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Fauvel C, Coisne A, Capoulade R, Bourg C, Diakov C, Ribeyrolles S, Jouan J, Folliguet T, Kibler M, Dreyfus J, Magne J, Bohbot Y, Pezel T, Modine T, Donal E. Unmet needs and knowledge gaps in aortic stenosis: A position paper from the Heart Valve Council of the French Society of Cardiology. Arch Cardiovasc Dis 2024:S1875-2136(24)00307-3. [PMID: 39353805 DOI: 10.1016/j.acvd.2024.06.004] [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: 03/17/2024] [Revised: 06/19/2024] [Accepted: 06/30/2024] [Indexed: 10/04/2024]
Abstract
Nowadays, valvular heart disease remains a significant challenge among cardiovascular diseases, affecting millions of people worldwide and exerting substantial pressure on healthcare systems. Within the spectrum of valvular heart disease, aortic stenosis is the most common valvular lesion in developed countries. Despite notable advances in understanding its pathophysiological processes, improved cardiovascular imaging techniques and expanding therapeutic options in recent years, there are still unmet needs and knowledge gaps regarding aortic stenosis pathophysiology, severity assessment, management and decision-making strategy. This review, prepared on behalf of the Heart Valve Council of the French Society of Cardiology, describes these gaps and future research perspectives to improve the outcome of patients with aortic stenosis.
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Affiliation(s)
- Charles Fauvel
- Cardiology Department, Rouen University Hospital, 76000 Rouen, France
| | - Augustin Coisne
- Institut Pasteur de Lille, CHU Lille, Lille University, INSERM, 59000 Lille, France
| | - Romain Capoulade
- L'Institut du Thorax, CHU Nantes, Nantes University, CNRS, INSERM, 44007 Nantes, France
| | - Corentin Bourg
- Department of Cardiology, CHU Rennes, University of Rennes, INSERM, LTSI - UMR 1099, 35000 Rennes, France
| | | | | | - Jérome Jouan
- Department of Cardiac and Thoracic Surgery, Limoges University Teaching Hospital, 87000 Limoges, France
| | - Thierry Folliguet
- Department of Cardiac Surgery, Henri Mondor University Hospital, AP-HP, 94000 Créteil, France
| | - Marion Kibler
- Department of Cardiovascular Surgery and Medicine, New Civil Hospital, CHU Strasbourg, Strasbourg University, 67000 Strasbourg, France
| | - Julien Dreyfus
- Cardiology Department, Centre Cardiologique du Nord, 93200 Saint-Denis, France
| | - Julien Magne
- Department of Cardiology, Dupuytren Hospital, CHU Limoges, 87000 Limoges, France; INSERM 1094, Limoges Faculty of Medicine, 87025 Limoges, France
| | - Yohann Bohbot
- Department of Cardiology, Amiens University Hospital, 80054 Amiens, France
| | - Théo Pezel
- Department of Radiology and Department of Cardiology, Lariboisière Hospital, AP-HP, Paris Cité University, 75010 Paris, France
| | - Thomas Modine
- Department of Cardiology and Cardiovascular Surgery, Haut-Lévêque Cardiological Hospital, Bordeaux University Hospital, 33604 Pessac, France
| | - Erwan Donal
- Department of Cardiology, CHU Rennes, University of Rennes, INSERM, LTSI - UMR 1099, 35000 Rennes, France.
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2
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Möller FN, Fan JL, Futral JE, Hodgman CF, Kayser B, Lovering AT. Cardiopulmonary haemodynamics in Tibetans and Han Chinese during rest and exercise. J Physiol 2024; 602:3893-3907. [PMID: 38924564 DOI: 10.1113/jp286303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 05/22/2024] [Indexed: 06/28/2024] Open
Abstract
During sea-level exercise, blood flow through intrapulmonary arteriovenous anastomoses (IPAVA) in humans without a patent foramen ovale (PFO) is negatively correlated with pulmonary pressure. Yet, it is unknown whether the superior exercise capacity of Tibetans well adapted to living at high altitude is the result of lower pulmonary pressure during exercise in hypoxia, and whether their cardiopulmonary characteristics are significantly different from lowland natives of comparable ancestry (e.g. Han Chinese). We found a 47% PFO prevalence in male Tibetans (n = 19) and Han Chinese (n = 19) participants. In participants without a PFO (n = 10 each group), we measured heart structure and function at rest and peak oxygen uptake (V ̇ O 2 peak ${{\dot{V}}_{{{{\mathrm{O}}}_{\mathrm{2}}}{\mathrm{peak}}}}$ ), peak power output (W ̇ p e a k ${{\dot{W}}_{peak}}$ ), pulmonary artery systolic pressure (PASP), blood flow through IPAVA and cardiac output (Q ̇ T ${{\dot{Q}}_{\mathrm{T}}} $ ) at rest and during recumbent cycle ergometer exercise at 760 Torr (SL) and at 410 Torr (ALT) barometric pressure in a pressure chamber. Tibetans achieved a higherW peak ${W}_{\textit{peak}}$ than Han, and a higherV ̇ O 2 peak ${{\dot{V}}_{{{{\mathrm{O}}}_{\mathrm{2}}}{\mathrm{peak}}}}$ at ALT without differences in heart rate, stroke volume orQ ̇ T ${{\dot{Q}}_{\mathrm{T}}} $ . Blood flow through IPAVA was generally similar between groups. Increases in PASP and total pulmonary resistance at ALT were comparable between the groups. There were no differences in the slopes of PASP plotted as a function ofQ ̇ T ${{\dot{Q}}_{\mathrm{T}}} $ during exercise. In those without PFO, our data indicate that the superior aerobic exercise capacity of Tibetans over Han Chinese is independent of cardiopulmonary features and more probably linked to differences in local muscular oxygen extraction. KEY POINTS: Patent foramen ovale (PFO) prevalence was 47% in Tibetans and Han Chinese living at 2 275 m. Subjects with PFO were excluded from exercise studies. Compared to Han Chinese, Tibetans had a higher peak workload with acute compression to sea level barometric pressure (SL) and acute decompression to 5000 m altitude (ALT). Comprehensive cardiac structure and function at rest were not significantly different between Han Chinese and Tibetans. Tibetans and Han had similar blood flow through intrapulmonary arteriovenous anastomoses (IPAVA) during exercise at SL. Peak pulmonary artery systolic pressure (PASP) and total pulmonary resistance were different between SL and ALT, with significantly increased PASP for Han compared to Tibetans at ALT. No differences were observed between groups at acute SL and ALT.
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Affiliation(s)
- Fabian N Möller
- Department of Aeronautics and Astronautics, Massachusetts Institute of Technology, Boston, MA, USA
- Department of Human Physiology, University of Oregon, Eugene, OR, USA
- German Sport University Cologne, Institute for Professional Sport Education and Qualification, Cologne, Germany
| | - Jui-Lin Fan
- Department of Physiology, Manaaki Manawa - The Centre for Heart Research, University of Auckland, Faculty of Medical and Health Sciences, Auckland, New Zealand
| | - Joel E Futral
- Department of Human Physiology, University of Oregon, Eugene, OR, USA
- Oregon Heart & Vascular Institute, Springfield, Oregon, USA
| | - Charles F Hodgman
- Department of Health and Human Performance, University of Houston, Houston, TX, USA
| | - Bengt Kayser
- University of Lausanne, Institute of Sports Sciences, Lausanne, Switzerland
| | - Andrew T Lovering
- Department of Human Physiology, University of Oregon, Eugene, OR, USA
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3
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Gentile F, Buoncristiani F, Sciarrone P, Bazan L, Panichella G, Gasparini S, Chubuchny V, Taddei C, Poggianti E, Fabiani I, Petersen C, Lancellotti P, Passino C, Emdin M, Giannoni A. Left ventricular outflow tract velocity-time integral improves outcome prediction in patients with secondary mitral regurgitation. Int J Cardiol 2023; 392:131272. [PMID: 37604287 DOI: 10.1016/j.ijcard.2023.131272] [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: 07/20/2023] [Revised: 08/12/2023] [Accepted: 08/17/2023] [Indexed: 08/23/2023]
Abstract
AIMS Left ventricular outflow velocity-time integral (LVOT-VTI) has been shown to improve outcome prediction in different patients' subsets, with or without heart failure (HF). Nevertheless, the prognostic value of LVOT-VTI in patients with HF and secondary mitral regurgitation (MR) has never been investigated so far. Therefore, in the present study, we aimed to assess the prognostic value different metrics of LV forward output, including LVOT-VTI, in HF patients with secondary MR. METHODS AND RESULTS Consecutive patients with HF and moderate-to-severe/severe secondary MR and systolic dysfunction (i.e., left ventricular ejection fraction [LVEF] <50%) were retrospectively selected and followed-up for the primary endpoint of cardiac death. Out of the 287 patients analyzed (aged 74 ± 11 years, 70% men, 46% ischemic etiology, mean LVEF 30 ± 9%, mean LVOT-VTI 20 ± 5 cm), 71 met the primary endpoint over a 33-month median follow-up (16-47 months). Patients with an LVOT-VTI ≤17 cm (n = 96, 32%) showed the greatest risk of cardiac death (Log Rank 44.3, p < 0.001) and all-cause mortality (Log rank 8.6, p = 0.003). At multivariable regression analysis, all the measures of LV forward volume (namely LVOT-VTI, stroke volume index, cardiac output, and cardiac index) were predictors of poor outcomes. Among these, LVOT-VTI was the most accurate in risk prediction (univariable C-statistics 0.70 [95%CI 0.64-0.77]). CONCLUSION Left ventricular forward output, noninvasively estimated through LVOT-VTI, improves outcome prediction in HF patients with low LVEF and secondary MR.
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Affiliation(s)
- Francesco Gentile
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy
| | | | | | - Lorenzo Bazan
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Giorgia Panichella
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Simone Gasparini
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy
| | | | | | | | | | | | - Patrizio Lancellotti
- University of Liège Hospital, Cardiology Department, GIGA Cardiovascular Sciences, CHU Sart Tilman, Liège, Belgium; Gruppo Villa Maria Care and Research, Maria Cecilia Hospital, Cotignola, and Anthea Hospital, Bari, Italy
| | - Claudio Passino
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy; Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Michele Emdin
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy; Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Alberto Giannoni
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy; Fondazione Toscana Gabriele Monasterio, Pisa, Italy.
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Gaspardone C, Morosato M, Morciano DA, Mager R, Fasolino A, Baldetti L, Romagnolo D, Fiore G, Ingallina G, Ancona F, Stella S, Godino C, Agricola E. A Novel Formula for Estimating Left Ventricular Outflow Tract Diameter. Can J Cardiol 2023; 39:1986-1988. [PMID: 37739341 DOI: 10.1016/j.cjca.2023.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 09/04/2023] [Accepted: 09/15/2023] [Indexed: 09/24/2023] Open
Affiliation(s)
- Carlo Gaspardone
- Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy; Cardiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Michele Morosato
- Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Riccardo Mager
- Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Luca Baldetti
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Davide Romagnolo
- Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy; Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giorgio Fiore
- Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy; Unit of Cardiovascular Imaging, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giacomo Ingallina
- Unit of Cardiovascular Imaging, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Ancona
- Unit of Cardiovascular Imaging, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Stefano Stella
- Unit of Cardiovascular Imaging, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Cosmo Godino
- Cardiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Eustachio Agricola
- Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy; Unit of Cardiovascular Imaging, IRCCS San Raffaele Scientific Institute, Milan, Italy.
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Villavicencio C, Daniel X, Cartanyá M, Leache J, Ferré C, Roure M, Bodí M, Vives M, Rodriguez A. CARDIAC OUTPUT IN CRITICALLY ILL PATIENTS CAN BE ESTIMATED EASILY AND ACCURATELY USING THE MINUTE DISTANCE OBTAINED BY PULSED-WAVE DOPPLER. Shock 2023; 60:553-559. [PMID: 37698504 DOI: 10.1097/shk.0000000000002210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
Abstract
ABSTRACT Background: Cardiac output (CO) assessment is essential for management of patients with circulatory failure. Among the different techniques used for their assessment, pulsed-wave Doppler cardiac output (PWD-CO) has proven to be an accurate and useful tool. Despite this, assessment of PWD-CO could have some technical difficulties, especially in the measurement of left ventricular outflow tract diameter (LVOTd). The use of a parameter such as minute distance (MD) which avoids LVOTd in the PWD-CO formula could be a simple and useful way to assess the CO in critically ill patients. Therefore, the aim of this study was to evaluate the correlation and agreement between PWD-CO and MD. Methods: A prospective and observational study was conducted over 2 years in a 30-bed intensive care unit (ICU). Adult patients who required CO monitoring were included. Clinical echocardiographic data were collected within the first 24 h and at least once more during the first week of ICU stay. PWD-CO was calculated using the average value of three LVOTd and left ventricular outflow tract velocity-time integral (LVOT-VTI) measurements, and heart rate. Minute distance was obtained from the product of LVOT-VTI × heart rate. Pulsed-wave Doppler cardiac output was correlated with MD using linear regression. Cardiac output was quantified from the MD using the equation defined by linear regression. Bland-Altman analysis was also used to evaluate the level of agreement between CO calculated from MD (MD-CO) and PWD-CO. The percentage error was calculated. Results: A total of 98 patients and 167 CO measurements were analyzed. Sixty-seven (68%) were male, the median age was 66 years (interquartile range [IQR], 53-75 years), and the median Acute Physiology and Chronic Health Evaluation II score was 22 (IQR, 16-26). The most common cause of admission was shock in 81 patients (82.7%). Sixty-nine patients (70.4%) were mechanically ventilated, and 68 (70%) required vasoactive drugs. The median CO was 5.5 L/min (IQR, 4.8-6.6 L/min), and the median MD was 1,850 cm/min (IQR, 1,520-2,160 cm/min). There was a significant correlation between PWD-CO and MD-CO in the general population ( R2 = 0.7; P < 0.05). This correlation improved when left ventricular ejection fraction (LVEF) was less than 60% ( R2 = 0.85, P < 0.05). Bland-Altman analysis showed good agreement between PWD-CO and MD-CO in the general population, the median bias was 0.02 L/min, the limits of agreement were -1.92 to +1.92 L/min. The agreement was better in patients with LVEF less than 60% with a median bias of 0.005 L/min and limits of agreement of -1.56 to 1.55 L/min. The percentage error was 17% in both cases. Conclusion: Measurement of MD in critically ill patients provides a simple and accurate estimate of CO, especially in patients with reduced or preserved LVEF. This would allow earlier cardiovascular assessment in patients with circulatory failure, which is of particular interest in difficult clinical or technical conditions.
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Affiliation(s)
| | - Xavier Daniel
- Critical Care Department, Joan XXIII - University Hospital, Tarragona, Spain
| | - Marc Cartanyá
- Critical Care Department, Joan XXIII - University Hospital, Tarragona, Spain
| | - Julen Leache
- Critical Care Department, Joan XXIII - University Hospital, Tarragona, Spain
| | - Cristina Ferré
- Critical Care Department, Joan XXIII - University Hospital, Tarragona, Spain
| | - Marina Roure
- Critical Care Department, Joan XXIII - University Hospital, Tarragona, Spain
| | - María Bodí
- Critical Care Department, Hospital Universitari Joan XXIII, URV/IISPV/CIBERES, 43005 Tarragona, Spain
| | - Marc Vives
- Department of Anesthesiology & Critical Care, Clínica Universidad de Navarra, Universidad de Navarra, Av. Pio XII, 36. 31008 Pamplona, Navarra, Spain
| | - Alejandro Rodriguez
- Critical Care Department, Hospital Universitari Joan XXIII, URV/IISPV/CIBERES, 43005 Tarragona, Spain
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6
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Canciello G, Pate S, Sannino A, Borrelli F, Todde G, Grayburn P, Losi MA, Esposito G. Pitfalls and Tips in the Assessment of Aortic Stenosis by Transthoracic Echocardiography. Diagnostics (Basel) 2023; 13:2414. [PMID: 37510158 PMCID: PMC10377988 DOI: 10.3390/diagnostics13142414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 07/17/2023] [Accepted: 07/18/2023] [Indexed: 07/30/2023] Open
Abstract
Aortic stenosis (AS) is a valvular heart disease that significantly contributes to cardiovascular morbidity and mortality worldwide. The condition is characterized by calcification and thickening of the aortic valve leaflets, resulting in a narrowed orifice and increased pressure gradient across the valve. AS typically progresses from a subclinical phase known as aortic sclerosis, where valve calcification occurs without a transvalvular gradient, to a more advanced stage marked by a triad of symptoms: heart failure, syncope, and angina. Echocardiography plays a crucial role in the diagnosis and evaluation of AS, serving as the primary non-invasive imaging modality. However, to minimize misdiagnoses, it is crucial to adhere to a standardized protocol for acquiring echocardiographic images. This is because, despite continuous advances in echocardiographic technology, diagnostic errors still occur during the evaluation of AS, particularly in classifying its severity and hemodynamic characteristics. This review focuses on providing guidance for the imager during the echocardiographic assessment of AS. Firstly, the review will report on how the echo machine should be set to improve image quality and reduce noise and artifacts. Thereafter, the review will report specific emphasis on accurate measurements of left ventricular outflow tract diameter, aortic valve morphology and movement, as well as aortic and left ventricular outflow tract velocities. By considering these key factors, clinicians can ensure consistency and accuracy in the evaluation of AS using echocardiography.
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Affiliation(s)
- Grazia Canciello
- Department of Advanced Biomedical Sciences, Federico II University, 80131 Naples, Italy
| | - Shabnam Pate
- Division of Cardiology, Baylor Scott & White Research Institute, Plano, TX 75204, USA
| | - Anna Sannino
- Department of Advanced Biomedical Sciences, Federico II University, 80131 Naples, Italy
- Division of Cardiology, Baylor Scott & White Research Institute, Plano, TX 75204, USA
| | - Felice Borrelli
- Department of Advanced Biomedical Sciences, Federico II University, 80131 Naples, Italy
| | - Gaetano Todde
- Department of Advanced Biomedical Sciences, Federico II University, 80131 Naples, Italy
| | - Paul Grayburn
- Division of Cardiology, Baylor Scott & White Research Institute, Plano, TX 75204, USA
| | - Maria-Angela Losi
- Department of Advanced Biomedical Sciences, Federico II University, 80131 Naples, Italy
| | - Giovanni Esposito
- Department of Advanced Biomedical Sciences, Federico II University, 80131 Naples, Italy
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7
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Gaspardone C, Romagnolo D, Baldetti L, Fasolino A, Peveri B, Calvo F, Gramegna M, Pazzanese V, Sacchi S, Beneduce A, Falasconi G, Fiore G, Rampa L, Ajello S, Scandroglio AM. A simplified echocardiographic formula to estimate cardiac index in the intensive care unit. Int J Cardiol 2023; 372:76-79. [PMID: 36496041 DOI: 10.1016/j.ijcard.2022.12.010] [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: 11/29/2022] [Accepted: 12/02/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM Measurement of cardiac index (CI) is crucial in the hemodynamic assessment of critically ill patients in the intensive care unit (ICU). The most reliable trans-thoracic echocardiography (TTE) technique for CI estimation is the left ventricular outflow tract (LVOT) Doppler method that requires, among other parameters, the LVOT cross-sectional area (CSA) measurement. However, inherent and practical disadvantages, mostly related to the ICU setting, hamper LVOT-CSA assessment. In this study, we aimed to validate a simplified formula, leveraging on LVOT-velocity time integral (VTI) and heart rate (HR) only, for non-invasive estimation of CI in ICU patients. METHODS AND RESULTS We prospectively enrolled 50 consecutive patients admitted to our ICU requiring pulmonary artery catheterization (PAC) over a one-year period. For each patient we measured the CI by PAC (CIPAC) and TTE. The latter was obtained both with the "traditional formula" (traditional CITTE), requiring LVOT-CSA assessment, and our new "simplified formula" (simplified CITTE). The correlation between the simplified CITTE and CIPAC was strong (r = 0.81) and resulted significantly greater than the traditional CITTE and CIPAC correlation (r = 0.70; p < 0.05 for Pearson r coefficients comparison). Both TTE-based CI showed an acceptable agreement (+0.19 ± 0.48 L/min/m2 for simplified CITTE and - 0.18 ± 0.58 L/min/m2 for traditional CITTE) with the reference CIPAC. CONCLUSION In this study, we validated a practical approach, leveraging on TTE LVOT-VTI and HR only, for non-invasive estimation of CI in ICU patients.
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Affiliation(s)
- Carlo Gaspardone
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Davide Romagnolo
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Luca Baldetti
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | | | - Beatrice Peveri
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Calvo
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Mario Gramegna
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Vittorio Pazzanese
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Stefania Sacchi
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Beneduce
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giulio Falasconi
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giorgio Fiore
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Lorenzo Rampa
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Silvia Ajello
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
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8
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Kenny JES. A theoretical foundation for relating the velocity time integrals of the left ventricular outflow tract and common carotid artery. J Clin Monit Comput 2023; 37:937-939. [PMID: 36625983 PMCID: PMC10175385 DOI: 10.1007/s10877-022-00969-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Accepted: 12/28/2022] [Indexed: 01/11/2023]
Affiliation(s)
- Jon-Emile S Kenny
- Health Sciences North Research Institute, 56 Walford Rd, Sudbury, ON, P3E 2H2, Canada. .,Flosonics Medical, Toronto, ON, Canada.
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9
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Higginson C, Willner N, Petruescu L, Beauchesne L, Coutinho T, Boodhwani M, Chan KL, Burwash IG, Messika-Zeitoun D. Prevalence and Phenotypic Characterization of Patients with Bicuspid Aortic Valve and Large Aortic Annular Diameter. J Am Soc Echocardiogr 2022; 36:436-437. [PMID: 36574931 DOI: 10.1016/j.echo.2022.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 12/22/2022] [Accepted: 12/22/2022] [Indexed: 12/26/2022]
Affiliation(s)
- Casey Higginson
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Nadav Willner
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Laura Petruescu
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Luc Beauchesne
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Thais Coutinho
- Division of Cardiology and Division of Cardiac Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Munir Boodhwani
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Kwan L Chan
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Ian G Burwash
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - David Messika-Zeitoun
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
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10
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Cramariuc D, Bahlmann E, Gerdts E. Grading of Aortic Stenosis: Is it More Complicated in Women? Eur Cardiol 2022; 17:e21. [PMID: 36643071 PMCID: PMC9820123 DOI: 10.15420/ecr.2022.13] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 06/29/2022] [Indexed: 12/14/2022] Open
Abstract
Aortic stenosis (AS) is the most common valvular heart disease and the main indication for valvular replacement in older women. Correct AS grading is mandatory for an adequate selection of patients for both surgical and transcatheter aortic valve replacement. Women and men have different AS severity grades at the same level of aortic valve calcification. Moreover, besides having smaller cardiac volumes, left ventricular outflow tract and aortic size, women have a specific pattern of left ventricular structural and functional remodelling in response to the AS-related chronic pressure overload. Here, the sex-specific cardiac changes in AS that make AS grading more challenging in women, with consequences for the management and outcome of this group of patients, are reviewed.
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Affiliation(s)
- Dana Cramariuc
- Department of Heart Disease, Haukeland University HospitalBergen, Norway,Department of Clinical Science, University of BergenBergen, Norway
| | - Edda Bahlmann
- Department of Cardiology, Asklepios Kliniken St. GeorgHamburg, Germany
| | - Eva Gerdts
- Department of Clinical Science, University of BergenBergen, Norway
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11
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Mercadal J, Borrat X, Hernández A, Denault A, Beaubien-Souligny W, González-Delgado D, Vives M, Carmona P, Nagore D, Sánchez E, Serna M, Cuesta P, Bengoetxea U, Miralles F. A simple algorithm for differential diagnosis in hemodynamic shock based on left ventricle outflow tract velocity–time integral measurement: a case series. Ultrasound J 2022; 14:36. [PMID: 36001157 PMCID: PMC9402822 DOI: 10.1186/s13089-022-00286-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 08/03/2022] [Indexed: 11/29/2022] Open
Abstract
Echocardiography has gained wide acceptance among intensive care physicians during the last 15 years. The lack of accredited formation, the long learning curve required and the excessive structural orientation of the present algorithms to evaluate hemodynamically unstable patients hampers its daily use in the intensive care unit. The aim of this article is to show 4 cases where the use of our simple algorithm based on VTI, was crucial. Subsequently, to explain the benefit of using the proposed algorithm with a more functional perspective, as a means for clinical decision-making. A simple algorithm based on left ventricle outflow tract velocity–time integral measurement for a functional hemodynamic monitoring on patients suffering hemodynamic shock or instability is proposed by Spanish Critical Care Ultrasound Network Group. This algorithm considers perfusion and congestion variables. Its simplicity might be useful for guiding physicians in their daily decision-making managing critically ill patients in hemodynamic shock.
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12
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Cox EGM, Koeze J, van der Horst ICC, Wiersema R. Calculated left ventricular outflow tract diameter for critically ill patients. J Intensive Care 2022; 10:31. [PMID: 35729661 PMCID: PMC9210692 DOI: 10.1186/s40560-022-00623-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 06/13/2022] [Indexed: 11/21/2022] Open
Abstract
A fast and reliable left ventricular outflow diameter (LVOTd) estimation may aid in quickly estimating cardiac output. However, obtaining a correct LVOTd can be difficult in intensive care patients, potentially leading to errors and a cardiac output deviation. In this study, the measured LVOTd was compared with the expected LVOTd when estimated using an existing formula in 1177 critically ill patients. We show that estimated LVOTd based on baseline data can aid when obtaining LVOTd is difficult or impossible and simplified estimation based on a formula may allow for more reliable and accessible measurement of cardiac output.
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Affiliation(s)
- Eline G M Cox
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | - Jacqueline Koeze
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Iwan C C van der Horst
- Department of Intensive Care Medicine, Maastricht University, Maastricht University Medical Centre+ Maastricht, Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Renske Wiersema
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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13
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Vulesevic B, Kubota N, Burwash IG, Cimadevilla C, Tubiana S, Duval X, Nguyen V, Arangalage D, Chan KL, Mulvihill EE, Beauchesne L, Messika-Zeitoun D. Size-adjusted aortic valve area: refining the definition of severe aortic stenosis. Eur Heart J Cardiovasc Imaging 2021; 22:1142-1148. [PMID: 33247914 PMCID: PMC8451205 DOI: 10.1093/ehjci/jeaa295] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 10/08/2020] [Indexed: 11/14/2022] Open
Abstract
AIMS Severe aortic valve stenosis (AS) is defined by an aortic valve area (AVA) <1 cm2 or an AVA indexed to body surface area (BSA) <0.6 cm/m2, despite little evidence supporting the latter approach and important intrinsic limitations of BSA indexation. We hypothesized that AVA indexed to height (H) might be more applicable to a wide range of populations and body morphologies and might provide a better predictive accuracy. METHODS AND RESULTS In 1298 patients with degenerative AS and preserved ejection fraction from three different countries and continents (derivation cohort), we aimed to establish an AVA/H threshold that would be equivalent to 1.0 cm2 for defining severe AS. In a distinct prospective validation cohort of 395 patients, we compared the predictive accuracy of AVA/BSA and AVA/H. Correlations between AVA and AVA/BSA or AVA/H were excellent (all R2 > 0.79) but greater with AVA/H. Regressions lines were markedly different in obese and non-obese patients with AVA/BSA (P < 0.0001) but almost identical with AVA/H (P = 0.16). AVA/BSA values that corresponded to an AVA of 1.0 cm2 were markedly different in obese and non-obese patients (0.48 and 0.59 cm2/m2) but not with AVA/H (0.61 cm2/m for both). Agreement for the diagnosis of severe AS (AVA < 1 cm2) was significantly higher with AVA/H than with AVA/BSA (P < 0.05). Similar results were observed across the three countries. An AVA/H cut-off value of 0.6 cm2/m [HR = 8.2(5.6-12.1)] provided the best predictive value for the occurrence of AS-related events [absolute AVA of 1 cm2: HR = 7.3(5.0-10.7); AVA/BSA of 0.6 cm2/m2 HR = 6.7(4.4-10.0)]. CONCLUSION In a large multinational/multiracial cohort, AVA/H was better correlated with AVA than AVA/BSA and a cut-off value of 0.6 cm2/m provided a better diagnostic and prognostic value than 0.6 cm2/m2. Our results suggest that severe AS should be defined as an AVA < 1 cm2 or an AVA/H < 0.6 cm2/m rather than a BSA-indexed value of 0.6 cm2/m2.
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Affiliation(s)
- Branka Vulesevic
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, ON K1Y 4W7, Canada
| | - Naozumi Kubota
- Department of Cardiology, Juntendo University, Tokyo, Japan
| | - Ian G Burwash
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, ON K1Y 4W7, Canada
| | - Claire Cimadevilla
- Department of Cardiology and Cardiac Surgery, Assistance Publique – Hôpitaux de Paris, 75018 Paris, France
| | - Sarah Tubiana
- Centre d’Investigations Cliniques, Assistance Publique – Hôpitaux de Paris, 75018 Paris, France
| | - Xavier Duval
- Centre de Ressources Biologiques, Assistance Publique – Hôpitaux de Paris, 75018 Paris, France
| | - Virginia Nguyen
- Department of Cardiology and Cardiac Surgery, Assistance Publique – Hôpitaux de Paris, 75018 Paris, France
| | - Dimitri Arangalage
- Department of Cardiology and Cardiac Surgery, Assistance Publique – Hôpitaux de Paris, 75018 Paris, France
| | - Kwan L Chan
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, ON K1Y 4W7, Canada
| | - Erin E Mulvihill
- Department of Biochemistry, Microbiology and Immunology, University of Ottawa, Ottawa, ON K1Y 4W7, Canada
| | - Luc Beauchesne
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, ON K1Y 4W7, Canada
| | - David Messika-Zeitoun
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, ON K1Y 4W7, Canada
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14
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Santangelo G, Rossi A, Toriello F, Badano LP, Messika Zeitoun D, Faggiano P. Diagnosis and Management of Aortic Valve Stenosis: The Role of Non-Invasive Imaging. J Clin Med 2021; 10:jcm10163745. [PMID: 34442039 PMCID: PMC8396987 DOI: 10.3390/jcm10163745] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 08/16/2021] [Accepted: 08/20/2021] [Indexed: 12/13/2022] Open
Abstract
Aortic stenosis is the most common heart valve disease necessitating surgical or percutaneous intervention. Imaging has a central role for the initial diagnostic work-up, the follow-up and the selection of the optimal timing and type of intervention. Referral for aortic valve replacement is currently driven by the severity and by the presence of aortic stenosis-related symptoms or signs of left ventricular systolic dysfunction. This review aims to provide an update of the imaging techniques and seeks to highlight a practical approach to help clinical decision making.
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Affiliation(s)
- Gloria Santangelo
- San Paolo Hospital, Division of Cardiology, Department of Health Sciences, University of Milan, 20142 Milan, Italy;
| | - Andrea Rossi
- Division of Cardiology, Azienda Ospedaliero Universitaria Verona, 37126 Verona, Italy;
| | - Filippo Toriello
- Fondazione IRCCS Ca’ Granda-Ospedale Maggiore Policlinico, Division of Cardiology, Department of Internal Medicine, University of Milan, 20122 Milan, Italy;
| | - Luigi Paolo Badano
- Department of Medicine and Surgery, University of Milano Bicocca, 20126 Milan, Italy;
- Department of Cardiac, Metabolic and Neural Sciences, Istituto Auxologico Italiano, IRCCS, 20149 Milan, Italy
| | - David Messika Zeitoun
- Department of Cardiology, University of Ottawa Heart Institute, Ottawa, ON K1Y 4W7, Canada;
| | - Pompilio Faggiano
- Fondazione Poliambulanza, Cardiovascular Disease Unit, Via Leonida Bissolati, 57, 25100 Brescia, Italy
- Correspondence:
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15
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Hahn RT, Douglas PS, Jaber WA, Leipsic J, Kapadia S, Thourani VH, Makkar R, Kodali S, Clavel MA, Khalique OK, Weissman NJ, Blanke P, Chen Y, Smith CR, Mack MJ, Leon MB, Pibarot P. Doppler Velocity Index Outcomes Following Surgical or Transcatheter Aortic Valve Replacement in the PARTNER Trials. JACC Cardiovasc Interv 2021; 14:1594-1606. [PMID: 34217631 DOI: 10.1016/j.jcin.2021.04.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 04/02/2021] [Accepted: 04/06/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVES The aim of this study was to assess the association between Doppler velocity index (DVI) and 2-year outcomes for balloon-expandable SAPIEN 3 transcatheter aortic valve replacement (TAVR) and for surgical aortic valve replacement (SAVR). BACKGROUND DVI >0.35 is normal for a prosthetic valve, but recent studies suggest that DVI <0.50 is associated with poor outcomes following TAVR. METHODS Patients with severe aortic stenosis enrolled in the PARTNER (Placement of Aortic Transcatheter Valve) 2 (intermediate surgical risk) or PARTNER 3 (low surgical risk) trial undergoing TAVR (n = 1,450) or SAVR (n = 1,303) were included. Patients were divided into 3 DVI groups on the basis of core laboratory-assessed discharge or 30-day echocardiograms: DVILOW (≤0.35), DVIINTERMEDIATE (>0.35 to ≤0.50), and DVIHIGH (>0.50). Two-year outcomes were assessed. RESULTS Following TAVR, there were no differences among the 3 DVI groups in composite outcomes of death, stroke, or rehospitalization or in any individual components of 2-year outcomes (P > 0.70 for all). Following SAVR, there was no difference among DVI groups in the composite outcome (P = 0.27), but there was a significant association with rehospitalization (P = 0.02). Restricted cubic-spline analysis for combined outcomes showed an increased risk with post-SAVR DVI ≤0.35 but no relationship post-TAVR. DVI ≤0.35 was associated with increased 2-year composite outcome for SAVR (HR: 1.81; 95% CI: 1.29-2.54; P < 0.001), with no adverse outcomes for TAVR (P = 0.86). CONCLUSIONS In intermediate- and low-risk cohorts of the PARTNER trials, DVI ≤0.35 predicted worse 2-year outcomes following SAVR, driven primarily by rehospitalization, with no adverse outcomes associated with DVI following TAVR with the balloon-expandable SAPIEN 3 valve.
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Affiliation(s)
- Rebecca T Hahn
- Columbia University Medical Center/NewYork-Presbyterian Hospital, New York, New York, USA.
| | - Pamela S Douglas
- Duke University Medical Center and Duke Clinical Research Institute, Durham, North Carolina, USA
| | | | - Jonathon Leipsic
- University of British Columbia and St. Paul's Hospital, Vancouver, British Columbia, Canada
| | | | | | - Raj Makkar
- Cedars Sinai, Los Angeles, California, USA
| | - Susheel Kodali
- Columbia University Medical Center/NewYork-Presbyterian Hospital, New York, New York, USA
| | | | - Omar K Khalique
- Columbia University Medical Center/NewYork-Presbyterian Hospital, New York, New York, USA
| | | | - Philipp Blanke
- University of British Columbia and St. Paul's Hospital, Vancouver, British Columbia, Canada
| | - Yanjun Chen
- Edwards Lifesciences, Irvine, California, USA
| | - Craig R Smith
- Columbia University Medical Center/NewYork-Presbyterian Hospital, New York, New York, USA
| | | | - Martin B Leon
- Columbia University Medical Center/NewYork-Presbyterian Hospital, New York, New York, USA
| | - Philippe Pibarot
- Department of Medicine, Laval University, Quebec City, Quebec, Canada
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16
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Pestelli G, Fiorencis A, Pergola V, Luisi GA, Smarrazzo V, Trevisan F, Mele D. Indirect ultrasound evaluation of left ventricular outflow tract diameter implications for heart failure and aortic stenosis severity assessment. Echocardiography 2021; 38:1104-1114. [PMID: 34037989 DOI: 10.1111/echo.15123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 04/26/2021] [Accepted: 05/07/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Whereas dependency of left ventricular outflow tract diameter (LVOTD) from body surface area (BSA) has been established and a BSA-based LVOTD formula has been derived, the relationship between LVOTD and aortic root and LV dimensions has never been explored. This may have implications for evaluation of LV output in heart failure (HF) and aortic stenosis (AS) severity. METHODS A cohort of 540 HF patients who underwent transthoracic echocardiography was divided in a derivation and validation subgroup. In the derivation subgroup (N = 340), independent determinants of LVOTD were analyzed to derive a regression equation, which was used for predicting LVOTD in the validation subgroup (N = 200) and compared with the BSA-derived formula. RESULTS LVOTD determinants in the derivation subgroup were sinuses of Valsalva diameter (SVD, beta = 0.392, P < .001), BSA (beta = 0.229, P < .001), LV end-diastolic diameter (LVEDD, beta = 0.145, P = .001), and height (beta = 0.125, P = .037). The regression equation for predicting LVOTD with the aforementioned variables (LVOTD = 6.209 + [0.201 × SVD] + [1.802 × BSA] + [0.03 × LVEDD] + [0.025 × Height]) did not differ from (P = .937) and was highly correlated with measured LVOTD (R = 0.739, P < .001) in the validation group. Repeated analysis with LV end-diastolic volume instead of LVEDD and/or accounting for gender showed similar results, whereas BSA-derived LVOTD values were different from measured LVOTD (P < .001). CONCLUSION Aortic root and LV dimensions affect LVOTD independently from anthropometric data and are included in a new comprehensive equation for predicting LVOTD. This should improve evaluation of LV output in HF and severity of AS when direct LVOTD measurement is difficult or impossible.
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Affiliation(s)
- Gabriele Pestelli
- Cardiology Unit, Morgagni-Pierantoni Hospital, Forlì, Italy.,Cardiovascular Research Unit, Fondazione Sacco, Forlì, Italy
| | | | - Valeria Pergola
- Cardiology Unit, University Hospital of Padova, Padova, Italy
| | | | | | | | - Donato Mele
- Cardiology Unit, University Hospital of Ferrara, Ferrara, Italy
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17
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Left ventricular output indices in hospitalized heart failure: when "simpler" may not mean "better". Int J Cardiovasc Imaging 2020; 37:59-68. [PMID: 32734497 DOI: 10.1007/s10554-020-01946-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 07/20/2020] [Indexed: 10/23/2022]
Abstract
Assessment of left ventricular (LV) output in hospitalized patients with heart failure (HF) is important to determine prognosis. Although echocardiographic LV ejection fraction (EF) is generally used to this purpose, its prognostic value is limited. In this investigation LV-EF was compared with other echocardiographic per-beat measures of LV output, including non-indexed stroke volume (SV), SV index (SVI), stroke distance (SD), ejection time (ET), and flow rate (FR), to determine the best predictor of all-cause mortality in patients hospitalized with HF. A final cohort of 350 consecutive patients hospitalized with HF who underwent echocardiography during hospitalization was studied. At a median follow-up of 2.7 years, 163 patients died. Non-survivors at follow-up had lower SD, SVI and SV, but not ET, FR and LV-EF than survivors. At multivariate analysis, only age, systolic blood pressure, chronic kidney disease, chronic obstructive pulmonary disease, use of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers and SVI remained significantly associated with outcome [HR for SVI 1.13 (1.04-1.22), P = 0.003]. In particular, for each 5 ml/m2 decrease in SVI, a 13% increase in risk of mortality for any cause was observed. SVI is a powerful prognosticator in HF patients, better than other per-beat measures, which may be simpler but partial or incomplete descriptors of LV output. SVI, therefore, should be considered for the routine echocardiographic evaluation of patients hospitalized with HF to predict prognosis.
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18
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Moderate Aortic Stenosis and Heart Failure With Reduced Ejection Fraction: Can Imaging Guide Us to Therapy? JACC Cardiovasc Imaging 2020; 12:172-184. [PMID: 30621989 DOI: 10.1016/j.jcmg.2018.10.021] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 10/17/2018] [Accepted: 10/18/2018] [Indexed: 11/21/2022]
Abstract
Clinical management of patients with only moderate aortic stenosis (AS) but symptoms of heart failure with a reduced left ventricular ejection fraction (HFrEF) is challenging. Current guidelines recommend clinical surveillance with multimodality imaging; aortic valve replacement (AVR) is deferred until the stenosis becomes severe. Given the known benefits of afterload reduction in management of patients with HFrEF, it has been hypothesized that AVR may be beneficial in patients with only moderate AS who present with HFrEF. In this article, we first review the current approach for management of patients with moderate AS and HFrEF based on close clinical and imaging surveillance with AVR delayed until AS is severe. We then discuss the case for transcatheter AVR (TAVR) earlier in the disease course, when AS is moderate, based on stress echocardiographic data. We conclude with a detailed summary of the TAVR UNLOAD (Transcatheter Aortic Valve Replacement to UNload the Left Ventricle in Patients With ADvanced Heart Failure) trial, in which patients with moderate AS and HFrEF are randomized to guideline-directed heart failure therapy alone versus guideline-directed heart failure therapy plus TAVR.
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19
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Echocardiographic discrepancies in severity grading of aortic valve stenosis with left ventricular outflow tract (LVOT) cut-off values in an Asian population. Int J Cardiovasc Imaging 2020; 36:615-621. [DOI: 10.1007/s10554-019-01755-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 12/19/2019] [Indexed: 10/25/2022]
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20
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Low Gradient Aortic Stenosis: Role of Echocardiography. CURRENT CARDIOVASCULAR IMAGING REPORTS 2019. [DOI: 10.1007/s12410-019-9518-0] [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]
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21
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Hagendorff A, Knebel F, Helfen A, Knierim J, Sinning C, Stöbe S, Fehske W, Ewen S. Expert consensus document on the assessment of the severity of aortic valve stenosis by echocardiography to provide diagnostic conclusiveness by standardized verifiable documentation. Clin Res Cardiol 2019; 109:271-288. [PMID: 31482241 DOI: 10.1007/s00392-019-01539-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Accepted: 08/14/2019] [Indexed: 02/06/2023]
Abstract
According to recent recommendations on echocardiographic assessment of aortic valve stenosis direct measurement of transvalvular peak jet velocity, calculation of transvalvular mean gradient from the velocities using the Bernoulli equation and calculation of the effective aortic valve area by continuity equation are the appropriate primary key instruments for grading severity of aortic valve stenosis. It is obvious that no gold standard can be declared for grading the severity of aortic stenosis. Thus, conclusions of the exclusive evaluation of aortic stenosis by Doppler echocardiography seem to be questionable due to the susceptibility to errors caused by methodological limitations, mathematical simplifications and inappropriate documentation. The present paper will address practical issues of echocardiographic documentation to satisfy the needs to analyze different scenarios of aortic stenosis due to various flow conditions and pressure gradients. Transesophageal and multidimensional echocardiography should be implemented for reliable measurement of geometric aortic valve area and of cardiac dimensions at an early stage of the diagnostic procedure to avoid misinterpretation due to inconsistent results.
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Affiliation(s)
- Andreas Hagendorff
- Department of Cardiology, University of Leipzig, Klinik und Poliklinik für Kardiologie, Liebigstraße 20, 04103, Leipzig, Germany.
| | - Fabian Knebel
- Department of Cardiology and Angiology, Universitätsmedizin Berlin, Campus Charité Mitte, Charitéplatz 1, 10117, Berlin, Germany
| | - Andreas Helfen
- Department of Cardiology, St. Marien Hospital Lünen, Altstadtstraße 23, 44534, Lünen, Germany
| | - Jan Knierim
- Department of Cardiovascular Surgery, University of Berlin, Deutsches Herzzentrum Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Christoph Sinning
- Department of Cardiology, University of Hamburg-Eppendorf, Martinistraße 52, 20251, Hamburg, Germany
| | - Stephan Stöbe
- Department of Cardiology, University of Leipzig, Liebigstraße 20, 04103, Leipzig, Germany
| | - Wolfgang Fehske
- Department of Cardiology St, Vinzenz-Hospital Köln, Merheimer Straße 221, 50733, Köln, Germany
| | - Sebastian Ewen
- Klinik für Innere Medizin III, Kardiologie, Angiologie Und Internistische Intensivmedizin, Universitätsklinikum Des Saarlandes, Kirrberger Str., 66421, Homburg, Germany
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22
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Contemporary Imaging of Aortic Stenosis. Heart Lung Circ 2019; 28:1310-1319. [PMID: 31266725 DOI: 10.1016/j.hlc.2019.05.177] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 04/29/2019] [Accepted: 05/17/2019] [Indexed: 12/26/2022]
Abstract
Degenerative or fibrocalcific aortic stenosis (AS) is now the most common native valvular heart disease assessed and managed by cardiologists in developed countries. Transthoracic echocardiography remains the quintessential imaging modality for the non-invasive characterisation of AS due to its widespread availability, superior assessment of flow haemodynamics, and a wealth of prognostic data accumulated over decades of clinical utility and research applications. With expanding technologies and increasing availability of treatment options such as transcatheter aortic valve replacements, in addition to conventional surgical approaches, accurate and precise assessment of AS severity is critical to guide decisions for and timing of interventions. Despite clear guideline echocardiographic parameters demarcating severe AS, discrepancies between transvalvular velocities, gradients, and calculated valve areas are commonly encountered in clinical practice. This often results in diagnostically challenging cases with significant implications. Greater emphasis must be placed on the quality of performance of basic two dimensional (2D) and Doppler measurements (attention to detail ensuring accuracy and precision), incorporating ancillary haemodynamic surrogates, understanding study- or patient-specific confounders, and recognising the role and limitations of stress echocardiography in the subgroups of low-flow low-gradient AS. A multiparametric approach, along with the incorporation of multimodality imaging (cardiac computed tomography or magnetic resonance imaging) in certain scenarios, is now mandatory to avoid incorrect misclassification of severe AS. This is essential to ensure appropriate selection of patients who would most benefit from interventions on the aortic valve to relieve the afterload mismatch resulting from truly severe valvular stenosis.
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23
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Lack of correlation between left ventricular outflow tract velocity time integral and stroke volume index in mechanically ventilated patients. Med Intensiva 2019; 43:73-78. [DOI: 10.1016/j.medin.2017.11.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 11/16/2017] [Accepted: 11/26/2017] [Indexed: 01/28/2023]
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24
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Low-Gradient Aortic Stenosis: Solving the Conundrum Using Multi-Modality Imaging. Prog Cardiovasc Dis 2018; 61:416-422. [DOI: 10.1016/j.pcad.2018.11.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 11/12/2018] [Indexed: 10/27/2022]
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25
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Díaz A, Zócalo Y, Cabrera-Fischer E, Bia D. Reference intervals and percentile curve for left ventricular outflow tract (LVOT), velocity time integral (VTI), and LVOT-VTI-derived hemodynamic parameters in healthy children and adolescents: Analysis of echocardiographic methods association and agreement. Echocardiography 2018; 35:2014-2034. [PMID: 30376592 DOI: 10.1111/echo.14176] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 07/20/2018] [Accepted: 09/27/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Echocardiographic reference intervals (RIs) for left ventricular outflow tract (LVOT) and velocity time integral (VTI) are scarce in pediatrics. AIMS (a) to generate RIs and percentiles for LVOT, VTI, and hemodynamic variables in healthy children and adolescents from Argentina; (b) to analyze the equivalence between stroke volume (SV), cardiac output (CO), and cardiac index (CI) obtained from two-dimensional echocardiography (2D) and LVOT-VTI analysis with pulsed wave Doppler (PWD); and (c) to analyze the association between subjects' characteristics and VTI and LVOT-VTI-derived parameters. METHODS Two-dimensional and PWD studies were done in 385 subjects (5-24 years). Mean and standard deviation age-related and body surface area (BSA)-related equations were obtained for VTI and LVOT-VTI-derived parameters (parametric regression methods based on fractional polynomials). BSA- and age-specific percentiles were determined. RESULTS Pulsed wave Doppler- and 2D-derived parameters were positively correlated. However, PWD values were always lower than those from 2D. Specific RIs for PWD and 2D data were necessary. Covariance analysis showed that sex-specific RIs were required for LVOT, but not for VTI, VTI-derived CO and CI. Age-related RIs were obtained for LVOT, LVOT-VTI, and VTI-derived CO and CI. BSA-related RIs for VTI-derived CO and CI were obtained. CONCLUSIONS Stroke volume, CO, and CI data from 2D and PWD are not equivalent. An accurate analysis of LVOT-VTI-derived parameters requires considering age and BSA. In this study, age- and BSA-related RIs and percentiles for LVOT, VTI, and hemodynamic parameters in healthy children and adolescents were determined, discriminating data according to the methodological approach (2D or PWD).
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Affiliation(s)
- Alejandro Díaz
- Instituto de Investigación en Ciencias de la Salud, UNICEN-CONICET, Tandil, Argentina
| | - Yanina Zócalo
- Physiology Department, School of Medicine, Centro Universitario de Investigación, Innovación y Diagnóstico Arterial (CUiiDARTE), Republic University, Montevideo, Uruguay
| | - Edmundo Cabrera-Fischer
- Instituto de Medicina Traslacional, Trasplante y Bioingeniería (IMTTyB), Universidad Favaloro, CONICET, Buenos Aires, Argentina
| | - Daniel Bia
- Physiology Department, School of Medicine, Centro Universitario de Investigación, Innovación y Diagnóstico Arterial (CUiiDARTE), Republic University, Montevideo, Uruguay
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Dini FL, Bajraktari G, Zara C, Mumoli N, Rosa GM. Optimizing Management of Heart Failure by Using Echo and Natriuretic Peptides in the Outpatient Unit. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1067:145-159. [PMID: 29374825 DOI: 10.1007/5584_2017_137] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Chronic heart failure (HF) is an important public health problem and is associated with high morbidity, high mortality, and considerable healthcare costs. More than 90% of hospitalizations due to worsening HF result from elevations of left ventricular (LV) filling pressures and fluid overload, which are often accompanied by the increased synthesis and secretion of natriuretic peptides (NPs). Furthermore, persistently abnormal LV filling pressures and a rise in NP circulating levels are well known indicators of poor prognosis. Frequent office visits with the resulting evaluation and management are most often needed. The growing pressure from hospital readmissions in HF patients is shifting the focus of interest from traditionally symptom-guided care to a more specific patient-centered follow-up care based on clinical findings, BNP and echo. Recent studies supported the value of serial NP measurements and Doppler echocardiographic biomarkers of elevated LV filling pressures as tools to scrutinize patients with impending clinically overt HF. Therefore, combination of echo and pulsed-wave blood-flow and tissue Doppler with NPs appears valuable in guiding ambulatory HF management, since they are potentially useful to distinguish stable patients from those at high risk of decompensation.
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Affiliation(s)
- Frank Lloyd Dini
- Cardiovascular and Thoracic Department, University of Pisa, Pisa, Italy. .,Unità Operativa Malattie Cardiovascolari 1, Dipartimento Cardio, Toracico e Vascolare, Azienda Ospedaliera-Universitaria Pisana, Pisa, Italy.
| | - Gani Bajraktari
- Department of Public Health and Clinical Medicine, Umeå University and Heart Centre, Umeå, Sweden.,Clinic of Cardiology, University Clinical Centre of Kosova, Prishtina, Kosovo
| | - Cornelia Zara
- Cardiovascular and Thoracic Department, University of Pisa, Pisa, Italy
| | - Nicola Mumoli
- Department of Internal Medicine, Livorno Hospital, Livorno, Italy
| | - Gian Marco Rosa
- Department of Internal Medicine and Medical Specialities, University of Genoa, Genoa, Italy
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Mǎrgulescu AD. Assessment of aortic valve disease - a clinician oriented review. World J Cardiol 2017; 9:481-495. [PMID: 28706584 PMCID: PMC5491466 DOI: 10.4330/wjc.v9.i6.481] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Revised: 03/11/2017] [Accepted: 05/19/2017] [Indexed: 02/06/2023] Open
Abstract
Aortic valve disease [aortic stenosis (AS) and aortic regurgitation (AR)] represents an important global health problem; when severe, aortic valve disease carries poor prognosis. For AS, aortic valve replacement, either surgical or interventional, may provide definite treatment in carefully selected patients. For AR, valve surgery (either replacement or - in selected cases - aortic valve repair) remains the gold standard of care. To properly identify those patients who are candidates for surgery, the clinician has to carefully assess the severity of valve disease with an understanding of the potential pitfalls involved in these assessments. This review focuses on the practical issues concerning the evaluation of patients with AS and AR from a general cardiologist’s perspective. The most important issues regarding the documentation of the severity of AS and AR are summarized. More specific issues, such as the role of stress echocardiography, other imaging techniques and details regarding the treatment options (medical, surgical, or interventional), are mentioned briefly.
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28
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Cardiac Imaging for Assessing Low-Gradient Severe Aortic Stenosis. JACC Cardiovasc Imaging 2017; 10:185-202. [DOI: 10.1016/j.jcmg.2017.01.002] [Citation(s) in RCA: 116] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 12/26/2016] [Accepted: 01/05/2017] [Indexed: 12/13/2022]
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Maeder MT, Karapanagiotidis S, Dewar EM, Kaye DM. Accuracy of Echocardiographic Cardiac Index Assessment in Subjects with Preserved Left Ventricular Ejection Fraction. Echocardiography 2015; 32:1628-38. [PMID: 25728504 DOI: 10.1111/echo.12928] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION We aimed to determine the accuracy of the echocardiographic assessment of cardiac index (CI) in subjects with preserved left ventricular ejection fraction (LVEF). METHODS Thirty-three subjects with LVEF >50%, normal sinus rhythm, and a broad spectrum of hemodynamic profiles underwent echocardiography immediately followed by right heart catheterization. As gold standards, CI was assessed using thermodilution [CI (TD)] and the Fick method [CI (F)]. Echocardiographic CI was assessed by four methods: from the left ventricular outflow tract (LVOT) velocity time integral and the LVOT diameter as measured [CI (LVOTm)] as well as estimated from body surface area [CI (LVOTe)], and from stroke volume indices assessed using the biplane [CI (BP)] and monoplane [CI (MP)] methods. RESULTS The mean CI (TD), CI (F), CI (LVOTm), CI (LVOTe), CI (BP), and CI (MP) were 3.0 ± 0.9, 3.1 ± 0.7, 2.8 ± 0.6, 3.3 ± 0.6, 2.0 ± 0.6, and 2.2 ± 0.7 L/min/m(2) . There were modest correlations between CI (TD) and CI (F) and all four noninvasive measures of CI with r(2) values ranging from 0.09 to 0.30. CI (LVOTm) underestimated CI (TD) and CI (F) by 0.3 and 0.3 L/min/m(2) , CI (LVOTe) overestimated CI (TD) and CI (F) by 0.3 and 0.2 L/min/m(2) , and CI (BP) and CI (MP) underestimated CI (TD) and CI (F) by 1.1 and 1.1 L/min/m(2) and 0.9 and 0.9 L/min/m(2) , respectively, with large limits of agreement for all comparisons. CONCLUSIONS In subjects with nondilated left ventricles with preserved LVEF, flow- or volume-based measures of CI by 2D echocardiography may not accurately reflect CI (TD) and CI (F). Further larger studies are required to verify our findings and to evaluate the accuracy of contrast and 3D echocardiography in this setting.
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Affiliation(s)
- Micha T Maeder
- Heart Failure Research Group, Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia.,Heart Center, Alfred Hospital, Melbourne, Victoria, Australia.,Cardiology Division, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Sofie Karapanagiotidis
- Heart Failure Research Group, Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia.,Heart Center, Alfred Hospital, Melbourne, Victoria, Australia
| | - Elizabeth M Dewar
- Heart Failure Research Group, Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia.,Heart Center, Alfred Hospital, Melbourne, Victoria, Australia
| | - David M Kaye
- Heart Failure Research Group, Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia.,Heart Center, Alfred Hospital, Melbourne, Victoria, Australia
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Nguyen V, Cimadevilla C, Estellat C, Codogno I, Huart V, Benessiano J, Duval X, Pibarot P, Clavel MA, Enriquez-Sarano M, Vahanian A, Messika-Zeitoun D. Haemodynamic and anatomic progression of aortic stenosis. Heart 2015; 101:943-7. [DOI: 10.1136/heartjnl-2014-307154] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 01/15/2015] [Indexed: 01/25/2023] Open
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31
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Hahn RT, Abraham T, Adams MS, Bruce CJ, Glas KE, Lang RM, Reeves ST, Shanewise JS, Siu SC, Stewart W, Picard MH. Guidelines for performing a comprehensive transesophageal echocardiographic examination: recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. J Am Soc Echocardiogr 2013; 26:921-64. [PMID: 23998692 DOI: 10.1016/j.echo.2013.07.009] [Citation(s) in RCA: 753] [Impact Index Per Article: 68.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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32
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Romagnoli S, Ricci Z, Romano SM, Dimizio F, Bonicolini E, Quattrone D, De Gaudio R. FloTrac/VigileoTM (Third Generation) and MostCare®/PRAM Versus Echocardiography for Cardiac Output Estimation in Vascular Surgery. J Cardiothorac Vasc Anesth 2013; 27:1114-21. [DOI: 10.1053/j.jvca.2013.04.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2013] [Indexed: 01/22/2023]
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Michelena HI, Margaryan E, Miller FA, Eleid M, Maalouf J, Suri R, Messika-Zeitoun D, Pellikka PA, Enriquez-Sarano M. Inconsistent echocardiographic grading of aortic stenosis: is the left ventricular outflow tract important? Heart 2013; 99:921-31. [DOI: 10.1136/heartjnl-2012-302881] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Underestimation of aortic valve area in calcified aortic valve disease: Effects of left ventricular outflow tract ellipticity. Int J Cardiol 2012; 157:347-53. [DOI: 10.1016/j.ijcard.2010.12.071] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2010] [Revised: 12/11/2010] [Accepted: 12/20/2010] [Indexed: 11/17/2022]
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35
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Focused rapid echocardiographic evaluation versus vascular cather-based assessment of cardiac output and function in critically ill trauma patients. J Trauma Acute Care Surg 2012; 72:1158-64. [DOI: 10.1097/ta.0b013e31824d1112] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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36
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Bharucha T, Fernandes F, Slorach C, Mertens L, Friedberg MK. Measurement of Effective Aortic Valve Area Using Three-Dimensional Echocardiography in Children Undergoing Aortic Balloon Valvuloplasty for Aortic Stenosis. Echocardiography 2011; 29:484-91. [DOI: 10.1111/j.1540-8175.2011.01595.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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37
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Messika-Zeitoun D, Detaint D, Leye M, Tribouilloy C, Michelena HI, Pislaru S, Brochet E, Iung B, Vahanian A, Enriquez-Sarano M. Comparison of Semiquantitative and Quantitative Assessment of Severity of Aortic Regurgitation: Clinical Implications. J Am Soc Echocardiogr 2011; 24:1246-52. [DOI: 10.1016/j.echo.2011.08.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2011] [Indexed: 10/17/2022]
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38
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Garcia J, Kadem L, Larose E, Clavel MA, Pibarot P. Comparison between cardiovascular magnetic resonance and transthoracic Doppler echocardiography for the estimation of effective orifice area in aortic stenosis. J Cardiovasc Magn Reson 2011; 13:25. [PMID: 21527021 PMCID: PMC3108925 DOI: 10.1186/1532-429x-13-25] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2010] [Accepted: 04/28/2011] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The effective orifice area (EOA) estimated by transthoracic Doppler echocardiography (TTE) via the continuity equation is commonly used to determine the severity of aortic stenosis (AS). However, there are often discrepancies between TTE-derived EOA and invasive indices of stenosis, thus raising uncertainty about actual definite severity. Cardiovascular magnetic resonance (CMR) has emerged as an alternative method for non-invasive estimation of valve EOA. The objective of this study was to assess the concordance between TTE and CMR for the estimation of valve EOA. METHODS AND RESULTS 31 patients with mild to severe AS (EOA range: 0.72 to 1.73 cm2) and seven (7) healthy control subjects with normal transvalvular flow rate underwent TTE and velocity-encoded CMR. Valve EOA was calculated by the continuity equation. CMR revealed that the left ventricular outflow tract (LVOT) cross-section is typically oval and not circular. As a consequence, TTE underestimated the LVOT cross-sectional area (ALVOT, 3.84 ± 0.80 cm2) compared to CMR (4.78 ± 1.05 cm2). On the other hand, TTE overestimated the LVOT velocity-time integral (VTILVOT: 21 ± 4 vs. 15 ± 4 cm). Good concordance was observed between TTE and CMR for estimation of aortic jet VTI (61 ± 22 vs. 57 ± 20 cm). Overall, there was a good correlation and concordance between TTE-derived and CMR-derived EOAs (1.53 ± 0.67 vs. 1.59 ± 0.73 cm2, r = 0.92, bias = 0.06 ± 0.29 cm2). The intra- and inter- observer variability of TTE-derived EOA was 5 ± 5% and 9 ± 5%, respectively, compared to 2 ± 1% and 7 ± 5% for CMR-derived EOA. CONCLUSION Underestimation of ALVOT by TTE is compensated by overestimation of VTILVOT, thereby resulting in a good concordance between TTE and CMR for estimation of aortic valve EOA. CMR was associated with less intra- and inter- observer measurement variability compared to TTE. CMR provides a non-invasive and reliable alternative to Doppler-echocardiography for the quantification of AS severity.
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Affiliation(s)
- Julio Garcia
- Québec Heart and Lung Institute, Laval University, Québec, Canada
- Laboratory of Cardiovascular Fluid Dynamics, Concordia University, Montréal, Canada
| | - Lyes Kadem
- Laboratory of Cardiovascular Fluid Dynamics, Concordia University, Montréal, Canada
| | - Eric Larose
- Québec Heart and Lung Institute, Laval University, Québec, Canada
| | | | - Philippe Pibarot
- Québec Heart and Lung Institute, Laval University, Québec, Canada
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Cabrera-Bueno F, Molina-Mora M, de Teresa-Galvan E. Baseline predictors of dynamic obstruction during stress echocardiogram: the importance of ventricular anatomy and body surface area. Echocardiography 2010; 27:220; author reply 221-2. [PMID: 20380686 DOI: 10.1111/j.1540-8175.2009.01116.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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40
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Clavel MA, Burwash IG, Mundigler G, Dumesnil JG, Baumgartner H, Bergler-Klein J, Sénéchal M, Mathieu P, Couture C, Beanlands R, Pibarot P. Validation of Conventional and Simplified Methods to Calculate Projected Valve Area at Normal Flow Rate in Patients With Low Flow, Low Gradient Aortic Stenosis: The Multicenter TOPAS (True or Pseudo Severe Aortic Stenosis) Study. J Am Soc Echocardiogr 2010; 23:380-6. [DOI: 10.1016/j.echo.2010.02.002] [Citation(s) in RCA: 102] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2009] [Indexed: 10/19/2022]
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41
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Reply. Echocardiography 2010. [DOI: 10.1111/j.1540-8175.2009.01117.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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42
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Johnson MA, Moss RR, Munt B. Determining aortic stenosis severity: what to do when measuring left ventricular outflow tract diameter is difficult. J Am Soc Echocardiogr 2009; 22:452-3. [PMID: 19450741 DOI: 10.1016/j.echo.2009.03.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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