosis is unknown. We hypothesised that OPG levels would reflect the extent of myocardial fibrosis in AS. We included 110 consecutive patients with AS who had undergone late-gadolinium contrast enhanced cardiovascular magnetic resonance (LGE-CMR). Patients were characterised according to pattern of fibrosis (no fibrosis, midwall fibrosis, or chronic myocardial infarction fibrosis). Serum OPG was measured with ELISA and compared between groups defined by valve stenosis severity. Some 36 patients had no fibrosis, 38 had midwall fibrosis, and 36 had chronic infarction. Patients with midwall fibrosis did not have higher levels of OPG compared to those without fibrosis (6.78 vs. 5.25 pmol/L, p = 0.12). There was no difference between those with midwall or chronic myocardial infarction fibrosis (6.78 vs. 6.97 pmol/L, p = 0.27). However, OPG levels in patients with chronic myocardial infarction fibrosis were significantly higher than those without fibrosis (p = 0.005).
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12
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Fung MJ, Thomas L, Leung DY. Alterations in Layer-Specific Left Ventricular Global Longitudinal and Circumferential Strain in Patients With Aortic Stenosis: A Comparison of Aortic Valve Replacement versus Conservative Management Over a 12-Month Period. J Am Soc Echocardiogr 2018; 32:92-101. [PMID: 30236621 DOI: 10.1016/j.echo.2018.07.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Impairment in left ventricular (LV) systolic strain in aortic stenosis (AS) is well documented. However, alterations in layer-specific LV global longitudinal strain (GLS) and global circumferential strain (GCS) and their recovery following surgical aortic valve replacement (AVR) have not been established. The aim of this study was to examine layer-specific changes in GLS and GCS in patients with AS undergoing AVR and compare these patients with those managed conservatively over 12 months. METHODS Eighty-six patients (mean age, 68.8 ± 12 years; 60 men) with AS (19 mild, 15 moderate, and 52 severe) were prospectively recruited. Patients with coronary disease or other significant valvular disease were excluded. Forty patients (46.5%) with severe AS underwent AVR. All patients underwent baseline echocardiography. Patients managed conservatively underwent follow-up echocardiography at 12 months. Patients undergoing AVR underwent follow-up echocardiography at 1 week and 3, 6, and 12 months after AVR. RESULTS There was worsening in subendocardial but not subepicardial or transmural GLS even in mild AS (-20.9 ± 1.0% vs -20.6 ± 0.8%, P = .012). In moderate AS, worsening in subendocardial (-19.6 ± 0.9% vs -18.2 ± 1.5%, P = .003), subepicardial (-14.9 ± 1.0% vs -13.8 ± 1.2%, P = .004), and transmural (-17.1 ± 0.9% vs -15.8 ± 1.3%, P = .03) GLS and a trend toward significant worsening in subendocardial GCS (-29.8 ± 5.16% vs -27.5 ± 5%, P = .054) were seen. Conservatively managed patients with severe AS had significant worsening in subendocardial (-16.1 ± 1.6% vs -13.9 ± 2.6%, P = .021), subepicardial (-11.6 ± 1.1% vs -10.1 ± 2.1%, P = .027), and transmural (-13.6 ± 1.3% vs -11.8 ± 2.3%, P = .02) GLS and subendocardial (-24.9 ± 3.6% vs -20.8 ± 4.5%, P = .002) and transmural (-16.9 ± 1.7% vs -14.3 ± 3.5%, P = .04) GCS on follow-up. Patients after AVR demonstrated significant improvement in GLS (from 3 months) and GCS (from 6 months) in both myocardial layers. CONCLUSIONS Patients with AS managed conservatively had worsening of GLS over 12 months despite preserved LV ejection fraction, detected earliest in the subendocardial layer. GCS became progressively impaired in moderate and severe AS. Improvement in LV strain after AVR was seen earlier with GLS (from 3 months) than with GCS (from 6 months) in both myocardial layers.
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Affiliation(s)
- Matle J Fung
- Cardiology Department, Liverpool Hospital, Liverpool, Sydney, Australia; South Western Sydney Clinical School, Faculty of Medicine, The University of New South Wales, Sydney, Australia.
| | - Liza Thomas
- Cardiology Department, Liverpool Hospital, Liverpool, Sydney, Australia; South Western Sydney Clinical School, Faculty of Medicine, The University of New South Wales, Sydney, Australia; Cardiology Department, Westmead Hospital, Westmead, Sydney, Australia; Faculty of Medicine, The University of Sydney, Sydney, Australia
| | - Dominic Y Leung
- Cardiology Department, Liverpool Hospital, Liverpool, Sydney, Australia; South Western Sydney Clinical School, Faculty of Medicine, The University of New South Wales, Sydney, Australia
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13
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Jeffrey RR, Hamburger RF, Gooden-Ebanks J, Petersen JW. Speckle Tracking Echocardiography Identifies Impaired Longitudinal Strain as a Common Deficit in Various Cardiac Diseases. CARDIOVASCULAR INNOVATIONS AND APPLICATIONS 2018. [DOI: 10.15212/cvia.2017.0040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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14
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Dimitriadis Z, Scholtz S, Scholtz W, Wiemer M, Piper C, Ensminger S, Fox H, Horstkotte D, Faber L. Impact of procedure-related conduction disturbances after transcatheter aortic valve implantation on myocardial performance and survival evaluated by conventional and speckle tracking echocardiography. Echocardiography 2018; 35:621-631. [PMID: 29437242 DOI: 10.1111/echo.13823] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES Although procedure-related new cardiac conduction disturbances (CCDs) remain an important issue in transcatheter aortic valve implantation (TAVI), their effect on myocardial function and overall patient outcome remains unclear. The goal of this study was to analyze the influence of procedure-related CCDs on systolic and diastolic LV performance and on patient survival after TAVI. METHODS AND RESULTS Ninety-five patients who underwent TAVI for severe symptomatic aortic stenosis (AS) and had a complete follow-up were evaluated with respect to procedure-related CCDs. Left ventricular (LV) performance was measured using standard echocardiographic parameters and speckle tracking analysis. Survival was assessed during longer-term follow-up (mean: 29.1 ± 16.9 months). After TAVI, the improvement of global LV function expressed as ejection fraction (LVEF; from 45.5 ± 10.0 to 47.8 ± 13.9%, P = .13) was not significant. New CCDs were found in 35.7% of TAVI recipients. A comparison between patients with and without new CCDs showed that LV systolic function improved in those without CCDs, while it tended to deteriorate in patients with CCDs (change in LVEF: 5.5 ± 12.3% vs -4.9% ± 11.5%, P = .001; change in global longitudinal strain (GLS): -1.1 ± 4.6% vs 1.2 ± 4.5%, P = .01). Changes in diastolic function did not differ significantly between the groups (changes in transmitral E/A-ratio: -0.3 ± 0.6 vs -0.5 ± 0.5, P = .1). Kaplan-Meier survival analysis revealed no significant differences between the two cohorts (P = .795). CONCLUSION Procedure-related conduction abnormalities after TAVI lead to an LBBB-related dyssynchrony with impairment of LV performance but not of overall survival.
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Affiliation(s)
- Zisis Dimitriadis
- Clinic for Cardiology, Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Smita Scholtz
- Clinic for Cardiology, Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Werner Scholtz
- Clinic for Cardiology, Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Marcus Wiemer
- Clinic for Cardiology, Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Cornelia Piper
- Clinic for Cardiology, Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Stephan Ensminger
- Clinic for Thoracic and Cardiovascular Surgery, Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Henrik Fox
- Clinic for Cardiology, Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Dieter Horstkotte
- Clinic for Cardiology, Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Lothar Faber
- Clinic for Cardiology, Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
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15
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Differential Myocardial Fibre Involvement by Strain Analysis in Patients With Aortic Stenosis. Heart Lung Circ 2017; 27:1357-1367. [PMID: 28966113 DOI: 10.1016/j.hlc.2017.08.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 05/28/2017] [Accepted: 08/18/2017] [Indexed: 11/20/2022]
Abstract
BACKGROUND Aortic stenosis (AS) is the most common valvular heart disease and can result in left ventricular (LV) systolic impairment. LV myocardial fibres are organised in layers: the subendocardial layer is orientated longitudinally and the subepicardial layer circumferentially. We hypothesised that there is differential involvement of myocardial fibres in patients with aortic stenosis. METHODS We performed multi-directional, multi-layered systolic strain analysis in 70 patients (aged 72±10.7years) with varying grades of AS severity (mean gradient 32.3±20mmHg, aortic valve area 1.1±0.6cm2) and in 30 controls. Clinical, demographic and resting echocardiographic data were recorded. Left ventricular subendocardial and subepicardial systolic strains were measured in the longitudinal, radial and circumferential axes. RESULTS Systolic subendocardial strain was significantly higher than subepicardial strain in all three axes in patients and in controls. There were significant differences in longitudinal, but not in circumferential and radial strain, or left ventricular ejection fraction (LVEF), between patient groups. Aortic valve mean gradient (MG) and valve area (AVA) correlated better with subendocardial longitudinal strain (r=0.548, p<0.001; r=-0.54, p<0.001 respectively) than with subepicardial longitudinal strain (r=0.496, p<0.001, r=-0.544, p<0.001 respectively). Correlations between circumferential and radial strain and MG or AVA were poor. CONCLUSIONS There was differential impairment in LV systolic strain in all three cardiac axes in patients with AS. Left ventricular longitudinal strain impairment was proportional to AS severity. Subendocardial longitudinal strain correlated better with AS severity than subepicardial longitudinal strain while correlations between circumferential and radial strain and AS severity were weak.
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16
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Guerra M, Mendes-Ferreira P, Adão R, Pereira E, Vieira M, Lourenço AP, Brás-Silva C, Bastos P, Vouga L, Leite-Moreira AF. Improvement in left intraventricular pressure gradients after aortic valve replacement in aortic stenosis patients. Exp Physiol 2017; 102:411-421. [DOI: 10.1113/ep086191] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 02/10/2017] [Indexed: 11/08/2022]
Affiliation(s)
- Miguel Guerra
- Department of Physiology and Cardiothoracic Surgery, Cardiovascular R&D Unit, Faculty of Medicine; University of Porto; Alameda Professor Hernâni Monteiro Porto Portugal
- Department of Cardiothoracic Surgery; Centro Hospitalar de Vila Nova de Gaia/Espinho; Rua Conceição Fernandes Vila Nova de Gaia Portugal
| | - Pedro Mendes-Ferreira
- Department of Physiology and Cardiothoracic Surgery, Cardiovascular R&D Unit, Faculty of Medicine; University of Porto; Alameda Professor Hernâni Monteiro Porto Portugal
| | - Rui Adão
- Department of Physiology and Cardiothoracic Surgery, Cardiovascular R&D Unit, Faculty of Medicine; University of Porto; Alameda Professor Hernâni Monteiro Porto Portugal
| | - Eulália Pereira
- Department of Cardiothoracic Surgery; Centro Hospitalar de Vila Nova de Gaia/Espinho; Rua Conceição Fernandes Vila Nova de Gaia Portugal
- Department of Cardiology; Centro Hospitalar de Vila Nova de Gaia/Espinho; Rua Conceição Fernandes Vila Nova de Gaia Portugal
| | - Manuela Vieira
- Department of Anesthesiology; Centro Hospitalar de Vila Nova de Gaia/Espinho; Rua Conceição Fernandes Vila Nova de Gaia Portugal
| | - André P. Lourenço
- Department of Physiology and Cardiothoracic Surgery, Cardiovascular R&D Unit, Faculty of Medicine; University of Porto; Alameda Professor Hernâni Monteiro Porto Portugal
| | - Carmen Brás-Silva
- Department of Physiology and Cardiothoracic Surgery, Cardiovascular R&D Unit, Faculty of Medicine; University of Porto; Alameda Professor Hernâni Monteiro Porto Portugal
- Faculty of Nutrition and Food Sciences; University of Porto; Porto Portugal
| | - Pedro Bastos
- Department of Physiology and Cardiothoracic Surgery, Cardiovascular R&D Unit, Faculty of Medicine; University of Porto; Alameda Professor Hernâni Monteiro Porto Portugal
- Department of Cardiothoracic Surgery; Centro Hospitalar São João; Alameda Professor Hernâni Monteiro Porto Portugal
| | - Luís Vouga
- Department of Cardiothoracic Surgery; Centro Hospitalar de Vila Nova de Gaia/Espinho; Rua Conceição Fernandes Vila Nova de Gaia Portugal
| | - Adelino F. Leite-Moreira
- Department of Physiology and Cardiothoracic Surgery, Cardiovascular R&D Unit, Faculty of Medicine; University of Porto; Alameda Professor Hernâni Monteiro Porto Portugal
- Department of Cardiothoracic Surgery; Centro Hospitalar São João; Alameda Professor Hernâni Monteiro Porto Portugal
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17
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Dimitriadis Z, Scholtz S, Ensminger S, Wiemer M, Fischbach T, Scholtz W, Piper C, Börgermann J, Bitter T, Horstkotte D, Faber L. Left ventricular adaptation after TAVI evaluated by conventional and speckle-tracking echocardiography. Int J Cardiol 2017; 228:633-637. [DOI: 10.1016/j.ijcard.2016.11.035] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 08/16/2016] [Accepted: 11/05/2016] [Indexed: 11/28/2022]
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18
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Kheiwa A, Aggarwal S, Forbes TJ, Turner DR, Kobayashi D. Impact of Transcatheter Intervention on Myocardial Deformation in Patients with Coarctation of the Aorta. Pediatr Cardiol 2016; 37:1590-1597. [PMID: 27638781 DOI: 10.1007/s00246-016-1474-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Accepted: 08/18/2016] [Indexed: 12/26/2022]
Abstract
Myocardial deformation measured by speckle tracking echocardiography can detect subtle abnormalities of left ventricular function before an obvious abnormality in traditional echocardiographic parameters such as ejection fraction is seen. We hypothesized that patients with coarctation of the aorta (CoA) may have impaired myocardial deformation that may persist even after successful transcatheter intervention. This is a retrospective study to assess the myocardial deformation in patients undergoing transcatheter intervention of CoA. The data were compared with age-matched normal controls. Echocardiographic parameters were obtained before, immediately and at median 6 months (range 3-8 months) after transcatheter intervention. Myocardial deformation indices were obtained off-line using Tomtec 2D Cardiac Performance Analysis Software. Repeated measure ANOVA was used to compare the indices between three time points. Independent sample t test or Chi-square test was used to compare data between groups. Twenty-four patients (age 13.5 ± 7.7 years) underwent successful transcatheter CoA intervention (stent 19, balloon angioplasty five) improving CoA peak gradient in the catheterization laboratory from 27.1 ± 11.3 to 4.5 ± 3.0 mmHg (p < 0.001). To compare with normal controls (n = 25, age 14.5 ± 1.9 years), fraction shortening was significantly higher in pre-intervention CoA patients (40.4 ± 7.1 vs. 33.8 ± 2.4 %, p < 0.001). In contrast, CoA patients had significantly abnormal left ventricular longitudinal strain compared to normal controls (-14.9 ± 2.6 vs. -20.5 ± 1.8 %, p < 0.001). In CoA patients, left ventricular longitudinal strain improved immediately and 3-8 months after intervention (-18.0 ± 2.9 and -17.6 ± 2.9 %, p < 0.007) but continued to be abnormal compared to normal controls. Patients with CoA had impaired myocardial deformation compared to normal controls. Myocardial mechanics improved but did not normalize even after successful transcatheter intervention on CoA in the short term.
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Affiliation(s)
- Ahmed Kheiwa
- Division of Cardiology, Carman and Ann Adams Department of Pediatrics, Children's Hospital of Michigan, Wayne State University School of Medicine, 3901 Beaubien Blvd, Detroit, MI, 48201-2119, USA.
| | - Sanjeev Aggarwal
- Division of Cardiology, Carman and Ann Adams Department of Pediatrics, Children's Hospital of Michigan, Wayne State University School of Medicine, 3901 Beaubien Blvd, Detroit, MI, 48201-2119, USA
| | - Thomas J Forbes
- Division of Cardiology, Carman and Ann Adams Department of Pediatrics, Children's Hospital of Michigan, Wayne State University School of Medicine, 3901 Beaubien Blvd, Detroit, MI, 48201-2119, USA
| | - Daniel R Turner
- Division of Cardiology, Carman and Ann Adams Department of Pediatrics, Children's Hospital of Michigan, Wayne State University School of Medicine, 3901 Beaubien Blvd, Detroit, MI, 48201-2119, USA
| | - Daisuke Kobayashi
- Division of Cardiology, Carman and Ann Adams Department of Pediatrics, Children's Hospital of Michigan, Wayne State University School of Medicine, 3901 Beaubien Blvd, Detroit, MI, 48201-2119, USA
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19
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Galli E, Leguerrier A, Flecher E, Leclercq C, Donal E. Increased valvulo-arterial impedance differently impacts left ventricular longitudinal, circumferential, and radial function in patients with aortic stenosis: A speckle tracking echocardiography study. Echocardiography 2016; 34:37-43. [PMID: 27805283 DOI: 10.1111/echo.13407] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 10/04/2016] [Accepted: 09/20/2016] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND In aortic stenosis (AS), the left ventricle (LV) should face an increased afterload that is due to both the stenotic aortic valve and the peripheral vascular resistance (PVR). Valvulo-arterial impedance (ZVa ) is a recently introduced parameter, which permits the evaluation of global LV afterload in AS. Aim of this study was to assess the influence of increasing ZVa on the longitudinal, circumferential, and radial components of LV mechanics. METHODS A total of 126 patients (mean age: 80.1±12.0 years, males: 47%) with severe AS (aortic surface <1 cm2 or <0.6 cm2 /m2 ) underwent standard echocardiography to characterize aortic valve gradients, LV function, and ZVa . 2D speckle tracking echocardiography was used to estimate global longitudinal (GLS), circumferential (GCS), and radial (GRS) LV strain. RESULTS The population was divided into four groups according to ZVa quartiles: Q1 (ZVa ≤3.43 mm Hg/mL/m2 ), Q2 (3.43<ZVa ≤4.1 mm Hg/mL/m2 ), Q3 (4.1<ZVa ≤5.1 mm Hg/mL/m2 ), ad Q4 (ZVa >5.1 mm Hg/mL/m2 ). ZVa increase from Q1 to Q4 was associated with a progressive reduction in GLS and GCS (ANOVA, both P<.0001). GRS was relatively insensitive to ZVa increase, a significant reduction of GRS appearing only in Q4 patients with respect to Q1 (29.7±16.4 vs 20.7±13.2%, P=.01). CONCLUSIONS Left ventricle myocardial fibers show a different response to afterload increase. Subendocardial fibers function is impaired earlier, whereas mid-wall circumferential fibers remain substantially unaffected, providing interesting insights into the mechanisms of LV dysfunction in AS.
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Affiliation(s)
- Elena Galli
- National Institute of Health and Medical Research, Medical Research Unit 1099, Rennes, France.,Signal and Image Treatment Laboratory, University of Rennes, Rennes, France.,Cardiology Unit, University Hospital of Rennes, Rennes, France
| | - Alain Leguerrier
- Cardiac, Vascular, and Thoracic Surgery Unit, University Hospital of Rennes, Rennes, France
| | - Erwan Flecher
- Cardiac, Vascular, and Thoracic Surgery Unit, University Hospital of Rennes, Rennes, France
| | - Christophe Leclercq
- Signal and Image Treatment Laboratory, University of Rennes, Rennes, France.,Cardiology Unit, University Hospital of Rennes, Rennes, France
| | - Erwan Donal
- National Institute of Health and Medical Research, Medical Research Unit 1099, Rennes, France.,Signal and Image Treatment Laboratory, University of Rennes, Rennes, France.,Cardiology Unit, University Hospital of Rennes, Rennes, France
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20
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Assessment of ventriculo-vascular properties in repaired coarctation using cardiac magnetic resonance-derived aortic, left atrial and left ventricular strain. Eur Radiol 2016; 27:167-177. [DOI: 10.1007/s00330-016-4373-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Revised: 02/10/2016] [Accepted: 04/18/2016] [Indexed: 10/21/2022]
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21
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Whitener G, McKenzie J, Akushevich I, White WD, Dhakal IB, Nicoara A, Swaminathan M. Discordance in Grading Methods of Aortic Stenosis by Pre-Cardiopulmonary Bypass Transesophageal Echocardiography. Anesth Analg 2016; 122:953-8. [DOI: 10.1213/ane.0000000000001099] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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22
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Rodrigues PG, Leite-Moreira AF, Falcão-Pires I. Myocardial reverse remodeling: how far can we rewind? Am J Physiol Heart Circ Physiol 2016; 310:H1402-22. [PMID: 26993225 DOI: 10.1152/ajpheart.00696.2015] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 03/04/2016] [Indexed: 12/19/2022]
Abstract
Heart failure (HF) is a systemic disease that can be divided into HF with reduced ejection fraction (HFrEF) and with preserved ejection fraction (HFpEF). HFpEF accounts for over 50% of all HF patients and is typically associated with high prevalence of several comorbidities, including hypertension, diabetes mellitus, pulmonary hypertension, obesity, and atrial fibrillation. Myocardial remodeling occurs both in HFrEF and HFpEF and it involves changes in cardiac structure, myocardial composition, and myocyte deformation and multiple biochemical and molecular alterations that impact heart function and its reserve capacity. Understanding the features of myocardial remodeling has become a major objective for limiting or reversing its progression, the latter known as reverse remodeling (RR). Research on HFrEF RR process is broader and has delivered effective therapeutic strategies, which have been employed for some decades. However, the RR process in HFpEF is less clear partly due to the lack of information on HFpEF pathophysiology and to the long list of failed standard HF therapeutics strategies in these patient's outcomes. Nevertheless, new proteins, protein-protein interactions, and signaling pathways are being explored as potential new targets for HFpEF remodeling and RR. Here, we review recent translational and clinical research in HFpEF myocardial remodeling to provide an overview on the most important features of RR, comparing HFpEF with HFrEF conditions.
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Affiliation(s)
- Patrícia G Rodrigues
- Department of Physiology and Cardiothoracic Surgery, Faculty of Medicine, Universidade do Porto, Porto, Portugal
| | - Adelino F Leite-Moreira
- Department of Physiology and Cardiothoracic Surgery, Faculty of Medicine, Universidade do Porto, Porto, Portugal
| | - Inês Falcão-Pires
- Department of Physiology and Cardiothoracic Surgery, Faculty of Medicine, Universidade do Porto, Porto, Portugal
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23
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Swan A, Prakash R, Chew DP, Perry R, Sinhal A, Selvanayagam JB, Joseph MX. Instantaneous Decrease in Left Ventricular Afterload during Transcatheter Aortic Valve Implantation Results in Immediate Changes in Left Ventricular Strain. Echocardiography 2015; 33:742-8. [PMID: 26676176 DOI: 10.1111/echo.13153] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Severe aortic stenosis causes chronic increased afterload on the left ventricle (LV) resulting in myocardial hypertrophy and ultimately dysfunction if left untreated. Transcatheter aortic valve implantation (TAVI) immediately decreases the afterload on the LV by reducing the pressure gradient through the aortic valve. In our study, we aim to evaluate immediate changes in LV mechanics using intra-procedural transesophageal echocardiography (TEE) to assess circumferential and radial strain via speckle tracking. Intra-operative TEE was performed during TAVI for 53 patients (mean age 84 ± 8 years). Two-dimensional images in the transgastric view were acquired at the level of the papillary muscle. Circumferential and radial strain was calculated using speckle tracking with Philips Qlab software. Global LV afterload was measured by calculating valvulo-arterial impedance (Zva). Immediately post-TAVI, there was a change in both radial strain rate (Pre: 0.73 ± 0.04 vs. Post: 0.88 ± 0.04 per second, P < 0.001) and circumferential strain rate (-0.53 ± 0.04 (pre) vs. -0.74 ± 0.04 (post) per second, P < 0.001). There was also an immediate improvement in circumferential global strain parameters (-14.5 ± 5% (pre) vs. -16.0 ± 4.7% (post), P < 0.05), whereas there was no significant change seen in global radial strain (15.6 ± 0.8% (pre) vs. 15.2 ± 0.9% (post), P = 0.69). No significant change was seen in LV ejection fraction (51.5 ± 14.2% (pre) vs. 52.1 ± 14.0% (post), P = 0.77). Speckle tracking using TEE images is feasible and identifies significant improvements in LV strain and strain rate immediately following TAVI that is not detected by conventional measure of LV function.
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Affiliation(s)
- Amy Swan
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, SA, Australia
| | - Roshan Prakash
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, SA, Australia
| | - Derek P Chew
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, SA, Australia.,Flinders University, Adelaide, SA, Australia
| | - Rebecca Perry
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, SA, Australia.,Flinders University, Adelaide, SA, Australia
| | - Ajay Sinhal
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, SA, Australia.,Flinders University, Adelaide, SA, Australia
| | - Joseph B Selvanayagam
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, SA, Australia.,Flinders University, Adelaide, SA, Australia.,Flinders Clinical Research (FCR), South Australian Health and Medical Research Institute, Adelaide, SA, Australia
| | - Majo X Joseph
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, SA, Australia.,Flinders University, Adelaide, SA, Australia
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24
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Herrmann S, Fries B, Liu D, Hu K, Stoerk S, Voelker W, Ruppert C, Lorenz K, Ertl G, Weidemann F. Differences in Natural History of Low- and High-Gradient Aortic Stenosis from Nonsevere to Severe Stage of the Disease. J Am Soc Echocardiogr 2015; 28:1270-1282.e4. [DOI: 10.1016/j.echo.2015.07.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2014] [Indexed: 10/23/2022]
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25
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Gavina C, Falcão-Pires I, Pinho P, Manso MC, Gonçalves A, Rocha-Gonçalves F, Leite-Moreira A. Relevance of residual left ventricular hypertrophy after surgery for isolated aortic stenosis. Eur J Cardiothorac Surg 2015; 49:952-9. [DOI: 10.1093/ejcts/ezv240] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Accepted: 05/12/2015] [Indexed: 11/13/2022] Open
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26
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Dulgheru R, Magne J, Davin L, Nchimi A, Oury C, Pierard LA, Lancellotti P. Left ventricular regional function and maximal exercise capacity in aortic stenosis. Eur Heart J Cardiovasc Imaging 2015; 17:217-24. [PMID: 26060203 DOI: 10.1093/ehjci/jev147] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
AIMS The objective assessment of maximal exercise capacity (MEC) using peak oxygen consumption (VO2) measurement may be helpful in the management of asymptomatic aortic stenosis (AS) patients. However, the relationship between left ventricular (LV) function and MEC has been relatively unexplored. We aimed to identify which echocardiographic parameters of LV systolic function can predict MEC in asymptomatic AS. METHODS AND RESULTS Asymptomatic patients with moderate to severe AS (n = 44, aortic valve area <1.5 cm(2), 66 ± 13 years, 75% of men) and preserved LV ejection fraction (LVEF > 50%) were prospectively referred for resting echocardiography and cardiopulmonary exercise test. LV longitudinal strain (LS) of each myocardial segment was measured by speckle tracking echocardiography (STE) from the apical (aLS) 4-, 2-, and 3-chamber views. An average value of the LS of the analysable segments was provided for each myocardial region: basal (bLS), mid (mLS), and aLS. LV circumferential and radial strains were measured from short-axis views. Peak VO2 was 20.1 ± 5.8 mL/kg/min (median 20.7 mL/kg/min; range 7.2-32.3 mL/kg/min). According to the median of peak VO2, patients with reduced MEC were significantly older (P < 0.001) and more frequently females (P = 0.05). There were significant correlations between peak VO2 and age (r = -0.44), LV end-diastolic volume (r = 0.35), LV stroke volume (r = 0.37), indexed stroke volume (r = 0.32), and E/e' ratio (r = -0.37, all P < 0.04). Parameters of AS severity and LVEF did not correlate with peak VO2 (P = NS for all). Among LV deformation parameters, bLS and mLS were significantly associated with peakVO2 (r = 0.43, P = 0.005, and r = 0.32, P = 0.04, respectively). With multivariable analysis, female gender (β = 4.9; P = 0.008) and bLS (β = 0.50; P = 0.03) were the only independent determinants (r(2) = 0.423) of peak VO2. CONCLUSION In asymptomatic AS, impaired LV myocardial longitudinal function determines reduced MEC. Basal LS was the only parameter of LV regional function independently associated with MEC.
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Affiliation(s)
- R Dulgheru
- University of Liege Hospital, GIGA-Cardiovascular Sciences, Heart Valve Clinic, Liege, Belgium Department of Cardiology and Radiology, University Hospital Sart-Tilman, Liege 4000, Belgium
| | - J Magne
- University of Liege Hospital, GIGA-Cardiovascular Sciences, Heart Valve Clinic, Liege, Belgium CHU Limoges, Hôpital Dupuytren, Service Cardiologie, Limoges F-87042, France Faculté de médecine de Limoges, INSERM 1094, 2, rue Marcland, 87000 Limoges, France
| | - L Davin
- University of Liege Hospital, GIGA-Cardiovascular Sciences, Heart Valve Clinic, Liege, Belgium Department of Cardiology and Radiology, University Hospital Sart-Tilman, Liege 4000, Belgium
| | - A Nchimi
- University of Liege Hospital, GIGA-Cardiovascular Sciences, Heart Valve Clinic, Liege, Belgium Department of Cardiology and Radiology, University Hospital Sart-Tilman, Liege 4000, Belgium
| | - C Oury
- GIGA-Cardiovascular Sciences, Human Genetics Unit, Laboratory of Thrombosis and Hemostasis, University of Liège, Liège, Belgium
| | - L A Pierard
- University of Liege Hospital, GIGA-Cardiovascular Sciences, Heart Valve Clinic, Liege, Belgium Department of Cardiology and Radiology, University Hospital Sart-Tilman, Liege 4000, Belgium
| | - P Lancellotti
- University of Liege Hospital, GIGA-Cardiovascular Sciences, Heart Valve Clinic, Liege, Belgium Department of Cardiology and Radiology, University Hospital Sart-Tilman, Liege 4000, Belgium GVM Care and Research, E.S. Health Science Foundation, Lugo (RA), Italy
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Ishikawa K, Aguero J, Oh JG, Hammoudi N, A Fish L, Leonardson L, Picatoste B, Santos-Gallego CG, M. Fish K, Hajjar RJ. Increased stiffness is the major early abnormality in a pig model of severe aortic stenosis and predisposes to congestive heart failure in the absence of systolic dysfunction. J Am Heart Assoc 2015; 4:JAHA.115.001925. [PMID: 25994443 PMCID: PMC4599422 DOI: 10.1161/jaha.115.001925] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background It remains unclear whether abnormal systolic function and relaxation are essential for developing heart failure in pathophysiology of severe aortic stenosis. Methods and Results Yorkshire pigs underwent surgical banding of the ascending aorta. The animals were followed for up to 5 months after surgery, and cardiac function was assessed comprehensively by invasive pressure–volume measurements, 3-dimensional echocardiography, echocardiographic speckle-tracking strain, and postmortem molecular and histological analyses. Pigs with aortic banding (n=6) exhibited significant left ventricular hypertrophy with increased stiffness compared with the control pigs (n=7) (end-diastolic pressure–volume relationship β: 0.053±0.017 versus 0.028±0.009 mm Hg/mL, P=0.007); however, all other parameters corresponding to systolic function, including ejection fraction, end-systolic pressure–volume relationship, preload recruitable stroke work, echocardiographic circumferential strain, and longitudinal strain, were not impaired in pigs with aortic banding. Relaxation parameters were also similar between groups. Sarcoplasmic reticulum calcium (Ca2+) ATPase protein levels in the left ventricle were similar. There were significant increases in 3-dimensional echocardiographic left atrial volumes, suggesting the usefulness of these indexes to detect increased stiffness. Right atrial pacing with a heart rate of 120 beats per minute induced increased end-diastolic pressure in pigs with aortic banding in contrast to decreased end-diastolic pressure in the control pigs. Histological evaluation revealed that increased stiffness was accompanied by cardiomyocyte hypertrophy and increased perimysial and perivascular fibrosis. Conclusion Increased stiffness is the major early pathological process that predisposes to congestive heart failure without abnormalities in systolic function and relaxation in a clinically relevant animal model of aortic stenosis.
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Affiliation(s)
- Kiyotake Ishikawa
- Cardiovascular Research Center, Icahn School of Medicine at Mount SinaiNew York, NY
| | - Jaume Aguero
- Cardiovascular Research Center, Icahn School of Medicine at Mount SinaiNew York, NY
| | - Jae Gyun Oh
- Cardiovascular Research Center, Icahn School of Medicine at Mount SinaiNew York, NY
| | - Nadjib Hammoudi
- Cardiovascular Research Center, Icahn School of Medicine at Mount SinaiNew York, NY
| | - Lauren A Fish
- Cardiovascular Research Center, Icahn School of Medicine at Mount SinaiNew York, NY
| | - Lauren Leonardson
- Cardiovascular Research Center, Icahn School of Medicine at Mount SinaiNew York, NY
| | - Belén Picatoste
- Cardiovascular Research Center, Icahn School of Medicine at Mount SinaiNew York, NY
| | | | - Kenneth M. Fish
- Cardiovascular Research Center, Icahn School of Medicine at Mount SinaiNew York, NY
| | - Roger J Hajjar
- Cardiovascular Research Center, Icahn School of Medicine at Mount SinaiNew York, NY
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28
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Carstensen HG, Larsen LH, Hassager C, Kofoed KF, Dalsgaard M, Kristensen CB, Jensen JS, Mogelvang R. Tissue Velocities and Myocardial Deformation in Asymptomatic and Symptomatic Aortic Stenosis. J Am Soc Echocardiogr 2015; 28:969-80. [PMID: 25944424 DOI: 10.1016/j.echo.2015.03.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Indexed: 12/21/2022]
Abstract
BACKGROUND Assessment of myocardial longitudinal function has proved to be a sensitive marker of deteriorating myocardial function in aortic stenosis, demonstrated by both color Doppler tissue imaging and recently by two-dimensional speckle-tracking echocardiography. The aim of this study was to compare velocity (color Doppler tissue imaging) and deformation (two-dimensional speckle-tracking echocardiography) in relation to global and regional longitudinal function in asymptomatic and severe symptomatic aortic stenosis. METHODS In a cross-sectional design, 231 patients with aortic stenosis were divided into four groups: asymptomatic moderate aortic stenosis (aortic valve area, 1.0-1.5 cm(2); n = 38), asymptomatic severe aortic stenosis (aortic valve area < 1.0 cm(2); n = 66), and symptomatic severe aortic stenosis with preserved (n = 68) and reduced (<50%) left ventricular ejection fraction (n = 59). RESULTS Among all global (peak systolic s', diastolic e' and a', longitudinal displacement, and global longitudinal strain and strain rate) and regional longitudinal (basal, middle, and apical longitudinal strain and strain rate) parameters, only diastolic e', longitudinal displacement, and basal longitudinal strain (BLS) remained significantly associated with symptomatic status, independent of age, gender, heart rate, aortic valve area, stroke volume index, left ventricular mass index, left atrial volume index, and tricuspid annular systolic plane excursion. Furthermore, in a model with the aforementioned parameters, including e', longitudinal displacement, and BLS, only BLS remained significantly associated with symptomatic status in the entire study population (BLS per one-unit decrease: odds ratio, 1.23; 95% CI, 1.04-1.46; P = .017). Furthermore, patients with BLS < 13% were more likely to be symptomatic (odds ratio, 4.97; 95% CI, 2.6-9.4; P < .001), and no patients with asymptomatic severe aortic stenosis with BLS ≥ 13% were admitted with myocardial infarction or heart failure during follow-up of 1,462 days. CONCLUSIONS Among the many echocardiographic measures of longitudinal velocity and deformation, BLS has the strongest association with symptomatic status in aortic stenosis, and BLS < 13% is related to adverse outcomes in severe asymptomatic aortic stenosis.
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Affiliation(s)
- Helle Gervig Carstensen
- Department of Cardiology, University Hospital of Copenhagen, Gentofte Hospital, Copenhagen, Denmark.
| | - Linnea Hornbech Larsen
- Department of Cardiology, University Hospital of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Christian Hassager
- Department of Cardiology, University Hospital of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Klaus Fuglsang Kofoed
- Department of Cardiology, University Hospital of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Morten Dalsgaard
- Department of Cardiology, University Hospital of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | | | - Jan Skov Jensen
- Department of Cardiology, University Hospital of Copenhagen, Gentofte Hospital, Copenhagen, Denmark
| | - Rasmus Mogelvang
- Department of Cardiology, University Hospital of Copenhagen, Rigshospitalet, Copenhagen, Denmark
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29
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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.
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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.
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30
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Parikh V, Kim C, Siegel RJ, Arsanjani R, Rader F. Natriuretic Peptides for Risk Stratification of Patients With Valvular Aortic Stenosis. Circ Heart Fail 2015; 8:373-80. [DOI: 10.1161/circheartfailure.114.001649] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Vishal Parikh
- From the Department of Medicine (V.P., C.K.) and Heart Institute (R.J.S., R.A., F.R.), Cedars-Sinai Medical Center, Los Angeles, CA
| | - Candice Kim
- From the Department of Medicine (V.P., C.K.) and Heart Institute (R.J.S., R.A., F.R.), Cedars-Sinai Medical Center, Los Angeles, CA
| | - Robert J. Siegel
- From the Department of Medicine (V.P., C.K.) and Heart Institute (R.J.S., R.A., F.R.), Cedars-Sinai Medical Center, Los Angeles, CA
| | - Reza Arsanjani
- From the Department of Medicine (V.P., C.K.) and Heart Institute (R.J.S., R.A., F.R.), Cedars-Sinai Medical Center, Los Angeles, CA
| | - Florian Rader
- From the Department of Medicine (V.P., C.K.) and Heart Institute (R.J.S., R.A., F.R.), Cedars-Sinai Medical Center, Los Angeles, CA
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31
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Carasso S, Mutlak D, Lessick J, Reisner SA, Rakowski H, Agmon Y. Symptoms in severe aortic stenosis are associated with decreased compensatory circumferential myocardial mechanics. J Am Soc Echocardiogr 2014; 28:218-25. [PMID: 25441330 DOI: 10.1016/j.echo.2014.09.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2014] [Indexed: 12/22/2022]
Abstract
BACKGROUND Symptomatic patients with severe aortic stenosis (AS) demonstrate abnormal left ventricular (LV) mechanics. The aim of this study was to compare mechanics in asymptomatic and symptomatic patients with severe AS using two-dimensional myocardial strain imaging. METHODS One hundred fifty-four patients with severe AS (aortic valve area ≤ 1.0 cm(2)) referred to a heart valve clinic from 2004 to 2011 were studied. Thirty patients were asymptomatic, with normal LV ejection fractions (≥ 55%), without other significant valvular disease or wall motion abnormalities. Thirty-two symptomatic patients who underwent early aortic valve replacement, with similar age, gender, LV ejection fraction, and aortic valve area, were selected for comparison. Both groups were also compared with 32 healthy subjects with similar age and gender distributions and normal echocardiographic results who served as controls. LV longitudinal and circumferential strain and rotation were measured using speckle-tracking software applied to archived echocardiographic studies. Conventional echocardiographic and myocardial mechanical parameters were compared among the study subgroups. RESULTS Patients with asymptomatic severe AS demonstrated smaller reductions in longitudinal strain, higher (supernormal) apical circumferential strain (-38 ± 6% vs -35 ± 4%, P < .05), and extreme (supernormal) apical rotation (12.2 ± 4.9° vs 2.9 ± 1.7°, P < .0005) compared with symptomatic patients. Apical rotation < 6° was the single significant predictor of symptoms in logistic regression analysis of clinical, echocardiographic, and mechanical parameters. Twelve asymptomatic patients underwent eventual aortic valve replacement and showed decreases in strain and apical rotation compared with baseline values. CONCLUSIONS Longitudinal strain was uniformly low in patients with severe AS and lower in those with symptoms. Compensatory circumferential myocardial mechanics (increased apical circumferential strain and rotation) were absent in symptomatic patients. Thus, myocardial mechanics may help in the follow-up of patients with severe AS and timing of valve surgery.
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Affiliation(s)
- Shemy Carasso
- Department of Cardiology, Rambam Health Care Campus, Haifa, Israel; Technion - Israel Institute of Technology, Haifa, Israel.
| | - Diab Mutlak
- Department of Cardiology, Rambam Health Care Campus, Haifa, Israel
| | - Jonathan Lessick
- Department of Cardiology, Rambam Health Care Campus, Haifa, Israel; Technion - Israel Institute of Technology, Haifa, Israel
| | - Shimon A Reisner
- Department of Cardiology, Rambam Health Care Campus, Haifa, Israel; Technion - Israel Institute of Technology, Haifa, Israel
| | - Harry Rakowski
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Yoram Agmon
- Department of Cardiology, Rambam Health Care Campus, Haifa, Israel; Technion - Israel Institute of Technology, Haifa, Israel
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32
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The Role of Biomarkers in Valvular Heart Disease: Focus on Natriuretic Peptides. Can J Cardiol 2014; 30:1027-34. [DOI: 10.1016/j.cjca.2014.07.014] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Revised: 07/10/2014] [Accepted: 07/10/2014] [Indexed: 01/26/2023] Open
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Clavel MA, Malouf J, Michelena HI, Suri RM, Jaffe AS, Mahoney DW, Enriquez-Sarano M. B-type natriuretic peptide clinical activation in aortic stenosis: impact on long-term survival. J Am Coll Cardiol 2014; 63:2016-25. [PMID: 24657652 DOI: 10.1016/j.jacc.2014.02.581] [Citation(s) in RCA: 138] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Revised: 02/15/2014] [Accepted: 02/25/2014] [Indexed: 12/23/2022]
Abstract
OBJECTIVES This study was conducted to define the association between serum B-type natriuretic peptide (BNP) activation and survival after the diagnosis of aortic stenosis (AS). BACKGROUND In AS, the link between BNP levels and clinical outcome is in dispute. Failure to account for the normal shifting of BNP ranges with aging in men and women, not using hard endpoints (survival), and not enrolling large series of patients have contributed to the uncertainty. METHODS A program of prospective measurement of BNP levels with Doppler echocardiographic AS assessment during the same episode of care was conducted. BNP ratio (measured BNP/maximal normal BNP value specific to age and sex) >1 defined BNP clinical activation. RESULTS In 1,953 consecutive patients with at least moderate AS (aortic valve area 1.03 ± 0.26 cm(2); mean gradient 36 ± 19 mm Hg), median BNP level was 252 pg/ml (interquartile range: 98 to 592 pg/ml); BNP ratio 2.46 (interquartile range 1.03 to 5.66); ejection fraction (EF) 57% ± 15%, and symptoms present in 60% of patients. After adjustment for all survival determinants, BNP clinical activation (BNP ratio >1) independently predicted mortality after diagnosis (p < 0.0001; hazard ratio [HR]: 1.91; 95% CI: 1.55 to 2.35) and provided incremental power to the survival predictive model (p < 0.0001). Eight-year survival was 62 ± 3% with normal BNP levels, 44 ± 3% with BNP ratio of 1 to 2 (adjusted HR: 1.49; 95% CI: 1.17 to 1.90), 25 ± 4% with BNP ratio of 2 to 3 (adjusted HR: 2.12; 95% CI: 1.63 to 2.75), and 15 ± 2% with BNP ratio of ≥3 (adjusted HR: 2.43; 95% CI: 1.94 to 3.05). This strong link to survival was confirmed in asymptomatic patients with normal EF (adjusted HR: 2.35 [95% CI: 1.57 to 3.56] for BNP clinical activation and 2.10 [95% CI: 1.32 to 3.36] for BNP ratio of 1 to 2, 2.25 [95% CI: 1.31 to 3.87] for BNP ratio of 2 to 3, 3.93 [95% CI: 2.40 to 6.43] for BNP ratio of ≥3). Aortic valve replacement was associated with survival improved by a similarly high margin (p = 0.54) with BNP ratio of <2 (HR: 0.68; 95% CI: 0.52 to 0.89; p = 0.003) or BNP ratio of >2 (HR: 0.56; 95% CI: 0.47 to 0.66; p < 0.0001). CONCLUSIONS In this large series of patients with AS, BNP clinical activation was associated with excess long-term mortality incrementally and independently of all baseline characteristics. Higher mortality with higher BNP clinical activation, even in asymptomatic patients, emphasizes the importance of appropriate clinical interpretation of BNP levels in managing patients with AS.
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Affiliation(s)
- Marie-Annick Clavel
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Joseph Malouf
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Hector I Michelena
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Rakesh M Suri
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Allan S Jaffe
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Douglas W Mahoney
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Maurice Enriquez-Sarano
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, Minnesota.
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Ribeiro HB, Urena M, Le Ven F, Nombela-Franco L, Allende R, Clavel MA, Dahou A, Côté M, Laflamme J, Laflamme L, DeLarochellière H, DeLarochellière R, Doyle D, Dumont E, Bergeron S, Pibarot P, Rodés-Cabau J. Long-term prognostic value and serial changes of plasma N-terminal prohormone B-type natriuretic peptide in patients undergoing transcatheter aortic valve implantation. Am J Cardiol 2014; 113:851-9. [PMID: 24528616 DOI: 10.1016/j.amjcard.2013.11.038] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Revised: 11/12/2013] [Accepted: 11/12/2013] [Indexed: 11/17/2022]
Abstract
Little is known about the usefulness of evaluating cardiac neurohormones in patients undergoing transcatheter aortic valve implantation (TAVI). The objectives of this study were to evaluate the baseline values and serial changes of N-terminal prohormone B-type natriuretic peptide (NT-proBNP) after TAVI, its related factors, and prognostic value. A total of 333 consecutive patients were included, and baseline, procedural, and follow-up (median 20 months, interquartile range 9 to 36) data were prospectively collected. Systematic NT-proBNP measurements were performed at baseline, hospital discharge, 1, 6, and 12 months, and yearly thereafter. Baseline NT-proBNP values were elevated in 86% of the patients (median 1,692 pg/ml); lower left ventricular ejection fraction and stroke volume index, greater left ventricular mass, and renal dysfunction were associated with greater baseline values (p <0.01 for all). Higher NT-proBNP levels were independently associated with increased long-term overall and cardiovascular mortalities (p <0.001 for both), with a baseline cut-off level of ∼2,000 pg/ml best predicting worse outcomes (p <0.001). At 6- to 12-month follow-up, NT-proBNP levels had decreased (p <0.001) by 23% and remained stable up to 4-year follow-up. In 39% of the patients, however, there was a lack of NT-proBNP improvement, mainly related to preprocedural chronic atrial fibrillation, lower mean transaortic gradient, and moderate-to-severe mitral regurgitation (p <0.01 for all). In conclusion, most patients undergoing TAVI presented high NT-proBNP levels, and a lack of improvement was observed in >1/3 of the patients after TAVI. Also, higher NT-proBNP levels predicted greater overall and cardiac mortalities at a median follow-up of 2 years. These findings support the implementation of NT-proBNP measurements for the clinical decision-making process and follow-up of patients undergoing TAVI.
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Affiliation(s)
- Henrique B Ribeiro
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Marina Urena
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Florent Le Ven
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Luis Nombela-Franco
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Ricardo Allende
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Marie-Annick Clavel
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Abdellaziz Dahou
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Mélanie Côté
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Jerôme Laflamme
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Louis Laflamme
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | | | | | - Daniel Doyle
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Eric Dumont
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Sebastien Bergeron
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Philippe Pibarot
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Josep Rodés-Cabau
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada.
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35
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Long Term Follow-Up After Aortic Valve Replacement (Ross Procedure): Echocardiographic Determinants of Ventricular Recovery. Heart Lung Circ 2014; 23:132-43. [DOI: 10.1016/j.hlc.2013.07.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2010] [Revised: 06/28/2013] [Accepted: 07/10/2013] [Indexed: 11/21/2022]
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36
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Dal-Bianco JP, Sengupta PP, Khandheria BK. Role of echocardiography in the diagnosis and management of asymptomatic severe aortic stenosis. Expert Rev Cardiovasc Ther 2014; 6:223-33. [DOI: 10.1586/14779072.6.2.223] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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37
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Dahl JS, Christensen NL, Videbæk L, Poulsen MK, Carter-Storch R, Hey TM, Pellikka PA, Steffensen FH, Møller JE. Left Ventricular Diastolic Function Is Associated With Symptom Status in Severe Aortic Valve Stenosis. Circ Cardiovasc Imaging 2014; 7:142-8. [DOI: 10.1161/circimaging.113.000636] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
In aortic valve stenosis (AS), the occurrence of heart failure symptoms does not always correlate with severity of valve stenosis and left ventricular (LV) function. Therefore, we tested the hypothesis that symptomatic patients with AS have impaired diastolic, longitudinal systolic function, and left atrial dilatation compared with asymptomatic patients.
Methods and Results—
In a retrospective descriptive study, we compared clinical characteristics and echocardiographic parameters in 99 symptomatic and 139 asymptomatic patients with severe AS and LV ejection fraction ≥50%. Independent predictors of symptomatic state were identified using logistic regression analysis. Symptomatic patients were younger (72±10 versus 76±12 years of age;
P
=0.002), presented less often with atrial fibrillation (13% versus 24%;
P
=0.05) and chronic obstructive pulmonary disease (2% versus 19%;
P
<0.001), and had a lower prevalence of hypertension (73% versus 40%;
P
<0.001). Despite similar AS severity, symptomatic patients had higher LV mass index (120±39 versus 95±25 g/m
2
;
P
<0.0001), increased relative wall thickness (0.61±0.15 versus 0.50±0.11;
P
<0.0001), shorter mitral deceleration time (199±58 versus 268±62 ms;
P
<0.0001), and increased left atrial volume index (49±18 versus 42±15 mL/m
2
;
P
=0.02). When adjusting for age, history of hypertension, atrial fibrillation, and chronic obstructive pulmonary disease in a multivariable logistic regression analysis, LV mass index, relative wall thickness, left atrial volume index, and deceleration time were still associated with the presence of symptoms.
Conclusions—
The present study demonstrates that symptomatic status in severe AS is associated with impaired diastolic function, LV hypertrophy, concentric remodeling, and left atrial dilatation when corrected for indices of AS severity.
Clinical Trial Registration—
URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT00294775.
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Affiliation(s)
- Jordi S. Dahl
- From the Department of Cardiology, Odense University Hospital, Odense, Denmark (J.S.D., N.L.C., L.V., M.K.P., R.C.-S., T.M.H., J.E.M.); Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (P.A.P.); and Department of Cardiology, Vejle Hospital, Vejle, Denmark (F.H.S.)
| | - Nicolaj L. Christensen
- From the Department of Cardiology, Odense University Hospital, Odense, Denmark (J.S.D., N.L.C., L.V., M.K.P., R.C.-S., T.M.H., J.E.M.); Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (P.A.P.); and Department of Cardiology, Vejle Hospital, Vejle, Denmark (F.H.S.)
| | - Lars Videbæk
- From the Department of Cardiology, Odense University Hospital, Odense, Denmark (J.S.D., N.L.C., L.V., M.K.P., R.C.-S., T.M.H., J.E.M.); Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (P.A.P.); and Department of Cardiology, Vejle Hospital, Vejle, Denmark (F.H.S.)
| | - Mikael K. Poulsen
- From the Department of Cardiology, Odense University Hospital, Odense, Denmark (J.S.D., N.L.C., L.V., M.K.P., R.C.-S., T.M.H., J.E.M.); Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (P.A.P.); and Department of Cardiology, Vejle Hospital, Vejle, Denmark (F.H.S.)
| | - Rasmus Carter-Storch
- From the Department of Cardiology, Odense University Hospital, Odense, Denmark (J.S.D., N.L.C., L.V., M.K.P., R.C.-S., T.M.H., J.E.M.); Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (P.A.P.); and Department of Cardiology, Vejle Hospital, Vejle, Denmark (F.H.S.)
| | - Thomas M. Hey
- From the Department of Cardiology, Odense University Hospital, Odense, Denmark (J.S.D., N.L.C., L.V., M.K.P., R.C.-S., T.M.H., J.E.M.); Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (P.A.P.); and Department of Cardiology, Vejle Hospital, Vejle, Denmark (F.H.S.)
| | - Patricia A. Pellikka
- From the Department of Cardiology, Odense University Hospital, Odense, Denmark (J.S.D., N.L.C., L.V., M.K.P., R.C.-S., T.M.H., J.E.M.); Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (P.A.P.); and Department of Cardiology, Vejle Hospital, Vejle, Denmark (F.H.S.)
| | - Flemming H. Steffensen
- From the Department of Cardiology, Odense University Hospital, Odense, Denmark (J.S.D., N.L.C., L.V., M.K.P., R.C.-S., T.M.H., J.E.M.); Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (P.A.P.); and Department of Cardiology, Vejle Hospital, Vejle, Denmark (F.H.S.)
| | - Jacob E. Møller
- From the Department of Cardiology, Odense University Hospital, Odense, Denmark (J.S.D., N.L.C., L.V., M.K.P., R.C.-S., T.M.H., J.E.M.); Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (P.A.P.); and Department of Cardiology, Vejle Hospital, Vejle, Denmark (F.H.S.)
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38
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Lisi M, Henein M, Cameli M, Ballo P, Reccia R, Bennati E, Chiavarelli M, Maccherini M, Mondillo S. Severity of aortic stenosis predicts early post-operative normalization of left atrial size and function detected by myocardial strain. Int J Cardiol 2013; 167:1450-5. [DOI: 10.1016/j.ijcard.2012.04.057] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2011] [Revised: 03/18/2012] [Accepted: 04/08/2012] [Indexed: 10/28/2022]
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39
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Lee HF, Hsu LA, Chan YH, Wang CL, Chang CJ, Kuo CT. Prognostic value of global left ventricular strain for conservatively treated patients with symptomatic aortic stenosis. J Cardiol 2013; 62:301-6. [PMID: 23867330 DOI: 10.1016/j.jjcc.2013.05.001] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Revised: 04/23/2013] [Accepted: 05/06/2013] [Indexed: 12/18/2022]
Abstract
AIMS Impaired left ventricular (LV) strain is associated with an increased risk of cardiac events in asymptomatic severe aortic stenosis (AS). We aimed to evaluate the prognostic value of global LV strain in conservatively treated patients with symptomatic AS. METHODS AND RESULTS This cohort study retrospectively reviewed symptomatic AS patients who were treated conservatively or surgically between July 2007 and April 2010. We measured their global longitudinal strain (GLS) and global circumferential strain (GCS). Clinical events were defined as readmission for heart failure or all-cause death for 2 years. GLS and GCS could predict a worse outcome in the conservatively treated group at cut-offs of =-16.5% (77% sensitivity and 67% specificity) and =-22.2% (92% sensitivity and 83% specificity), respectively. By univariate Cox regression analysis, age, logistic EuroSCORE, aortic valve area, GLS, and GCS were significant predictors. When adjusted for age, logistic EuroSCORE, and aortic valve area, impaired GLS and GCS were independently associated with a higher risk of clinical events. CONCLUSION In conservatively treated patients with symptomatic AS, impaired GLS and GCS were associated with an increased risk of cardiac events during a 2-year follow-up. Global LV strain may help to define a higher risk subset; therefore, a larger and prospective observation study would be necessary.
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Affiliation(s)
- Hsin-Fu Lee
- First Division of Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, 5, Fushin Street, Kweishan Hsiang, Taoyuan, Taiwan
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40
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Van der Ende J, Vázquez Antona CA, Erdmenger Orellana J, Romero Cárdenas Á, Roldan FJ, Vargas Barrón J. Left ventricular longitudinal strain measured by speckle tracking as a predictor of the decrease in left ventricular deformation in children with congenital stenosis of the aorta or coarctation of the aorta. ULTRASOUND IN MEDICINE & BIOLOGY 2013; 39:1207-1214. [PMID: 23643058 DOI: 10.1016/j.ultrasmedbio.2013.02.015] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2012] [Revised: 01/17/2013] [Accepted: 02/21/2013] [Indexed: 06/02/2023]
Abstract
Children born with a left ventricular outflow tract obstruction (LVOTO) can present with symptoms of left ventricular (LV) failure while ejection fraction (EF) is normal. A more sensitive parameter of systolic function might be obtained with speckle tracking echocardiography, which describes ventricular longitudinal deformation in strain values. It is presumed that despite a normal or only slight decrease in ejection fraction, patients with a LVOTO demonstrate aberrations in the longitudinal deformation of the left ventricle. In addition, it is expected that after a successful intervention, longitudinal deformation returns to normal values. Standard trans-thoracic echocardiography was performed on 33 consecutive patients with a LVOTO, either an isolated aortic coarctation (AoCo) or an isolated aortic stenosis (AoSt). Before intervention a significant decrease in strain values was observed compared with the control group (N = 40), with an additional decrease in strain values in the first week after intervention (N = 16). Strain values recovered after a mean follow-up period of 42 wk (N = 9), though normal values were never reached. In addition, patients with an AoCo had a smaller decrease in strain values compared with patients with AoSt. All strain values were measured with a concomitant ejection fraction between normal limits. It is concluded that patients with a congenital LVOTO have decreased ventricular systolic function measured as strain values, whereas their ejection fraction is within the normal range. Therefore, as ejection fraction may not be an accurate measure, speckle tracking-based strain may be significant in the identification of subtle changes in longitudinal deformation and may create opportunities for patients to benefit from early treatment for heart failure.
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Affiliation(s)
- J Van der Ende
- Department of Pediatric Cardiology, Leiden University Medical Center Leiden, The Netherlands.
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41
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Luszczak J, Olszowska M, Drapisz S, Plazak W, Karch I, Komar M, Goralczyk T, Podolec P. Assessment of left ventricle function in patients with symptomatic and asymptomatic aortic stenosis by 2-dimensional speckle-tracking imaging. Med Sci Monit 2013. [PMID: 23197243 PMCID: PMC3560794 DOI: 10.12659/msm.883587] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background Global longitudinal peak strain (GLPS) quantifies left ventricle (LV) long-axis contractility. Early detection of LV systolic dysfunction is pivotal in diagnosis and treatment of patients with aortic stenosis (AS). This study was performed to assess LV longitudinal systolic function by GLPS derived from 2-dimensional speckle tracking imaging (2D-STI) in AS patients in comparison to standard echocardiographic parameters. Material/Methods Laboratory tests, standard echocardiography, tissue Doppler imaging (TDI) and 2D-STI examinations with GLPS calculation were performed in 49 consecutive patients with moderate to severe AS with LV ejection fraction ≥50% and 18 controls. Results While LVEF do not differentiate AS patients from controls, GLPS was significantly decreased in the AS group (−15.30±3.25% vs. −19.60±2.46% in controls, p<0.001). GLPS was significantly reduced in symptomatic AS patients as compared to the asymptomatic AS group [−15.5 (11.8–16.8) vs. −17.5 (14.7–18.9)%, p=0.02]. Conclusions In aortic stenosis patients, despite normal left ventricle ejection fraction, long-axis left ventricular function is impaired, which manifests in global longitudinal peak strain reduction. GLPS reveals that LV function impairment is more pronounced in symptomatic as compared to asymptomatic AS patients. Further studies are needed to determine the prognostic significance of early LV function impairment in aortic stenosis patients showed by GLPS.
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Affiliation(s)
- Joanna Luszczak
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, John Paul II Hospital, Cracow, Poland.
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42
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Wang B, Chen H, Shu X, Hong T, Lai H, Wang C, Cheng L. Emerging role of echocardiographic strain/strain rate imaging and twist in systolic function evaluation and operative procedure in patients with aortic stenosis. Interact Cardiovasc Thorac Surg 2013; 17:384-91. [PMID: 23644729 DOI: 10.1093/icvts/ivt171] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Systolic function of the left ventricle is vital for patients with aortic stenosis. Unfortunately, the most widely used clinical parameter, the left ventricular ejection fraction, is not sensitive enough, especially for patients with left ventricular hypertrophy. Echocardiographic strain/strain rate and twist are emerging parameters for left ventricular systolic and diastolic function evaluation. Aortic stenosis could reduce strain/strain rate while magnifying twist. Furthermore, strain/strain rate correlates well with the prognosis of patients with aortic stenosis. Most importantly the circumferential strain, strain rate and twist also play a role in differentiating cardiac compensation or decompensation. In any case, these parameters could normalize after successful surgical aortic valve replacement or transcatheter aortic valve replacement. Regardless of these advantages, clinical evidence is needed to ensure their usefulness.
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Affiliation(s)
- Bin Wang
- Department of Cardiac Surgery, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai, China
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43
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Friedberg MK, Wu S, Slorach C. Left-Right Ventricular Interactions in Pediatric Aortic Stenosis: Right Ventricular Myocardial Strain before and after Aortic Valvuloplasty. J Am Soc Echocardiogr 2013; 26:390-7. [DOI: 10.1016/j.echo.2012.12.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2012] [Indexed: 11/17/2022]
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44
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Lauten J, Rost C, Breithardt OA, Seligmann C, Klinghammer L, Daniel WG, Flachskampf FA. Invasive Hemodynamic Characteristics of Low Gradient Severe Aortic Stenosis Despite Preserved Ejection Fraction. J Am Coll Cardiol 2013; 61:1799-808. [DOI: 10.1016/j.jacc.2013.02.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2012] [Revised: 01/29/2013] [Accepted: 02/03/2013] [Indexed: 02/06/2023]
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45
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Bauer F, Coutant V, Bernard M, Stepowski D, Tron C, Cribier A, Bessou JP, Eltchaninoff H. Patients With Severe Aortic Stenosis and Reduced Ejection Fraction: Earlier Recovery of Left Ventricular Systolic Function After Transcatheter Aortic Valve Implantation Compared With Surgical Valve Replacement. Echocardiography 2013; 30:865-70. [DOI: 10.1111/echo.12171] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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46
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Bartko PE, Heinze G, Graf S, Clavel MA, Khorsand A, Bergler-Klein J, Burwash IG, Dumesnil JG, Sénéchal M, Baumgartner H, Rosenhek R, Pibarot P, Mundigler G. Two-Dimensional Strain for the Assessment of Left Ventricular Function in Low Flow–Low Gradient Aortic Stenosis, Relationship to Hemodynamics, and Outcome. Circ Cardiovasc Imaging 2013; 6:268-76. [DOI: 10.1161/circimaging.112.980201] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- Philipp Emanuel Bartko
- From the Department of Internal Medicine II, Division of Cardiology, (P.E.B., S.G., A.K., J.B.-K., R.R., G.M.) and Center for Medical Statistics, Informatics and Intelligent Systems (G.H.), Medical University of Vienna, Vienna, Austria; Laval Hospital/Québec Heart Institute, Laval University, Québec, Canada (M.A.C., J.G.D., M.S., P.P.); University of Ottawa Heart Institute, Ottawa, Ontario, Canada (I.G.B.); and Department of Cardiovascular Medicine, Divsion of Adult Congenital and Valvular Heart
| | - Georg Heinze
- From the Department of Internal Medicine II, Division of Cardiology, (P.E.B., S.G., A.K., J.B.-K., R.R., G.M.) and Center for Medical Statistics, Informatics and Intelligent Systems (G.H.), Medical University of Vienna, Vienna, Austria; Laval Hospital/Québec Heart Institute, Laval University, Québec, Canada (M.A.C., J.G.D., M.S., P.P.); University of Ottawa Heart Institute, Ottawa, Ontario, Canada (I.G.B.); and Department of Cardiovascular Medicine, Divsion of Adult Congenital and Valvular Heart
| | - Senta Graf
- From the Department of Internal Medicine II, Division of Cardiology, (P.E.B., S.G., A.K., J.B.-K., R.R., G.M.) and Center for Medical Statistics, Informatics and Intelligent Systems (G.H.), Medical University of Vienna, Vienna, Austria; Laval Hospital/Québec Heart Institute, Laval University, Québec, Canada (M.A.C., J.G.D., M.S., P.P.); University of Ottawa Heart Institute, Ottawa, Ontario, Canada (I.G.B.); and Department of Cardiovascular Medicine, Divsion of Adult Congenital and Valvular Heart
| | - Marie-Annick Clavel
- From the Department of Internal Medicine II, Division of Cardiology, (P.E.B., S.G., A.K., J.B.-K., R.R., G.M.) and Center for Medical Statistics, Informatics and Intelligent Systems (G.H.), Medical University of Vienna, Vienna, Austria; Laval Hospital/Québec Heart Institute, Laval University, Québec, Canada (M.A.C., J.G.D., M.S., P.P.); University of Ottawa Heart Institute, Ottawa, Ontario, Canada (I.G.B.); and Department of Cardiovascular Medicine, Divsion of Adult Congenital and Valvular Heart
| | - Aliasghar Khorsand
- From the Department of Internal Medicine II, Division of Cardiology, (P.E.B., S.G., A.K., J.B.-K., R.R., G.M.) and Center for Medical Statistics, Informatics and Intelligent Systems (G.H.), Medical University of Vienna, Vienna, Austria; Laval Hospital/Québec Heart Institute, Laval University, Québec, Canada (M.A.C., J.G.D., M.S., P.P.); University of Ottawa Heart Institute, Ottawa, Ontario, Canada (I.G.B.); and Department of Cardiovascular Medicine, Divsion of Adult Congenital and Valvular Heart
| | - Jutta Bergler-Klein
- From the Department of Internal Medicine II, Division of Cardiology, (P.E.B., S.G., A.K., J.B.-K., R.R., G.M.) and Center for Medical Statistics, Informatics and Intelligent Systems (G.H.), Medical University of Vienna, Vienna, Austria; Laval Hospital/Québec Heart Institute, Laval University, Québec, Canada (M.A.C., J.G.D., M.S., P.P.); University of Ottawa Heart Institute, Ottawa, Ontario, Canada (I.G.B.); and Department of Cardiovascular Medicine, Divsion of Adult Congenital and Valvular Heart
| | - Ian Gordon Burwash
- From the Department of Internal Medicine II, Division of Cardiology, (P.E.B., S.G., A.K., J.B.-K., R.R., G.M.) and Center for Medical Statistics, Informatics and Intelligent Systems (G.H.), Medical University of Vienna, Vienna, Austria; Laval Hospital/Québec Heart Institute, Laval University, Québec, Canada (M.A.C., J.G.D., M.S., P.P.); University of Ottawa Heart Institute, Ottawa, Ontario, Canada (I.G.B.); and Department of Cardiovascular Medicine, Divsion of Adult Congenital and Valvular Heart
| | - Jean Gaston Dumesnil
- From the Department of Internal Medicine II, Division of Cardiology, (P.E.B., S.G., A.K., J.B.-K., R.R., G.M.) and Center for Medical Statistics, Informatics and Intelligent Systems (G.H.), Medical University of Vienna, Vienna, Austria; Laval Hospital/Québec Heart Institute, Laval University, Québec, Canada (M.A.C., J.G.D., M.S., P.P.); University of Ottawa Heart Institute, Ottawa, Ontario, Canada (I.G.B.); and Department of Cardiovascular Medicine, Divsion of Adult Congenital and Valvular Heart
| | - Mario Sénéchal
- From the Department of Internal Medicine II, Division of Cardiology, (P.E.B., S.G., A.K., J.B.-K., R.R., G.M.) and Center for Medical Statistics, Informatics and Intelligent Systems (G.H.), Medical University of Vienna, Vienna, Austria; Laval Hospital/Québec Heart Institute, Laval University, Québec, Canada (M.A.C., J.G.D., M.S., P.P.); University of Ottawa Heart Institute, Ottawa, Ontario, Canada (I.G.B.); and Department of Cardiovascular Medicine, Divsion of Adult Congenital and Valvular Heart
| | - Helmut Baumgartner
- From the Department of Internal Medicine II, Division of Cardiology, (P.E.B., S.G., A.K., J.B.-K., R.R., G.M.) and Center for Medical Statistics, Informatics and Intelligent Systems (G.H.), Medical University of Vienna, Vienna, Austria; Laval Hospital/Québec Heart Institute, Laval University, Québec, Canada (M.A.C., J.G.D., M.S., P.P.); University of Ottawa Heart Institute, Ottawa, Ontario, Canada (I.G.B.); and Department of Cardiovascular Medicine, Divsion of Adult Congenital and Valvular Heart
| | - Raphael Rosenhek
- From the Department of Internal Medicine II, Division of Cardiology, (P.E.B., S.G., A.K., J.B.-K., R.R., G.M.) and Center for Medical Statistics, Informatics and Intelligent Systems (G.H.), Medical University of Vienna, Vienna, Austria; Laval Hospital/Québec Heart Institute, Laval University, Québec, Canada (M.A.C., J.G.D., M.S., P.P.); University of Ottawa Heart Institute, Ottawa, Ontario, Canada (I.G.B.); and Department of Cardiovascular Medicine, Divsion of Adult Congenital and Valvular Heart
| | - Philippe Pibarot
- From the Department of Internal Medicine II, Division of Cardiology, (P.E.B., S.G., A.K., J.B.-K., R.R., G.M.) and Center for Medical Statistics, Informatics and Intelligent Systems (G.H.), Medical University of Vienna, Vienna, Austria; Laval Hospital/Québec Heart Institute, Laval University, Québec, Canada (M.A.C., J.G.D., M.S., P.P.); University of Ottawa Heart Institute, Ottawa, Ontario, Canada (I.G.B.); and Department of Cardiovascular Medicine, Divsion of Adult Congenital and Valvular Heart
| | - Gerald Mundigler
- From the Department of Internal Medicine II, Division of Cardiology, (P.E.B., S.G., A.K., J.B.-K., R.R., G.M.) and Center for Medical Statistics, Informatics and Intelligent Systems (G.H.), Medical University of Vienna, Vienna, Austria; Laval Hospital/Québec Heart Institute, Laval University, Québec, Canada (M.A.C., J.G.D., M.S., P.P.); University of Ottawa Heart Institute, Ottawa, Ontario, Canada (I.G.B.); and Department of Cardiovascular Medicine, Divsion of Adult Congenital and Valvular Heart
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47
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Løgstrup BB, Andersen HR, Thuesen L, Christiansen EH, Terp K, Klaaborg KE, Poulsen SH. Left ventricular global systolic longitudinal deformation and prognosis 1 year after femoral and apical transcatheter aortic valve implantation. J Am Soc Echocardiogr 2013; 26:246-54. [PMID: 23306032 DOI: 10.1016/j.echo.2012.12.006] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Indexed: 12/18/2022]
Abstract
BACKGROUND Aortic valve replacement is the recommended therapy for patients with severe aortic stenosis who have symptoms or decreased left ventricular (LV) function. Transcatheter aortic valve implantation (TAVI) is a treatment alternative in surgically high-risk or inoperable patients with severe aortic stenosis. The objective of this study was to analyze LV function assessed by global LV longitudinal systolic strain (GLS) and relation to prognosis in patients with severe aortic stenosis treated with femoral or apical TAVI. METHODS Two-dimensional echocardiography was performed before and 1 year after TAVI. Ejection fraction (EF) was retrospectively measured using the biplane Simpson's method, and GLS was obtained as an average of 16 segments in the three standard apical views by speckle-tracking. GE Vivid 7 and Vivid 9 machines were used for echocardiography, and speckle-tracking analysis was performed using EchoPAC PC '08 version 7.0.1. RESULTS The total population consisted of 100 TAVI patients. Eighty-one patients survived to 1-year follow-up, with a mean age of 81 ± 7 years (range, 64-93 years) and a mean European System for Cardiac Operative Risk Evaluation score of 9.6 ± 2.7. Nineteen patients died before 1-year follow-up (12 women), with a mean age of 82 ± 7 years (range, 66-92 years) and a mean European System for Cardiac Operative Risk Evaluation score of 10.5 ± 2.8. No differences were found between the 19 patients who died before follow-up and the 81 patients who survived to 1-year follow-up. GLS was increased significantly 1 year after TAVI. In 34 patients with EFs > 50%, GLS increased from -15.3 ± 3.4 to -17.1 ± 3.6 (P = .04). In these patients, the mean EF increased numerically from 57.9 ± 5.3% to 60 ± 7.7% (P = .19). In 74 patients with EFs ≤ 50%, mean GLS and EF improved significantly from -10 ± 2.8 to -13.8 ± 3.8 (P < .0001) and 39 ± 9.4% to 52 ± 12.5% (P < .0001), respectively. The 1-year gain in EF was the same after femoral TAVI (9.7 ± 10.1%) and after apical TAVI (8 ± 10.8%) (P = .52). Furthermore, GLS did not differ significantly after femoral and apical TAVI (-3.8 ± 3.3 and -2.6 ± 3.7, respectively, P = .21). There was no difference in causes of death according to approach. In the total population (n = 100), 35 deaths occurred, 19 before 1-year follow-up and 16 afterward. The median follow-up time was 30 months. Twenty-five patients (71%) died from cardiac causes. Overall 1-year mortality was 19%, and overall 2-year mortality was 28%. In the patients who died, the median survival time in the apical group was 28.5 ± 15.4 months, compared with 31.6 ± 19 months in the femoral group (P = .47). There was no impact on prognosis according to high (≥47.5%) versus low (<47.5%) baseline EF or high (≥11.95%) versus low (<11.95%) baseline GLS. However, the magnitude of changes in GLS seemed to have a prognostic impact. CONCLUSIONS LV EF and longitudinal systolic deformation were improved in TAVI independent of technical approach using the Edwards SAPIEN valve prosthesis during 1-year follow-up. The mortality rate was comparable between technical approaches and independent of baseline LV function. However, patients with the greatest improvement in LV systolic longitudinal deformation after TAVI had a lower mortality rate.
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48
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Staron A, Bansal M, Kalakoti P, Nakabo A, Gasior Z, Pysz P, Wita K, Jasinski M, Sengupta PP. Speckle tracking echocardiography derived 2-dimensional myocardial strain predicts left ventricular function and mass regression in aortic stenosis patients undergoing aortic valve replacement. Int J Cardiovasc Imaging 2012. [PMID: 23197274 DOI: 10.1007/s10554-012-0160-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Regression of left ventricular (LV) mass in severe aortic stenosis (AS) following aortic valve replacement (AVR) reduces the potential risk of sudden death and congestive heart failure associated with LV hypertrophy. We investigated whether abnormalities of resting LV deformation in severe AS can predict the lack of regression of LV mass following AVR. Two-dimensional speckle tracking echocardiography (STE) was performed in a total of 100 subjects including 60 consecutive patients with severe AS having normal LV ejection fraction (EF > 50 %) and 40 controls. STE was performed preoperatively and at 4 months following AVR, including longitudinal strain assessed from the apical 4-chamber and 2-chamber views and the circumferential and rotational mechanics measured from the apical short axis view. In comparison with controls, the patients with AS showed a significantly lower LV longitudinal (p < 0.001) and circumferential strain (p < 0.05) and higher apical rotation (p < 0.001). Following AVR, a significant improvement was seen in both strains (p < 0.001 for each respectively), however, apical rotation remained unchanged (p = 0.14). On multivariate analysis, baseline LV mass (odds ratio 1.02; p = 0.011), left atrial volume (odds ratio 0.81; p = 0.048) and circumferential strain (odds ratio 0.84; p = 0.02) independently predicted LV mass regression (>10 %) following AVR. In conclusion, STE can quantify the burden of myocardial dysfunction in patients with severe AS despite the presence of normal LV ejection fraction. Furthermore, resting abnormalities in circumferential strain at LV apex is related with a hemodynamic milieu associated with the lack of LV mass regression during short-term follow up after AVR.
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Affiliation(s)
- Adam Staron
- 2nd Cardiology Department, Medical University of Silesia, Katowice, Poland
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49
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Torres-Ramalho P, Araújo JP, Bettencourt P, Moura LM. Natriuretic peptides in aortic stenosis. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2012. [DOI: 10.1016/j.repce.2012.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Torres-Ramalho P, Araújo JP, Bettencourt P, Moura LM. Natriuretic peptides in aortic stenosis. Rev Port Cardiol 2012; 31:655-60. [DOI: 10.1016/j.repc.2012.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2011] [Accepted: 04/23/2012] [Indexed: 01/17/2023] Open
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