1
|
Chiang C, Brandon M, Danley K, Luo S, Honasoge A, Derbas LA, Jolly N, Collado F, Kavinsky CJ, Suradi HS. Functional and Quality of Life Outcomes After TAVR in Patients With Low Gradient Aortic Stenosis. Curr Probl Cardiol 2024; 49:101941. [PMID: 37454826 DOI: 10.1016/j.cpcardiol.2023.101941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 07/04/2023] [Indexed: 07/18/2023]
Abstract
Severe aortic stenosis is a common valvular heart disease associated with significant mortality and morbidity. Transcatheter aortic valve replacement (TAVR) is an effective treatment for this condition. Less data is available regarding functional and quality-of-life outcomes in patients with severe, low-gradient aortic stenosis following TAVR. This single-center, retrospective study compared changes in New York Heart Association (NYHA) class and Kansas City Cardiomyopathy Questionnaire (KCCQ) scores at 30 days and 1 year in patients with 3 variants of severe, low-gradient aortic stenosis following TAVR. Secondary outcomes included 1-year major adverse cardiovascular event. A total of 170 patients were included. All 3 low-gradient variants had significant improvement in NYHA class and KCCQ overall scores at 30 days and 1 year. There were no significant differences in KCCQ overall scores between the 3 groups and no significant differences in secondary outcomes. Patients with low-gradient aortic stenosis experienced significant improvements in functional and quality-of-life outcomes following TAVR.
Collapse
|
2
|
Assadi H, Matthews G, Zhao X, Li R, Alabed S, Grafton-Clarke C, Mehmood Z, Kasmai B, Limbachia V, Gosling R, Yashoda GK, Halliday I, Swoboda P, Ripley DP, Zhong L, Vassiliou VS, Swift AJ, Geest RJVD, Garg P. Cardiac MR modelling of systolic and diastolic blood pressure. Open Heart 2023; 10:e002484. [PMID: 38114194 DOI: 10.1136/openhrt-2023-002484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 11/01/2023] [Indexed: 12/21/2023] Open
Abstract
AIMS Blood pressure (BP) is a crucial factor in cardiovascular health and can affect cardiac imaging assessments. However, standard outpatient cardiovascular MR (CMR) imaging procedures do not typically include BP measurements prior to image acquisition. This study proposes that brachial systolic BP (SBP) and diastolic BP (DBP) can be modelled using patient characteristics and CMR data. METHODS In this multicentre study, 57 patients from the PREFER-CMR registry and 163 patients from other registries were used as the derivation cohort. All subjects had their brachial SBP and DBP measured using a sphygmomanometer. Multivariate linear regression analysis was applied to predict brachial BP. The model was subsequently validated in a cohort of 169 healthy individuals. RESULTS Age and left ventricular ejection fraction were associated with SBP. Aortic forward flow, body surface area and left ventricular mass index were associated with DBP. When applied to the validation cohort, the correlation coefficient between CMR-derived SBP and brachial SBP was (r=0.16, 95% CI 0.011 to 0.305, p=0.03), and CMR-derived DBP and brachial DBP was (r=0.27, 95% CI 0.122 to 0.403, p=0.0004). The area under the curve (AUC) for CMR-derived SBP to predict SBP>120 mmHg was 0.59, p=0.038. Moreover, CMR-derived DBP to predict DBP>80 mmHg had an AUC of 0.64, p=0.002. CONCLUSION CMR-derived SBP and DBP models can estimate brachial SBP and DBP. Such models may allow efficient prospective collection, as well as retrospective estimation of BP, which should be incorporated into assessments due to its critical effect on load-dependent parameters.
Collapse
Affiliation(s)
- Hosamadin Assadi
- Department of Cardiovascular and Metabolic Health, University of East Anglia, Norwich, UK
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Gareth Matthews
- Department of Cardiovascular and Metabolic Health, University of East Anglia, Norwich, UK
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Xiaodan Zhao
- National Heart Research Institute, National Heart Centre, Singapore
| | - Rui Li
- Department of Cardiovascular and Metabolic Health, University of East Anglia, Norwich, UK
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Samer Alabed
- Department of Infection, Immunity & Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Ciaran Grafton-Clarke
- Department of Cardiovascular and Metabolic Health, University of East Anglia, Norwich, UK
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Zia Mehmood
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Bahman Kasmai
- Department of Cardiovascular and Metabolic Health, University of East Anglia, Norwich, UK
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Vaishali Limbachia
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Rebecca Gosling
- Department of Infection, Immunity & Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | | | - Ian Halliday
- Department of Infection, Immunity & Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | | | - David Paul Ripley
- Department of Cardiology, Northumbria Specialist Emergency Care Hospital, Cramlington, UK
| | - Liang Zhong
- National Heart Research Institute, National Heart Centre, Singapore
- Cardiovascular Science Academic Program, Duke-NUS Medical School, Singapore
| | - Vassilios S Vassiliou
- Department of Cardiovascular and Metabolic Health, University of East Anglia, Norwich, UK
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Andrew J Swift
- Department of Infection, Immunity & Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Rob J van der Geest
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Pankaj Garg
- Department of Cardiovascular and Metabolic Health, University of East Anglia, Norwich, UK
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| |
Collapse
|
3
|
Çelikbudak Orhon C, Stergiopulos N, Noble S, Giannakopoulos G, Müller H, Adamopoulos D. The Impact of Left Ventricular Performance and Afterload on the Evaluation of Aortic Valve Stenosis: A 1D Mathematical Modeling Approach. Bioengineering (Basel) 2023; 10:425. [PMID: 37106613 PMCID: PMC10136235 DOI: 10.3390/bioengineering10040425] [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: 02/27/2023] [Revised: 03/22/2023] [Accepted: 03/24/2023] [Indexed: 03/30/2023] Open
Abstract
The transaortic valvular pressure gradient (TPG) plays a central role in decision-making for patients suffering from severe aortic stenosis. However, the flow-dependence nature of the TPG makes the diagnosis of aortic stenosis challenging since the markers of cardiac performance and afterload present high physiological interdependence and thus, isolated effects cannot be measured directly in vivo. We used a validated 1D mathematical model of the cardiovascular system, coupled with a model of aortic stenosis, to assess and quantify the independent effect of the main left ventricular performance parameters (end-systolic (Ees) and end-diastolic (Eed) elastance) and principal afterload indices (total vascular resistance (TVR) and total arterial compliance (TAC)) on the TPG for different levels of aortic stenosis. In patients with critical aortic stenosis (aortic valve area (AVA) ≤ 0.6 cm2), a 10% increase of Eed from the baseline value was associated with the most important effect on the TPG (-5.6 ± 0.5 mmHg, p < 0.001), followed by a similar increase of Ees (3.4 ± 0.1 mmHg, p < 0.001), in TAC (1.3 ±0.2 mmHg, p < 0.001) and TVR (-0.7 ± 0.04 mmHg, p < 0.001). The interdependence of the TPG left ventricular performance and afterload indices become stronger with increased aortic stenosis severity. Disregarding their effects may lead to an underestimation of stenosis severity and a potential delay in therapeutic intervention. Therefore, a comprehensive evaluation of left ventricular function and afterload should be performed, especially in cases of diagnostic challenge, since it may offer the pathophysiological mechanism that explains the mismatch between aortic severity and the TPG.
Collapse
Affiliation(s)
- Cemre Çelikbudak Orhon
- Laboratory of Hemodynamics and Cardiovascular Technology, Institute of Bioengineering, Ecole Polytechnique Fédérale de Lausanne, 1015 Lausanne, Switzerland
| | - Nikolaos Stergiopulos
- Laboratory of Hemodynamics and Cardiovascular Technology, Institute of Bioengineering, Ecole Polytechnique Fédérale de Lausanne, 1015 Lausanne, Switzerland
| | - Stéphane Noble
- Faculty of Medicine, University of Geneva, 1211 Geneva, Switzerland
- Department of Internal Medicine, Division of Cardiology, Hopitaux Universitaires de Genève (HUG), 1205 Geneva, Switzerland
| | - Georgios Giannakopoulos
- Department of Internal Medicine, Division of Cardiology, Hopitaux Universitaires de Genève (HUG), 1205 Geneva, Switzerland
| | - Hajo Müller
- Faculty of Medicine, University of Geneva, 1211 Geneva, Switzerland
- Department of Internal Medicine, Division of Cardiology, Hopitaux Universitaires de Genève (HUG), 1205 Geneva, Switzerland
| | - Dionysios Adamopoulos
- Faculty of Medicine, University of Geneva, 1211 Geneva, Switzerland
- Department of Internal Medicine, Division of Cardiology, Hopitaux Universitaires de Genève (HUG), 1205 Geneva, Switzerland
| |
Collapse
|
4
|
Kadwalwala M, Downey B, Patel A, Dehn M, Wessler B. Blood pressure changes during routine transthoracic echocardiography. INTERNATIONAL JOURNAL OF CARDIOLOGY. CARDIOVASCULAR RISK AND PREVENTION 2023; 16:200170. [PMID: 36874037 PMCID: PMC9975242 DOI: 10.1016/j.ijcrp.2023.200170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 01/07/2023] [Accepted: 01/12/2023] [Indexed: 01/15/2023]
Abstract
Background Increased afterload affects many of the flow dependent metrics assessed during transthoracic echocardiography (TTE) especially in the evaluation valvular disease. A single timepoint blood pressure (BP) may not accurately reflect the afterload present at the time of flow-dependent imaging and quantification. We assessed the magnitude of change in BP at discrete timepoints during routine TTE. Method We conducted a prospective study where participants underwent automated BP measurement while undergoing a clinically indicated TTE. The first reading was obtained right after the patient lay supine and subsequent readings were taken at 10-min intervals during image acquisition. Result We included 50 participants (66% were male, with a mean age of 64 years). After 10 min, 40 (80%) participants had a drop in systolic BP of >10 mmHg. Compared to the baseline, there was a significant drop in systolic BP (mean decrease 20.0 ± 12.8 mmHg; P < 0.05), and diastolic BP (mean decrease 15.7 ± 13.2 mmHg; P < 0.05) at 10 min. The systolic BP remained different from the baseline value throughout the duration of the study (average decrease from baseline to study end was 12.4 ± 16.0 mmHg, p < 0.05). Conclusion BP recorded just prior to TTE does not accurately reflect the afterload present during most of the study. This finding has important implications for valvular heart disease imaging protocols that incorporate flow dependent metrics, where the presence or absence of hypertension may lead to under- or over-estimation of disease severity.
Collapse
Affiliation(s)
| | - Brian Downey
- Tufts Medical Center, 800 Washington Street, Boston, MA 02111, USA
| | - Ayan Patel
- Tufts Medical Center, 800 Washington Street, Boston, MA 02111, USA
| | - Monica Dehn
- Tufts Medical Center, 800 Washington Street, Boston, MA 02111, USA
| | - Benjamin Wessler
- Tufts Medical Center, 800 Washington Street, Boston, MA 02111, USA
| |
Collapse
|
5
|
Pagoulatou S, Adamopoulos D, Rovas G, Bikia V, Müller H, Giannakopoulos G, Mauler-Wittwer S, Licker MJ, Stergiopulos N, Noble S. Arterial Wave Reflection and Aortic Valve Stenosis: Diagnostic Challenges and Prognostic Significance. Front Cardiovasc Med 2022; 9:863968. [PMID: 35872923 PMCID: PMC9304587 DOI: 10.3389/fcvm.2022.863968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 05/30/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionArterial wave reflection is an important component of the left ventricular afterload, affecting both pressure and flow to the aorta. The aim of the present study was to evaluate the impact of wave reflection on transvalvular pressure gradients (TPG), a key parameter for the evaluation of aortic valve stenosis (AS), as well as its prognostic significance in patients with AS undergoing a transcatheter aortic valve replacement (TAVR).Materials and MethodsThe study population consisted of 351 patients with AS (mean age 84 ± 6 years, 43% males) who underwent a complete hemodynamic evaluation before the TAVR. The baseline assessment included right and left heart catheterization, transthoracic echocardiography, and a thorough evaluation of the left ventricular afterload by means of wave separation analysis. The cohort was divided into quartiles according to the transit time of the backward pressure wave (BWTT). Primary endpoint was all-cause mortality at 1 year.ResultsEarly arrival of the backward pressure wave was related to lower cardiac output (Q1: 3.7 ± 0.9 lt/min vs Q4: 4.4 ± 1.0 lt/min, p < 0.001) and higher aortic systolic blood pressure (Q1: 132 ± 26 mmHg vs Q4: 117 ± 26 mmHg, p < 0.001). TPG was significantly related to the BWTT, patients in the arrival group exhibiting the lowest TPG (mean TPG, Q1: 37.6 ± 12.7 mmHg vs Q4: 44.8 ± 14.7 mmHg, p = 0.005) for the same aortic valve area (AVA) (Q1: 0.58 ± 0.35 cm2 vs 0.61 ± 0.22 cm2, p = 0.303). In multivariate analysis, BWTT remained an independent determinant of mean TPG (beta 0.3, p = 0.002). Moreover, the prevalence of low-flow, low-gradient AS with preserved ejection fraction was higher in patients with early arterial reflection arrival (Q1: 33.3% vs Q4: 14.9%, p = 0.033). Finally, patients with early arrival of the reflected wave (Q1) exhibited higher all-cause mortality at 1 year after the TAVR (unadjusted HR: 2.33, 95% CI: 1.17–4.65, p = 0.016).ConclusionEarly reflected wave arrival to the aortic root is associated with poor prognosis and significant aortic hemodynamic alterations in patients undergoing a TAVR for AS. This is related to a significant decrease in TPG for a given AVA, leading to a possible underestimation of the AS severity.
Collapse
Affiliation(s)
- Stamatia Pagoulatou
- Laboratory of Hemodynamics and Cardiovascular Technology, École Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland
| | - Dionysios Adamopoulos
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Department of Cardiology, Hôpitaux Universitaires de Genève (HUG), Geneva, Switzerland
- *Correspondence: Dionysios Adamopoulos,
| | - Georgios Rovas
- Laboratory of Hemodynamics and Cardiovascular Technology, École Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland
| | - Vasiliki Bikia
- Laboratory of Hemodynamics and Cardiovascular Technology, École Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland
| | - Hajo Müller
- Department of Cardiology, Hôpitaux Universitaires de Genève (HUG), Geneva, Switzerland
| | | | - Sarah Mauler-Wittwer
- Department of Cardiology, Hôpitaux Universitaires de Genève (HUG), Geneva, Switzerland
| | - Marc-Joseph Licker
- Department of Anaesthesiology, Hôpitaux Universitaires de Genève (HUG), Geneva, Switzerland
| | - Nikolaos Stergiopulos
- Laboratory of Hemodynamics and Cardiovascular Technology, École Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland
| | - Stéphane Noble
- Department of Cardiology, Hôpitaux Universitaires de Genève (HUG), Geneva, Switzerland
| |
Collapse
|
6
|
Comparison of Simultaneous Transthoracic Versus Transesophageal Echocardiography for Assessment of Aortic Stenosis. Am J Cardiol 2022; 163:77-84. [PMID: 34782124 DOI: 10.1016/j.amjcard.2021.09.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Revised: 09/16/2021] [Accepted: 09/20/2021] [Indexed: 11/20/2022]
Abstract
Transthoracic echocardiography (TTE) is the gold standard for aortic stenosis (AS) assessment. Transesophageal echocardiography (TEE) provides better resolution, but its effect on AS assessment is unclear. To answer this question, we studied 56 patients with ≥moderate AS. Initial TTE (TTE1) was followed by conscious sedation with simultaneous TEE and TTE2. Based on conservative versus actionable implication, AS types were dichotomized into group A, comprising moderate and normal-flow low-gradient, and group B, comprising high gradient, low ejection fraction low-flow low-gradient, and paradoxical low-flow low-gradient AS. Paired analysis of echocardiographic variables and AS types measured by TEE versus TTE2 and by TEE versus TTE1 was performed. TEE versus simultaneous TTE2 comparison demonstrated higher mean gradients (31.7 ± 10.5 vs 27.4 ± 10.5 mm Hg) and velocities (359 ± 60.6 vs 332 ± 63.1 cm/s) with TEE, but lower left ventricular outflow velocity-time-integral (VTI1) (18.6 ± 5.1 vs 20.2 ± 6.1 cm), all p <0.001. This resulted in a lower aortic valve area (0.8 ± 0.21 vs 0.87 ± 0.28 cm2), p <0.001, and a net relative risk of 1.86 of group A to B upgrade. TEE versus (awake state) TTE1 comparison revealed a larger decrease in VTI1 because of a higher initial awake state VTI1 (22 ± 5.6 cm), resulting in similar Doppler-velocity-index and aortic valve area decrease with TEE, despite a slight increase in mean gradients of 0.8 mm Hg (confidence interval -1.44 to 3.04) and velocities of 10 cm/s (confidence interval -1.5 to 23.4). This translated into a net relative risk of 1.92 of group A to B upgrade versus TTE1. In conclusion, TEE under conscious sedation overestimates AS severity compared with both awake state TTE and simultaneous sedation state TTE, accounted for by different Doppler insonation angles obtained in transapical versus transgastric position.
Collapse
|