1
|
Gracia Baena JM, Marsal Mora JR, Llorca Cardeñosa S, Calaf Vall I, Zielonka M, Godoy P. Impact of severe aortic stenosis on quality of life. PLoS One 2023; 18:e0287508. [PMID: 37343035 DOI: 10.1371/journal.pone.0287508] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 05/30/2023] [Indexed: 06/23/2023] Open
Abstract
INTRODUCTION Among individuals ≥ 65 years old, aortic stenosis is highly prevalent and the number of cases is expected to increase in the coming decades, due to the increased life expectancy. Nevertheless, the actual aortic stenosis burden is not well known in population settings and the impact of aortic stenosis on quality of life has not been studied. The aim of this study was to evaluate aortic stenosis impact on health-related quality of life in patients > 65 years old. METHODS An epidemiological case-control study was carried out to compare quality of life in patients ≥65 years old with severe symptomatic aortic stenosis. Demographical and clinical information was prospectively obtained and quality of life information was collected with the Short Form Health Survey_v2 (SF-12) questionnaire. The association between quality of life and aortic stenosis was determined using multiple logistic regression models. RESULTS Patients with severe aortic stenosis self-perceived worse quality of life on all dimensions and summary components of the SF-12 questionnaire. In the final multiple logistic regression model a significant inverse association was observed between the dimensions 'physical role' and 'social role' (p = 0.002 and p = 0.005) and an association close to significance with 'physical role' (p = 0.052) of the SF-12 questionnaire. CONCLUSION The use of quality of life scales allows the assessment of the impact of aortic stenosis on quality of life and may improve the therapeutic approach to severe aortic stenosis, providing evidence for patient-centered care.
Collapse
Affiliation(s)
- Juan Manuel Gracia Baena
- Cardiac Surgery Department, Vall d'Hebron University Hospital, Barcelona, Spain
- Applied Epidemiology Unit, Department of Medicine and Surgery, University of Lleida, Lleida, Spain
| | - Josep Ramon Marsal Mora
- Lleida Research Support Unit, Foundation University Institute for Primary Health Care Research Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
| | - Sara Llorca Cardeñosa
- Applied Epidemiology Unit, Department of Medicine and Surgery, University of Lleida, Lleida, Spain
| | - Imma Calaf Vall
- Applied Epidemiology Unit, Department of Medicine and Surgery, University of Lleida, Lleida, Spain
| | - Marta Zielonka
- Applied Epidemiology Unit, Department of Medicine and Surgery, University of Lleida, Lleida, Spain
| | - Pere Godoy
- Applied Epidemiology Unit, Department of Medicine and Surgery, University of Lleida, Lleida, Spain
- CIBER Epidemiology and Public Health CIBERESP, Institute of Health Carlos III, Madrid, Spain
- Catalan Public Health Agency (ASPCAT), Barcelona, Spain
| |
Collapse
|
2
|
Pellikka PA, Padang R, Scott CG, Murphy SME, Fabunmi R, Thaden JJ. Impact of Managing Provider Type on Severe Aortic Stenosis Management and Mortality. J Am Heart Assoc 2022; 11:e025164. [PMID: 35766279 PMCID: PMC9333396 DOI: 10.1161/jaha.121.025164] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Many patients with symptomatic severe aortic stenosis do not undergo aortic valve replacement (AVR) despite clinical guidelines. This study analyzed the association of managing provider type with cardiac specialist follow-up, AVR, and mortality for patients with newly diagnosed severe aortic stenosis (sAS). Methods and Results We identified adults with newly diagnosed sAS per echocardiography performed between January 2017 and March 2019 using Optum electronic health record data. We then selected from those meeting all eligibility criteria patients managed by a primary care provider (n=1707 [25%]) or cardiac specialist (n=5039 [75%]). We evaluated the association of managing provider type with cardiac specialist follow-up, AVR, and mortality, as well as the independent association of cardiac specialist follow-up and AVR with mortality, within 1 year of echocardiography detecting sAS. A subgroup analysis was limited to patients with symptomatic sAS. Patient characteristics and comorbidities at baseline were used for covariate-adjusted cause-specific and multivariable Cox proportional hazard models assessing group differences in outcomes by managing provider type. An adjusted Cox proportional hazard model with additional time-dependent covariates for follow-up and AVR was used to assess these practices' association with mortality. Within 1 year of echocardiography detecting sAS, data revealed that primary care provider management was associated with lower rates of cardiac specialist follow-up (hazard ratio [HR], 0.47 [95% CI, 0.43-0.50], P<0.0001) and AVR (HR, 0.58 [95% CI, 0.53-0.64], P<0.0001) and with higher 1-year mortality (HR, 1.45 [95% CI, 1.26-1.66], P<0.0001). Cardiac specialist follow-up and AVR were independently associated with lower mortality (follow-up: HR, 0.55 [95% CI, 0.48-0.63], P<0.0001; AVR: HR, 0.70 [95% CI, 0.60-0.83], P<0.0001). Results were similar for patients with symptomatic sAS. All analyses were adjusted for baseline patient characteristics and comorbidities. Conclusions For patients newly diagnosed with sAS, we observed differences in rates of cardiac specialist follow-up and AVR and risk of mortality between primary care provider- versus cardiologist-managed patients with sAS. In addition, a lower likelihood of receiving follow-up and AVR was independently associated with higher mortality.
Collapse
Affiliation(s)
| | | | | | | | | | - Jeremy J Thaden
- Department of Cardiovascular Medicine Mayo Clinic Rochester MN
| |
Collapse
|
3
|
Lowenstern A, Sheridan P, Wang TY, Boero I, Vemulapalli S, Thourani VH, Leon MB, Peterson ED, Brennan JM. Sex disparities in patients with symptomatic severe aortic stenosis. Am Heart J 2021; 237:116-126. [PMID: 33722584 DOI: 10.1016/j.ahj.2021.01.021] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 01/28/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND We evaluated whether there is equitable distribution across sexes of treatment and outcomes for aortic valve replacement (AVR), via surgical (SAVR) or transcatheter (TAVR) methods, in symptomatic severe aortic stenosis (ssAS) patients. METHODS Using de-identified data, we identified 43,822 patients with ssAS (2008-2016). Multivariate competing risk models were used to determine the likelihood of any AVR, while accounting for the competing risk of death. Association between sex and 1-year mortality, stratified by AVR status, was evaluated using multivariate Cox regression models with AVR as a time-dependent variable. RESULTS Among patients with ssAS, 20,986 (47.9%) were female. Females were older (median age 81 vs. 78, P<0.001), more likely to have body mass index <20 (8.5% vs. 3.5%), and home oxygen use (4.4% vs. 3.4%, P<0001 for all). Overall, 12,129 (27.7%) patients underwent AVR for ssAS. Females were less likely to undergo AVR compared with males (24.1% vs. 31.0%, adjusted hazard ratio [HR] 0.80, 95% confidence interval [CI] 0.77-0.83), but when treated, were more likely to undergo TAVR (37.9% vs. 30.9%, adjusted HR 1.21, 95% CI 1.15-1.27). Untreated females and males had similarly high rates of mortality at 1 year (31.1% vs. 31.3%, adjusted HR 0.98, 95% CI 0.94-1.03). Among those undergoing AVR, females had significantly higher mortality (10.2% vs. 9.4%, adjusted HR 1.24, 95% CI 1.10-1.41), driven by increased SAVR-associated mortality (9.0% vs. 7.6%, adjusted HR 1.43, 95% CI 1.21-1.69). CONCLUSIONS Treatment rates for ssAS patients remain suboptimal with disparities in female treatment.
Collapse
Affiliation(s)
- Angela Lowenstern
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Paige Sheridan
- Department of Family Medicine and Public Health, University of San Diego, San Diego, CA; Boston Consulting Group, Boston, MA
| | - Tracy Y Wang
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | | | - Vinod H Thourani
- Department of Cardiovascular Surgery, Marcus Valve Center, Piedmont Heart Institute, Atlanta, GA
| | - Martin B Leon
- Columbia University Medical Center and New York Presbyterian Hospital, New York, NY
| | - Eric D Peterson
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - J Matthew Brennan
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC.
| |
Collapse
|
4
|
Human aortic valve interstitial cells obtained from patients with aortic valve stenosis are vascular endothelial growth factor receptor 2 positive and contribute to ectopic calcification. J Pharmacol Sci 2020; 145:213-221. [PMID: 33451756 DOI: 10.1016/j.jphs.2020.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Revised: 12/09/2020] [Accepted: 12/11/2020] [Indexed: 01/08/2023] Open
Abstract
Since aortic valve stenosis (AVS) is the most frequent and serious valvular heart disease in the elderly, and is accompanied by irreversible valve calcification, medicinal prevention of AVS is important. Although we recently demonstrated that human aortic valve interstitial cells (HAVICs) obtained from patients with AVS were highly sensitive to ectopic calcification stimulation, the cell types contributing to calcification are unknown. We aimed to immunocytochemically characterize HAVICs and identify their contribution to valve calcification. HAVICs were isolated from patients with AVS and cultured on non-coated dishes. Immunocytochemical features and HAVIC differentiation were analyzed in passage 1 (P1). The immunohistochemical features of the calcified aortic valve were analyzed. Most cultured P1 HAVICs were CD73-, CD90-, and CD105-positive, and CD45-and CD34-negative. HAVICs were vascular endothelial growth factor receptor 2 (VEGFR2)-positive; however, approximately half were α-smooth muscle actin (SMA)-positive, colonized, and easily differentiated into osteoblastic cells. Calcified aortic valve immunohistochemistry showed that all cells were positive for VEGFR2 and partly α-SMA. Further, VEGFR2-positive cells were more sensitive to tumor necrosis factor-α-induced ectopic calcification with or without α-SMA positivity. We conclude that HAVICs obtained from patients with AVS are VEGFR2-positive undifferentiated mesenchymal cells and may contribute to aortic valve ectopic calcification.
Collapse
|
5
|
Matthew Brennan J, Leon MB, Sheridan P, Boero IJ, Chen Q, Lowenstern A, Thourani V, Vemulapalli S, Thomas K, Wang TY, Peterson ED. Racial Differences in the Use of Aortic Valve Replacement for Treatment of Symptomatic Severe Aortic Valve Stenosis in the Transcatheter Aortic Valve Replacement Era. J Am Heart Assoc 2020; 9:e015879. [PMID: 32777969 PMCID: PMC7660794 DOI: 10.1161/jaha.119.015879] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 06/19/2020] [Indexed: 12/11/2022]
Abstract
Background Aortic valve replacement (AVR) is a life-saving treatment for patients with symptomatic severe aortic valve stenosis. We sought to determine whether transcatheter AVR has resulted in a more equitable treatment rate by race in the United States. Methods and Results A total of 32 853 patients with symptomatic severe aortic valve stenosis were retrospectively identified via Optum's deidentified electronic health records database (2007-2017). AVR rates in non-Hispanic Black and White patients were assessed in the year after diagnosis. Multivariate Fine-Gray hazards models were used to evaluate the likelihood of AVR by race, with adjustment for patient factors and the managing cardiologist. Time-trend and 1-year symptomatic severe aortic valve stenosis survival analyses were also performed. From 2011 to 2016, the rate of AVR increased from 20.1% to 37.1%. Overall, Black individuals were less likely than Whites to receive AVR (22.9% versus 31.0%; unadjusted hazard ratio [HR], 0.70; 95% CI, 0.62-0.79; fully adjusted HR, 0.76; 95% CI, 0.67-0.85). Yet, during 2015 to 2016, AVR racial differences were attenuated (29.5% versus 35.2%; adjusted HR, 0.86; 95% CI, 0.74-1.02) because of greater uptake of transcatheter AVR in Blacks than Whites (53.4% of AVRs versus 47.3%; P=0.128). Untreated patients had significantly higher 1-year mortality than those treated (adjusted HR, 0.57; 95% CI, 0.53-0.61), which was consistent by race (interaction P value=0.52). Conclusions Although transcatheter AVR has increased the use of AVR in the United States, treatment rates remain low. Black patients with symptomatic severe aortic valve stenosis were less likely than White patients to receive AVR, yet these differences have recently narrowed.
Collapse
Affiliation(s)
| | - Martin B. Leon
- Columbia University Medical Center and New York Presbyterian HospitalNew YorkNY
| | - Paige Sheridan
- Department of Family Medicine and Public HealthUniversity of San DiegoSan DiegoCA
- Boston Consulting GroupBostonMA
| | | | | | | | - Vinod Thourani
- Georgetown University School of MedicineMedstar Heart and Vascular InstituteWashingtonDC
| | | | | | | | | |
Collapse
|
6
|
Taniguchi T, Morimoto T, Takeji Y, Kato T, Kimura T. Contemporary issues in severe aortic stenosis: review of current and future strategies from the Contemporary Outcomes after Surgery and Medical Treatment in Patients with Severe Aortic Stenosis registry. Heart 2020; 106:802-809. [PMID: 32114519 DOI: 10.1136/heartjnl-2019-315672] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 01/10/2020] [Accepted: 01/13/2020] [Indexed: 02/07/2023] Open
Abstract
Contemporary Outcomes after Surgery and Medical Treatment in Patients with Severe Aortic Stenosis (CURRENT AS) registry was a large Japanese multicentre retrospective registry of consecutive patients with severe aortic stenosis (AS) before introduction of transcatheter aortic valve implantation. We sought to overview the data from the CURRENT AS registry to discuss the three major contemporary issues related to clinical practice in patients with severe AS: (1) under-referral/underuse of surgical aortic valve replacement (SAVR) in symptomatic patients with severe AS, (2) management of asymptomatic patients with severe AS and (3) management of patients with low-gradient severe aortic stenosis (LG-AS). First, despite the dismal prognosis of symptomatic patients with severe AS, SAVR, including those performed during follow-up, was reported to be underused. In the CURRENT AS registry, overall 53% of symptomatic patients underwent aortic valve replacement (AVR) during follow-up. Second, we reported that compared with conservative strategy, initial AVR strategy was associated with lower risk of all-cause death and heart failure hospitalisation in asymptomatic patients with severe AS. Although current recommendations for AVR are mainly dependent on the patient symptoms, some patients may not complain of any symptom because of their sedentary lifestyle. We also reported several important objective factors associated with worse clinical outcomes in asymptomatic patients with severe AS for risk stratification. Finally, initial AVR strategy was associated with better long-term clinical outcomes than conservative strategy in both patients with high-gradient AS and patients with LG-AS. The favourable effect of initial AVR strategy was also seen in patients with LG-AS with left ventricular ejection fraction of ≥50%.
Collapse
Affiliation(s)
- Tomohiko Taniguchi
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Fukuoka, Japan
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan.,Department of Cardiovascular Medicine, Faculty of Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yasuaki Takeji
- Department of Cardiovascular Medicine, Faculty of Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takao Kato
- Department of Cardiovascular Medicine, Faculty of Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Faculty of Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | | |
Collapse
|
7
|
van Beek-Peeters JJAM, van Noort EHM, Faes MC, de Vos AJBM, van Geldorp MWA, Minkman MMN, van der Meer NJM. Shared decision making in older patients with symptomatic severe aortic stenosis: a systematic review. Heart 2020; 106:647-655. [PMID: 32001621 DOI: 10.1136/heartjnl-2019-316055] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 11/24/2019] [Accepted: 12/19/2019] [Indexed: 12/18/2022] Open
Abstract
This review provides an overview of the status of shared decision making (SDM) in older patients regarding treatment of symptomatic severe aortic stenosis (SSAS). The databases Embase, Medline Ovid, Cinahl and Cochrane Dare were searched for relevant studies from January 2002 to May 2018 regarding perspectives of professionals, patients and caregivers; aspects of decision making; type of decision making; application of the six domains of SDM; barriers to and facilitators of SDM. The systematic search yielded 1842 articles, 15 studies were included. Experiences of professionals and informal caregivers with SDM were scarcely found. Patient refusal was a frequently reported result of decision making, but often no insight was given into the decision process. Most studies investigated the 'decision' and 'option' domains of SDM, yet no study took all six domains into account. Problem analysis, personalised treatment aims, use of decision aids and integrating patient goals in decisions lacked in all studies. Barriers to and facilitators of SDM were 'individualised formal and informal information support' and 'patients' opportunity to use their own knowledge about their health condition and preferences for SDM'. In conclusion, SDM is not yet common practice in the decision making process of older patients with SSAS. Moreover, the six domains of SDM are not often applied in this process. More knowledge is needed about the implementation of SDM in the context of SSAS treatment and how to involve patients, professionals and informal caregivers.
Collapse
Affiliation(s)
| | | | - Miriam C Faes
- Department of Geriatrics, Amphia Hospital, Breda, The Netherlands
| | | | | | - Mirella M N Minkman
- TIAS, School for Business and Society, Tilburg University, Tilburg, The Netherlands.,Vilans, Centre of Expertise for Long-term Care, Utrecht, The Netherlands
| | - Nardo J M van der Meer
- TIAS, School for Business and Society, Tilburg University, Tilburg, The Netherlands.,Department of Anesthesiology, Amphia Hospital, Breda, The Netherlands
| |
Collapse
|
8
|
Yang W, Yu Z, Chiyoya M, Liu X, Daitoku K, Motomura S, Imaizumi T, Fukuda I, Furukawa KI, Tsuji M, Seya K. Menaquinone-4 Accelerates Calcification of Human Aortic Valve Interstitial Cells in High-Phosphate Medium through PXR. J Pharmacol Exp Ther 2019; 372:277-284. [PMID: 31843813 DOI: 10.1124/jpet.119.263160] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 12/11/2019] [Indexed: 12/13/2022] Open
Abstract
Recently, we confirmed that in human aortic valve interstitial cells (HAVICs) isolated from patients with aortic valve stenosis (AVS), calcification is induced in high inorganic phosphate (high-Pi) medium by warfarin (WFN). Because WFN is known as a vitamin K antagonist, reducing the formation of blood clots by vitamin K cycle, we hypothesized that vitamin K regulates WFN-induced HAVIC calcification. Here, we sought to determine whether WFN-induced HAVIC calcification in high-Pi medium is inhibited by menaquinone-4 (MK-4), the most common form of vitamin K2 in animals. HAVICs obtained from patients with AVS were cultured in α-modified Eagle's medium containing 10% FBS, and when the cells reached 80%-90% confluency, they were further cultured in the presence or absence of MK-4 and WFN for 7 days in high-Pi medium (3.2 mM Pi). Intriguingly, in high-Pi medium, MK-4 dose-dependently accelerated WFN-induced HAVIC calcification and also accelerated the calcification when used alone (at 10 nM). Furthermore, MK-4 enhanced alkaline phosphatase (ALP) activity in HAVICs, and 7 days of MK-4 treatment markedly upregulated the gene expression of the calcification marker bone morphogenetic protein 2 (BMP2). Notably, MK-4-induced calcification was potently suppressed by two pregnane X receptor (PXR) inhibitors, ketoconazole and coumestrol; conversely, PXR activity was weakly increased, but in a statistically significant and dose-dependent manner, by MK-4. Lastly, in physiologic-Pi medium, MK-4 increased BMP2 gene expression and accelerated excess BMP2 (30 ng/ml)-induced HAVIC calcification. These results suggest that MK-4, namely vitamin K2, accelerates calcification of HAVICs from patients with AVS like WFN via PXR-BMP2-ALP pathway. SIGNIFICANCE STATEMENT: For aortic valve stenosis (AVS) induced by irreversible valve calcification, the most effective treatment is surgical aortic or transcatheter aortic valve replacement, but ∼20% of patients are deemed unsuitable because of its invasiveness. For effective drug treatment strategies for AVS, the mechanisms underlying aortic valve calcification must be elucidated. Here, we show that menaquinone-4 accelerates warfarin-induced calcification of AVS-patient human aortic valve interstitial cells in high inorganic phosphate medium; this effect is mediated by pregnane X receptor-bone morphogenetic protein 2-alkaline phosphatase signaling, which could be targeted for novel drug development.
Collapse
Affiliation(s)
- Wei Yang
- Departments of Thoracic and Cardiovascular Surgery (W.Y., Z.Y., M.C., X.L., K.D., I.F.), Vascular Biology (T.I., K.S.), and Pharmacology (S.M., K.-I.F.), Hirosaki University Graduate School Medicine, Hirosaki, Japan; and Institute of Molecular Function, Saitama, Japan (M.T.)
| | - Zaiqiang Yu
- Departments of Thoracic and Cardiovascular Surgery (W.Y., Z.Y., M.C., X.L., K.D., I.F.), Vascular Biology (T.I., K.S.), and Pharmacology (S.M., K.-I.F.), Hirosaki University Graduate School Medicine, Hirosaki, Japan; and Institute of Molecular Function, Saitama, Japan (M.T.)
| | - Mari Chiyoya
- Departments of Thoracic and Cardiovascular Surgery (W.Y., Z.Y., M.C., X.L., K.D., I.F.), Vascular Biology (T.I., K.S.), and Pharmacology (S.M., K.-I.F.), Hirosaki University Graduate School Medicine, Hirosaki, Japan; and Institute of Molecular Function, Saitama, Japan (M.T.)
| | - Xu Liu
- Departments of Thoracic and Cardiovascular Surgery (W.Y., Z.Y., M.C., X.L., K.D., I.F.), Vascular Biology (T.I., K.S.), and Pharmacology (S.M., K.-I.F.), Hirosaki University Graduate School Medicine, Hirosaki, Japan; and Institute of Molecular Function, Saitama, Japan (M.T.)
| | - Kazuyuki Daitoku
- Departments of Thoracic and Cardiovascular Surgery (W.Y., Z.Y., M.C., X.L., K.D., I.F.), Vascular Biology (T.I., K.S.), and Pharmacology (S.M., K.-I.F.), Hirosaki University Graduate School Medicine, Hirosaki, Japan; and Institute of Molecular Function, Saitama, Japan (M.T.)
| | - Shigeru Motomura
- Departments of Thoracic and Cardiovascular Surgery (W.Y., Z.Y., M.C., X.L., K.D., I.F.), Vascular Biology (T.I., K.S.), and Pharmacology (S.M., K.-I.F.), Hirosaki University Graduate School Medicine, Hirosaki, Japan; and Institute of Molecular Function, Saitama, Japan (M.T.)
| | - Tadaatsu Imaizumi
- Departments of Thoracic and Cardiovascular Surgery (W.Y., Z.Y., M.C., X.L., K.D., I.F.), Vascular Biology (T.I., K.S.), and Pharmacology (S.M., K.-I.F.), Hirosaki University Graduate School Medicine, Hirosaki, Japan; and Institute of Molecular Function, Saitama, Japan (M.T.)
| | - Ikuo Fukuda
- Departments of Thoracic and Cardiovascular Surgery (W.Y., Z.Y., M.C., X.L., K.D., I.F.), Vascular Biology (T.I., K.S.), and Pharmacology (S.M., K.-I.F.), Hirosaki University Graduate School Medicine, Hirosaki, Japan; and Institute of Molecular Function, Saitama, Japan (M.T.)
| | - Ken-Ichi Furukawa
- Departments of Thoracic and Cardiovascular Surgery (W.Y., Z.Y., M.C., X.L., K.D., I.F.), Vascular Biology (T.I., K.S.), and Pharmacology (S.M., K.-I.F.), Hirosaki University Graduate School Medicine, Hirosaki, Japan; and Institute of Molecular Function, Saitama, Japan (M.T.)
| | - Motonori Tsuji
- Departments of Thoracic and Cardiovascular Surgery (W.Y., Z.Y., M.C., X.L., K.D., I.F.), Vascular Biology (T.I., K.S.), and Pharmacology (S.M., K.-I.F.), Hirosaki University Graduate School Medicine, Hirosaki, Japan; and Institute of Molecular Function, Saitama, Japan (M.T.)
| | - Kazuhiko Seya
- Departments of Thoracic and Cardiovascular Surgery (W.Y., Z.Y., M.C., X.L., K.D., I.F.), Vascular Biology (T.I., K.S.), and Pharmacology (S.M., K.-I.F.), Hirosaki University Graduate School Medicine, Hirosaki, Japan; and Institute of Molecular Function, Saitama, Japan (M.T.)
| |
Collapse
|
9
|
Yu Z, Seya K, Chiyoya M, Daitoku K, Motomura S, Imaizumi T, Fukuda I, Furukawa KI. Warfarin calcifies human aortic valve interstitial cells at high-phosphate conditions via pregnane X receptor. J Bone Miner Metab 2019; 37:944-956. [PMID: 30963258 DOI: 10.1007/s00774-019-01001-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 03/18/2019] [Indexed: 10/27/2022]
Abstract
Warfarin, a vitamin K antagonist, is the most common anticoagulant used to prevent thromboembolisms associated with atrial fibrillation or following valvular surgery. Although several studies have revealed that long-term warfarin use accelerates aortic valve calcification and the development of aortic stenosis (AS), the detailed mechanism for this phenomenon remains unclear. Therefore, our aim was twofold: to establish the conditions for warfarin-induced calcification of human aortic valve interstitial cells (HAVICs) using high-inorganic phosphate (Pi) conditions and to investigate the underlying mechanism. We prepared and cultured HAVICs from aortic valves affected by calcific aortic valve stenosis (AS group) and aortic valves affected by aortic regurgitation but without any signs of calcification (non-AS group). Under Pi concentrations of 3.2 mM, warfarin significantly increased the calcification and alkaline phosphatase (ALP) activity of AS but not non-AS group HAVICs. Furthermore, gene expression of bone morphogenetic protein 2 (BMP2), a calcigenic marker, was significantly increased following 7 days of warfarin treatment. Warfarin-induced calcification of AS group HAVICs at 3.2 mM Pi was significantly inhibited by dorsomorphin, a Smad inhibitor, and the pregnane X receptor (PXR) inhibitors, ketoconazole and coumestrol, but was unaffected by SN-50, an NF-κB inhibitor. Warfarin was also able to increase BMP2 gene expression at a physiological Pi concentration (1.0 mM). Furthermore, excess BMP2 (30 ng/mL) facilitated warfarin-induced ALP upregulation and HAVIC calcification, an effect which was significantly reduced in the presence of coumestrol. Together, our results suggest that warfarin accelerates calcification of HAVICs from AS patients via the PXR-BMP2-ALP pathway.
Collapse
Affiliation(s)
- Zaiqiang Yu
- Department of Thoracic and Cardiovascular Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Kazuhiko Seya
- Department of Vascular Biology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Mari Chiyoya
- Department of Thoracic and Cardiovascular Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Kazuyuki Daitoku
- Department of Thoracic and Cardiovascular Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Shigeru Motomura
- Department of Pharmacology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Tadaatsu Imaizumi
- Department of Vascular Biology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Ikuo Fukuda
- Department of Thoracic and Cardiovascular Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Ken-Ichi Furukawa
- Department of Pharmacology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan.
| |
Collapse
|
10
|
Grossi EA, A Moore K, Gunnarsson C. Use of echocardiograms in the Medicare population: a diagnostic tool in the fight against severe aortic stenosis. J Comp Eff Res 2019; 8:265-272. [PMID: 30638067 DOI: 10.2217/cer-2018-0071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM To estimate undiagnosed aortic stenosis (AS) in the Medicare population. METHODS Patients enrolled (2011-2014) were eligible. After criteria were applied, time zero was the first record of an echocardiogram (ECHO) for the ECHO-AS cohort and randomly assigned for the no-ECHO cohort. The ECHO-AS cohort was propensity matched to patients in the no-ECHO cohort, and survival analysis was performed. RESULTS Of the 854,493 (25%) patients who received an ECHO, 1 in 4 were diagnosed with AS. After propensity matching, the no-ECHO cohort who died, almost half (49%) had a record of a cardiovascular event prior to their death. The no-ECHO cohort had statistically significant (p = 0.003) higher risk of death than their ECHO-AS counterparts. CONCLUSION In the Medicare population, patients aged 65 years or older, with increased risk factors for and symptoms common in AS patients, should be considered for diagnostic ECHOs.
Collapse
Affiliation(s)
- Eugene A Grossi
- Department of Cardiothoracic Surgery, NYU - Langone Medical Center, New York, NY 10016, USA
| | | | | |
Collapse
|
11
|
Tang L, Gössl M, Ahmed A, Garberich R, Bradley SM, Niikura H, Witt D, Pedersen WR, Bae R, Lesser JR, Harris KM, Sun B, Mudy K, Sorajja P. Contemporary Reasons and Clinical Outcomes for Patients With Severe, Symptomatic Aortic Stenosis Not Undergoing Aortic Valve Replacement. Circ Cardiovasc Interv 2018; 11:e007220. [DOI: 10.1161/circinterventions.118.007220] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Liang Tang
- Valve Science Center, Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, MN (L.T., M.G., A.A., R.G., S.M.B., H.N., D.W., W.R.P., R.B., J.R.L., K.M.H., B.S., K.M., P.S.)
- Department of Cardiology, The Second Xiangya Hospital of Central South University, Changsha, China (L.T.)
| | - Mario Gössl
- Valve Science Center, Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, MN (L.T., M.G., A.A., R.G., S.M.B., H.N., D.W., W.R.P., R.B., J.R.L., K.M.H., B.S., K.M., P.S.)
| | - Aisha Ahmed
- Valve Science Center, Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, MN (L.T., M.G., A.A., R.G., S.M.B., H.N., D.W., W.R.P., R.B., J.R.L., K.M.H., B.S., K.M., P.S.)
| | - Ross Garberich
- Valve Science Center, Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, MN (L.T., M.G., A.A., R.G., S.M.B., H.N., D.W., W.R.P., R.B., J.R.L., K.M.H., B.S., K.M., P.S.)
| | - Steven M. Bradley
- Valve Science Center, Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, MN (L.T., M.G., A.A., R.G., S.M.B., H.N., D.W., W.R.P., R.B., J.R.L., K.M.H., B.S., K.M., P.S.)
| | - Hiroki Niikura
- Valve Science Center, Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, MN (L.T., M.G., A.A., R.G., S.M.B., H.N., D.W., W.R.P., R.B., J.R.L., K.M.H., B.S., K.M., P.S.)
| | - Dawn Witt
- Valve Science Center, Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, MN (L.T., M.G., A.A., R.G., S.M.B., H.N., D.W., W.R.P., R.B., J.R.L., K.M.H., B.S., K.M., P.S.)
| | - Wesley R. Pedersen
- Valve Science Center, Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, MN (L.T., M.G., A.A., R.G., S.M.B., H.N., D.W., W.R.P., R.B., J.R.L., K.M.H., B.S., K.M., P.S.)
| | - Richard Bae
- Valve Science Center, Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, MN (L.T., M.G., A.A., R.G., S.M.B., H.N., D.W., W.R.P., R.B., J.R.L., K.M.H., B.S., K.M., P.S.)
| | - John R. Lesser
- Valve Science Center, Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, MN (L.T., M.G., A.A., R.G., S.M.B., H.N., D.W., W.R.P., R.B., J.R.L., K.M.H., B.S., K.M., P.S.)
| | - Kevin M. Harris
- Valve Science Center, Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, MN (L.T., M.G., A.A., R.G., S.M.B., H.N., D.W., W.R.P., R.B., J.R.L., K.M.H., B.S., K.M., P.S.)
| | - Benjamin Sun
- Valve Science Center, Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, MN (L.T., M.G., A.A., R.G., S.M.B., H.N., D.W., W.R.P., R.B., J.R.L., K.M.H., B.S., K.M., P.S.)
| | - Karol Mudy
- Valve Science Center, Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, MN (L.T., M.G., A.A., R.G., S.M.B., H.N., D.W., W.R.P., R.B., J.R.L., K.M.H., B.S., K.M., P.S.)
| | - Paul Sorajja
- Valve Science Center, Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, MN (L.T., M.G., A.A., R.G., S.M.B., H.N., D.W., W.R.P., R.B., J.R.L., K.M.H., B.S., K.M., P.S.)
| |
Collapse
|
12
|
Thoenes M, Bramlage P, Zamorano P, Messika-Zeitoun D, Wendt D, Kasel M, Kurucova J, Steeds RP. Patient screening for early detection of aortic stenosis (AS)-review of current practice and future perspectives. J Thorac Dis 2018; 10:5584-5594. [PMID: 30416809 DOI: 10.21037/jtd.2018.09.02] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
In Europe, approximately one million people over 75 years suffer from severe aortic stenosis (AS), one of the most serious and most common valve diseases, and this disease burden is increasing with the aging population. A diagnosis of severe symptomatic AS is associated with an average life expectancy of 2-3 years and necessitates a timely valve intervention. Guidelines for valve replacement therapy have been established but only a proportion of patients with symptomatic AS actually receive this life-saving treatment. The decision for valve intervention in asymptomatic patients with severe AS is often more challenging and likely results in fewer patients receiving treatment in comparison to their symptomatic counterparts. This article reviews the epidemiology and clinical manifestations of AS, the associated economic burden of AS to the healthcare system, the diagnosis of AS and the possible mechanisms for the introduction of routine screening in elderly patients. Elderly patients typically visit healthcare providers more frequently than younger patients, thereby providing increased opportunities for ad hoc AS screening and this, along with raising patient awareness of the symptoms of AS, has the potential to result in the earlier diagnosis and treatment of AS and increased patient survival.
Collapse
Affiliation(s)
- Martin Thoenes
- Léman Research Institute, Schaffhausen am Rheinfall, Switzerland.,Edwards Lifesciences, Nyon, Switzerland
| | - Peter Bramlage
- Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany
| | | | | | - Daniel Wendt
- Klinik für Thorax- und Kardiovaskuläre Chirurgie, Westdeutsches Herzzentrum Essen, Universitätsklinikum Essen, Essen, Germany
| | | | | | - Richard P Steeds
- Queen Elizabeth Hospital & Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| |
Collapse
|
13
|
Oterhals K, Haaverstad R, Nordrehaug JE, Eide GE, Norekvål TM. Self-reported health status, treatment decision and survival in asymptomatic and symptomatic patients with aortic stenosis in a Western Norway population undergoing conservative treatment: a cross-sectional study with 18 months follow-up. BMJ Open 2017; 7:e016489. [PMID: 28827255 PMCID: PMC5629730 DOI: 10.1136/bmjopen-2017-016489] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 07/05/2017] [Accepted: 07/19/2017] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES To investigate symptoms and self-reported health of patients conservatively treated for aortic stenosis (AS) and to identify factors associated with treatment decision and patient outcomes. DESIGN A cross-sectional survey with an 18-month follow-up. SETTING One tertiary university hospital in Western Norway. PARTICIPANTS In all, 1436 patients were diagnosed with AS between 2000 and 2012, and those 245 still under conservative treatment in 2013 were included in this study. PRIMARY AND SECONDARY OUTCOME MEASURES Primary outcome measures were symptoms and self-reported health status. Secondary outcomes were treatment decision and patient survival after 18 months. RESULTS A total of 136 patients with mean (SD) age 79 (12) years, 52% men responded. Among conservatively treated patients 77% were symptomatic. The symptom most frequently experienced was dyspnoea. Symptomatic patients reported worse physical and mental health compared with asymptomatic patients (effect size 1.24 and 0.74, respectively). In addition, symptomatic patients reported significantly higher levels of anxiety and depression compared with asymptomatic patients. However, symptom status did not correlate with haemodynamic severity of AS. After 18 months, 117 (86%) were still alive, 20% had undergone surgical aortic valve replacement (AVR) and 7% transcatheter aortic valve implantation (TAVI). When adjusting for age, gender, symptomatic status, severity of AS and European system for cardiac operative risk evaluation (EuroSCORE), patients with severe AS had more than sixfold chance of being scheduled for AVR or TAVI compared with those with moderate AS (HR 6.3, 95% CI 1.9 to 21.2, p=0.003). Patients with EuroSCORE ≥11 had less chance for undergoing AVR or TAVI compared with those with EuroSCORE ≤5 (HR 0.06, 95% CI 0.01 to 0.46, p=0.007). CONCLUSIONS Symptoms affected both physical and mental health in conservatively treated patients with AS. Many patients with symptomatic severe AS are not scheduled for surgery, despite the recommendations in current guidelines. The referral practice for AVR is a path for further investigation.
Collapse
Affiliation(s)
- Kjersti Oterhals
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Rune Haaverstad
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, Faculty of Medicine and Dentistry, University of Bergen, Bergen, Norway
| | - Jan Erik Nordrehaug
- Department of Clinical Science, Faculty of Medicine and Dentistry, University of Bergen, Bergen, Norway
- Department of Cardiology, Stavanger University Hospital, Stavanger, Norway
| | - Geir Egil Eide
- Department of Research and Development, Centre for Clinical Research, Haukeland University Hospital, Bergen, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Tone M Norekvål
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, Faculty of Medicine and Dentistry, University of Bergen, Bergen, Norway
| |
Collapse
|
14
|
Dharmarajan K, Foster J, Coylewright M, Green P, Vavalle JP, Faheem O, Huang PH, Krishnaswamy A, Thourani VH, McCoy LA, Wang TY. The medically managed patient with severe symptomatic aortic stenosis in the TAVR era: Patient characteristics, reasons for medical management, and quality of shared decision making at heart valve treatment centers. PLoS One 2017; 12:e0175926. [PMID: 28430791 PMCID: PMC5400246 DOI: 10.1371/journal.pone.0175926] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 04/03/2017] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Little is known about patients with severe symptomatic aortic stenosis (AS) who receive medical management despite evaluation at a heart valve treatment center. OBJECTIVE We identified patient characteristics associated with medical management, physician-reported reasons for selecting medical management, and patients' perceptions of their involvement and satisfaction with treatment selection. METHODS AND RESULTS Of 454 patients evaluated for AS at 9 established heart valve treatment centers from December 12, 2013 to August 19, 2014, we included 407 with severe symptomatic AS. Information was collected using medical record review and survey of patients and treating physicians. Of 407 patients, 212 received transcatheter aortic valve replacement (TAVR), 124 received surgical aortic valve replacement (SAVR), and 71 received medical management (no SAVR/TAVR). Thirty-day predicted mortality was higher in patients receiving TAVR (8.7%) or medical management (9.8%) compared with SAVR (3.4%) (P<0.001). Physician-reported reasons for medical management included patient preference (31.0%), medical futility (19.7%), inoperability/anatomic infeasibility (11.3%), and inadequate vascular access (8.5%). Compared with patients receiving AVR, medically managed patients were less likely to report that they received enough information about the pros and cons of treatment options (P = 0.03), that their physicians involved them in treatment decisions (P<0.001), and that final decisions were the right ones (P<0.001). CONCLUSIONS Patient preference was the most common physician-reported reason for selecting non-invasive AS management, yet patients not undergoing AVR after valve center evaluation reported being less likely to receive sufficient education about treatment options and more likely to feel uncertain about final treatment decisions. Greater attention to shared decision making may improve the experience of care for this vulnerable group of patients.
Collapse
Affiliation(s)
- Kumar Dharmarajan
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, United States of America
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT, United States of America
| | - Jill Foster
- American College of Cardiology, Washington, DC, United States of America
| | - Megan Coylewright
- Section of Cardiovascular Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, United States of America
| | - Philip Green
- Division of Cardiology, Center for Interventional Vascular Therapy, Columbia University Medical Center, New York, NY, United States of America
| | - John P. Vavalle
- Division of Cardiology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Osman Faheem
- Prima Care Cardiology, Fall River, MA, United States of America
| | - Pei-Hsiu Huang
- Sutter Heart & Vascular Institute, Sacramento, CA, United States of America
| | - Amar Krishnaswamy
- Department of Cardiovascular Medicine, Division of Interventional Cardiology, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Vinod H. Thourani
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Lisa A. McCoy
- Duke Clinical Research Institute, Durham, NC, United States of America
| | - Tracy Y. Wang
- Duke Clinical Research Institute, Durham, NC, United States of America
| |
Collapse
|
15
|
Moore M, Chen J, Mallow PJ, Rizzo JA. The direct health-care burden of valvular heart disease: evidence from US national survey data. CLINICOECONOMICS AND OUTCOMES RESEARCH 2016; 8:613-627. [PMID: 27799803 PMCID: PMC5076539 DOI: 10.2147/ceor.s112691] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose This study quantified the overall effects of aortic valve disease (AVD) and mitral valve disease (MVD) by disease severity on direct health-care costs to insurers and patients. Materials and methods Based on 1996–2011 data from the Medical Expenditure Panel Survey (MEPS), a large, nationally representative US database, multivariate analyses were performed to assess the relationship between AVD and MVD and direct annual health-care costs to insurers and patients, at individual and US-aggregate levels. Adults aged 18 years and over with diagnosis codes for AVD or MVD based on International Classification of Diseases (ninth revision) diagnosis codes were identified. Subjects were further classified as symptomatic AVD, asymptomatic AVD, symptomatic MVD, and asymptomatic MVD. These classifications were determined with clinical assistance and based in part on data availability in the MEPS. Results The MEPS database included 148 patients with AVD: 53 patients with symptomatic AVD, 95 patients with asymptomatic AVD, and 1,051 with MVD, including 315 patients with symptomatic MVD and 736 patients with asymptomatic MVD. Symptomatic AVD had the largest incremental effect on annual per patient health-care expenditure: $12,789 for symptomatic AVD, $10,816 for asymptomatic AVD, $5,163 for symptomatic MVD, and $1,755 for asymptomatic MVD. When aggregated to the US population, heart-valve disease accounted for an incremental annual cost of $23.4 billion. The largest aggregate annual costs were incurred by patients with symptomatic MVD ($7.6 billion), followed by symptomatic AVD ($5.6 billion), asymptomatic MVD ($5.6 billion), and asymptomatic AVD ($4.6 billion). Conclusion The annualized incremental costs of heart-valve disease were substantial for all groups examined, and greatest for patients with symptomatic MVD. This reflects the relatively high prevalence associated with this group. With a growing and aging population, the prevalence of heart-valve disease is expected to rise, increasing the burden on public health.
Collapse
Affiliation(s)
- Matt Moore
- Global Health Economic Strategy, Edwards Lifesciences Inc, Irvine, CA
| | - Jie Chen
- Department of Health Services and Administration, University of Maryland, College Park, MD
| | - Peter J Mallow
- Health Economics and Outcomes Research, CTI Clinical Trial & Consulting Services Inc, Cincinnati, OH
| | - John A Rizzo
- Department of Preventive Medicine and Economics, Stony Brook University, Stony Brook, NY, USA
| |
Collapse
|
16
|
Hu K, Wan Y, Hong T, Lu SY, Guo CF, Li J, Wang CS. Therapeutic Decision-Making for Elderly Patients With Symptomatic Severe Valvular Heart Diseases. Int Heart J 2016; 57:434-40. [PMID: 27396559 DOI: 10.1536/ihj.16-027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The aim of this study was to determine how older age and co-morbidities affect the treatment decision-making and long-term survival in elderly patients with symptomatic severe valvular heart diseases.A total of 181 elderly patients (mean age, 78.4 ± 3.4 years) hospitalized between January 2003 and June 2012 with symptomatic severe valvular heart diseases were enrolled. Cardiac and geriatric factors associated with treatment decision-making were analyzed. Survival outcomes were investigated.Surgical treatment was performed in 116 (64%) patients (surgical group) and 65 patients (36%) were treated conservatively (conservative group). The most common [62% (40/65)] reason for refusing surgical treatment was high operative risk as assessed by the physicians who initially cared for the patients. Multivariate logistic regression analysis identified female gender, chronic renal insufficiency, older age, pneumonia, and emergent status as independent predictors of the conservative treatment. Patients with isolated aortic valve disease tended to undergo an operation. Overall 5-year survival in the surgical group was 76.8% versus 42.9% in the conservative group (P < 0.0001). After matching using the propensity score, the surgical group still had a better long-term survival than the conservative group (P = 0.001). Cox regression analysis revealed conservative treatment as the single risk factor associated with poor long-term survival in all series.Approximately 40% of the elderly patients with symptomatic severe heart valve disease were treated conservatively despite a definite indication for surgical intervention. Cardiac and geriatric co-morbidities profoundly affect the treatment decision-making. Interdisciplinary discussion should be encouraged to optimize therapeutic options for elderly patients with valvular heart disease.
Collapse
Affiliation(s)
- Kui Hu
- Department of Cardiovascular Surgery, Zhongshan Hospital, Fudan University, The Shanghai Institute of Cardiovascular Diseases
| | | | | | | | | | | | | |
Collapse
|
17
|
Thyregod HGH, Holmberg F, Gerds TA, Ihlemann N, Søndergaard L, Steinbrüchel DA, Olsen PS. Heart Team therapeutic decision-making and treatment in severe aortic valve stenosis. SCAND CARDIOVASC J 2016; 50:146-53. [PMID: 26825285 DOI: 10.3109/14017431.2016.1148825] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Objectives After transcatheter aortic valve implantation (TAVI) has been available for high-risk patients with severe aortic valve stenosis (AVS), the decision-making of the Heart Team (HT) has not been examined. Design All adult patients with severe AVS referred to a large tertiary medical centre in 2011 were prospectively included. Multivariate regression analysis identified independent factors associated with treatment decisions. Results A total of 487 patients were included (mean age: 75 years, NYHA class III-IV: 47%). The HT proposed medical therapy (MT) in 35 (7%), TAVI in 60 (12%), and surgical aortic valve replacement (SAVR) in 392 (81%) of patients. In patients referred to intervention, TAVI compared with SAVR patients were older (OR = 1.17 per year, 95% CI 1.09-1.26; p < 0.01) with more previous coronary artery bypass surgery (OR = 385, 79-2738; p < 0.01), obesity (OR = 4.69, 1.51-13.77; p < 0.01), and chronic obstructive pulmonary disease (COPD) (OR = 3.66, 1.21-10.75; p = 0.02). MT patients compared with patients referred to any intervention were older, had a higher prevalence of COPD, peripheral arterial disease, previous myocardial infarction, and cerebrovascular disease. Conclusions The HT proposed intervention in 93% of patients with severe AVS despite high age, advanced symptoms and a high burden of co-morbidity. TAVI was reserved for older patients particularly with previous CABG.
Collapse
Affiliation(s)
| | - Fredrik Holmberg
- a Department of Cardiothoracic Surgery, Rigshospitalet , University of Copenhagen , Copenhagen , Denmark
| | - Thomas Alexander Gerds
- b Section for Biostatistics, Department of Public Health , University of Copenhagen , Copenhagen , Denmark
| | - Nikolaj Ihlemann
- c Department of Cardiology, Rigshospitalet , Copenhagen University Hospital , Copenhagen , Denmark
| | - Lars Søndergaard
- c Department of Cardiology, Rigshospitalet , Copenhagen University Hospital , Copenhagen , Denmark
| | | | - Peter Skov Olsen
- a Department of Cardiothoracic Surgery, Rigshospitalet , University of Copenhagen , Copenhagen , Denmark
| |
Collapse
|
18
|
Zur Leitlinie Herzklappenerkrankungen der ESC und EACTS Version 2012. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2014. [DOI: 10.1007/s00398-013-1027-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
|
19
|
Isolated aortic valve replacement in octogenarians before and after the introduction of trans-catheter aortic valve implantation. Heart Lung Circ 2013; 23:249-55. [PMID: 24252451 DOI: 10.1016/j.hlc.2013.10.083] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Revised: 08/22/2013] [Accepted: 10/17/2013] [Indexed: 11/22/2022]
Abstract
BACKGROUND Trans-catheter aortic valve implantation (TAVI) became available at Auckland City Hospital in 2011 for patients with severe aortic stenosis in whom surgical aortic valve replacement (AVR) was deemed at high risk. We assessed whether introduction of TAVI affected the characteristics and outcomes of octogenarians undergoing AVR. METHODS Isolated AVR performed in patients ≥80 years of age during 2008-2012 were divided into two groups, pre- and post-TAVI introduction, for analyses. RESULTS Isolated AVR was undertaken in 35 and 33 octogenarians pre- and post-TAVI introduction. The post-TAVI group were older (84.2 vs 82.3 years, P=0.003), had lower ejection fraction (P=0.026), more had inpatient surgery (76% vs 29%, P<0.001), with higher EuroSCORE II (5.4 vs 3.9%, P=0.033). Operative mortality was 0.0% in both groups. One-year survival was similar (97.6% vs 94.3%, P=0.613), but composite morbidity was lower in the post-TAVI group (9.1% vs 31.4%, P=0.035). Chronic respiratory disease (P=0.043) independently predicted mortality during follow-up, while number of coronary vessel>50% stenosis (P=0.050), creatinine clearance (P=0.016) and being in the pre-TAVI era group (P=0.022) predicted composite morbidity. CONCLUSIONS Since TAVI was introduced, mean age and risk scores significantly increased in octogenarians undergoing AVR, while mortality rates remained similar and composite morbidity decreased.
Collapse
|
20
|
Pereira E, Silva G, Caeiro D, Fonseca M, Sampaio F, Fonseca C, Primo J, Simões L, Vouga L, Gama V. Cirurgia cardíaca na estenose aórtica severa: o que mudou com o advento do tratamento percutâneo? Rev Port Cardiol 2013; 32:749-56. [DOI: 10.1016/j.repc.2013.04.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2012] [Revised: 11/11/2012] [Accepted: 04/11/2013] [Indexed: 10/26/2022] Open
|
21
|
Pereira E, Silva G, Caeiro D, Fonseca M, Sampaio F, Fonseca C, Primo J, Simões L, Vouga L, Gama V. What has changed in surgical treatment of severe aortic stenosis with the advent of percutaneous intervention? REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2013. [DOI: 10.1016/j.repce.2013.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
|
22
|
Bazeed MF, Rezk AI, Moselhy MS. Value of cardiac CT in comprehensive aortic valve and root evaluation before percutaneous aortic valve replacement. Acta Radiol 2013; 54:498-504. [PMID: 23535182 DOI: 10.1177/0284185113477391] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Aortic stenosis (AS) is the most frequent valvular heart disease, and patients who develop AS are at a high risk of sudden death. There is no medical cure available, and aortic valve replacement is the only effective treatment for advanced disease. Preoperative evaluation is the cornerstone of therapy and is necessary for selecting the implantation technique and valve. PURPOSE To evaluate the role of cardiac CT in comprehensive aortic valve and aortic root evaluation before percutaneous aortic valve replacement. MATERIAL AND METHODS Thirty-four patients with severe aortic valve stenosis were evaluated by cardiac CT. The aortic valve calcification grade defined by cardiac CT was compared to the operative findings. The mean calculated aortic annulus diameter (CAAD) measured by cardiac CT was compared to the aortic annulus diameter measured by transthoracic echocardiography (TTE) as well as during the operation. The distances from the aortic valve annulus to the coronary ostia (right and left) were measured by cardiac CT and compared to the intraoperative measurements. The findings from the CT coronary angiography and conventional coronary angiography were compared. RESULTS There was strong agreement (k = 0.865) between the calcification grade by cardiac CT and the intraoperative grading. There was a stronger correlation (r = 0.948) between the CAAD assessed by cardiac CT and intraoperatively compared to the correlation between the intraoperative versus TTE measurements (r = 0.660). The distances measured between the aortic annulus and the right and left coronary artery ostia by cardiac CT were strongly correlated with the distances measured intraoperatively (r = 0.966 and 0.940 in the right and left sides, respectively). Cardiac CT detected three coronary artery stenotic lesions and three patent stents. All findings were confirmed by conventional coronary angiography. Thirteen percent of the evaluated coronary artery segments were of non-diagnostic quality by cardiac CT. CONCLUSION Cardiac CT substantially facilitates the assessment of aortic root morphology prior to aortic valve replacement.
Collapse
Affiliation(s)
| | - Ahmad Ibrahim Rezk
- Department of Cardiac Surgery, Faculty of Medicine, Aim Shams University
| | | |
Collapse
|
23
|
Evidencia del coste-efectividad de la implantación transcatéter de la prótesis valvular aórtica (TAVI) Edwards SAPIEN en pacientes de alto riesgo con estenosis aórtica sintomática en España: resultados preliminares. ACTA ACUST UNITED AC 2013. [DOI: 10.1007/s40277-013-0001-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
24
|
Vahanian A, Alfieri O, Andreotti F, Antunes MJ, Barón-Esquivias G, Baumgartner H, Andrew Borger M, Carrel TP, De Bonis M, Evangelista A, Falk V, Iung B, Lancellotti P, Pierard L, Price S, Schäfers HJ, Schuler G, Stepinska J, Swedberg K, Takkenberg J, Von Oppell UO, Windecker S, Zamorano JL, Zembala M, Bax JJ, Baumgartner H, Ceconi C, Dean V, Deaton C, Fagard R, Funck-Brentano C, Hasdai D, Hoes A, Kirchhof P, Knuuti J, Kolh P, McDonagh T, Moulin C, Popescu BA, Reiner Ž, Sechtem U, Anton Sirnes P, Tendera M, Torbicki A, Vahanian A, Windecker S, Popescu BA, Von Segesser L, Badano LP, Bunc M, Claeys MJ, Drinkovic N, Filippatos G, Habib G, Kappetein AP, Kassab R, Lip GY, Moat N, Nickenig G, Otto CM, Pepper J, Piazza N, Pieper PG, Rosenhek R, Shuka N, Schwammenthal E, Schwitter J, Tornos Mas P, Trindade PT, Walther T. Guíade práctica clínica sobre el tratamiento de las valvulopatías (versión 2012). Rev Esp Cardiol (Engl Ed) 2013. [DOI: 10.1016/j.recesp.2012.10.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
25
|
van Geldorp MWA, Heuvelman HJ, Kappetein AP, Busschbach JJV, Cohen DJ, Takkenberg JJM, Bogers AJJC. Quality of life among patients with severe aortic stenosis. Neth Heart J 2012; 21:21-7. [PMID: 23229811 DOI: 10.1007/s12471-012-0364-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND The disease burden of patients with severe aortic stenosis is not often explored, while the incidence is increasing and many patients who have an indication for aortic valve replacement are not referred for surgery. We studied the quality of life of 191 patients with severe aortic stenosis, hypothesising that symptomatic patients have a far worse quality of life than the general population, which could enforce the indication for surgery. METHODS The SF-36v2 Health Survey was completed by 191 consecutive patients with symptomatic or asymptomatic severe aortic stenosis. RESULTS Asymptomatic patients (n = 59) had health scores comparable with the general Dutch population but symptomatic patients (n = 132) scored significantly lower across different age categories. Physical functioning, general health and vitality were impaired, as well as social functioning and emotional well-being. There was no relation between degree of stenosis and physical or mental health scores. CONCLUSIONS Both physical and emotional problems have a major impact on normal daily life and social functioning of symptomatic patients with severe aortic stenosis, regardless of age. If the aortic stenosis is above the 'severe' threshold, the degree of stenosis does not predict disease burden. These results encourage to reconsider a conservative approach in symptomatic patients with severe aortic stenosis. Using the SF-36v2 Health Survey together with this study, an individual patient's quality of life profile can be assessed and compared with the patient group or with the general population. This can assist in decision making for the individual patient.
Collapse
Affiliation(s)
- M W A van Geldorp
- Department of Cardio-thoracic Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands,
| | | | | | | | | | | | | |
Collapse
|
26
|
van Geldorp MWA, Heuvelman HJ, Kappetein AP, Busschbach JJV, Takkenberg JJM, Bogers AJJC. The effect of aortic valve replacement on quality of life in symptomatic patients with severe aortic stenosis. Neth Heart J 2012; 21:28-35. [PMID: 23239448 DOI: 10.1007/s12471-012-0362-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Although symptomatic patients with severe aortic stenosis have a high disease burden and guidelines recommend aortic valve replacement, many are treated conservatively. This study describes to what extent quality of life is changed by aortic valve replacement relative to conservative treatment. METHODS This observational study followed 132 symptomatic patients with severe aortic stenosis who were subjected to an SF-36v2TM Health Survey. RESULTS At baseline 84 patients were treated conservatively, 48 were referred for aortic valve replacement. In the conservatively treated group 15 patients died during a mean follow-up of 18 months (Kaplan-Meier survival was 85 % and 72 % at one and 2 years respectively) and 22 patients crossed over to the surgical group. Of the resulting 70 patients in the surgical group 3 patients died during a mean follow-up of 11 months (survival 95 % at 1 year). Physical functioning, vitality and general health improved significantly 1 year after aortic valve replacement. In conservatively treated patients physical quality of life deteriorated over time while general health, vitality and social functioning showed a declining trend. Mental health remained stable in both groups. CONCLUSIONS Aortic valve replacement improves physical quality of life, general health and vitality in patients with symptomatic severe aortic stenosis. Besides having a low life expectancy, conservatively treated patients experience deterioration of physical quality of life. Health surveys such as the SF-36v2TM can be valuable tools in monitoring the burden of disease for an individual patient and offer additional help in treatment decisions.
Collapse
Affiliation(s)
- M W A van Geldorp
- Department of Cardio-thoracic Surgery, Catharina Hospital, PO Box 1350, 5602 ZA, Eindhoven, the Netherlands,
| | | | | | | | | | | |
Collapse
|
27
|
Clinical course of patients diagnosed with severe aortic stenosis in the Rotterdam area: insights from the AVARIJN study. Neth Heart J 2012; 20:487-93. [PMID: 22864980 DOI: 10.1007/s12471-012-0309-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
OBJECTIVE To prospectively evaluate the clinical course of patients with severe aortic stenosis (AS) and identify factors associated with treatment selection and patient outcome. METHODS Patients diagnosed with severe AS in the Rotterdam area were included between June 2006 and May 2009. Patient characteristics, echocardiogram, brain natriuretic peptide (NT-proBNP), and treatment strategy were assessed at baseline, and after 6, 12, and 24 months. Endpoints were aortic valve replacement (AVR) / transcatheter aortic valve implantation (TAVI) and death. RESULTS The study population comprised 191 patients, 132 were symptomatic and 59 asymptomatic at study entry. Two-year cumulative survival of symptomatic patients was 89.8 % (95 % CI 79.8-95.0 %) after AVR/TAVI and 72.6 % (95 % CI 59.7-82.0 %) with conservative treatment. Two-year cumulative survival of asymptomatic patients was 91.5 % (95 % CI 80.8-96.4 %). Two-year cumulative incidence of AVR/TAVI was 55.9 % (95 % CI 47.5-63.5 %) in symptomatic patients. Sixty-eight percent of asymptomatic patients developed symptoms, median time to symptoms was 13 months; AVR/TAVI cumulative incidence was 38.3 % (95 % CI 23.1-53.3 %). Elderly symptomatic patients with multiple comorbidities were more likely to receive conservative treatment. CONCLUSIONS In contemporary Dutch practice many symptomatic patients do not receive invasive treatment of severe AS. Two-thirds of asymptomatic patients develop symptoms within 2 years, illustrating the progressive nature of severe AS. Treatment optimisation may be achieved through careful individualised assessment in a multidisciplinary setting.
Collapse
|
28
|
Malouf J, Le Tourneau T, Pellikka P, Sundt TM, Scott C, Schaff HV, Enriquez-Sarano M. Aortic valve stenosis in community medical practice: Determinants of outcome and implications for aortic valve replacement. J Thorac Cardiovasc Surg 2012; 144:1421-7. [DOI: 10.1016/j.jtcvs.2011.09.075] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2011] [Revised: 08/26/2011] [Accepted: 09/26/2011] [Indexed: 10/14/2022]
|
29
|
Badran AA, Vohra HA, Livesey SA. Unoperated severe aortic stenosis: decision making in an adult UK-based population. Ann R Coll Surg Engl 2012; 94:416-21. [PMID: 22943332 PMCID: PMC3954323 DOI: 10.1308/003588412x13171221591817] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Severe symptomatic aortic stenosis is associated with a poor prognosis, with most patients dying 2–3 years after diagnosis. We analysed the proportion of patients with severe aortic stenosis not referred for aortic valve replacement (AVR) in a UK-based population and the clinical factors contributing to this. METHODS Retrospective analysis of patients with echocardiographic evidence of severe aortic stenosis was performed at a university teaching hospital. RESULTS A total of 178 consecutive patients with severe aortic stenosis (AVA: <1cm2, mean pressure gradient: ≥40mmHg, or visually severe on echocardiography) were included in the study. Eighty-three patients did not have AVR (95% confidence interval: 39–54%). The cohort included 146 symptomatic patients (82%) and 32 (18%) who were asymptomatic. The most common reason for non-referral in symptomatic patients was ‘high operative risk’ and in asymptomatic patients ‘no symptoms’. Of the patients who did not have AVR, only 19% (n=16) were referred for a surgical opinion. None of the patients in the asymptomatic group underwent echocardiographic stress imaging. The thirty-day operative mortality rate in the AVR group was 2.3%. Symptomatic patients who underwent AVR had superior survival, even after adjusting for co-morbidities (p<0.001). CONCLUSIONS A considerable proportion of patients with severe aortic stenosis are not referred for surgery although they have a clear indication for AVR. Patients are often estimated as being too high risk or having prohibitive co-morbidities. Among asymptomatic patients, stress imaging was rarely used despite its useful role prognostically and in deciding the best time for intervention.
Collapse
Affiliation(s)
- A A Badran
- Wessex Cardiac Centre, Southampton General Hospital, UK
| | | | | |
Collapse
|
30
|
Schouten HJ, van Ginkel S, Koek H(D, Geersing GJ, Oudega R, Moons KG, van Delden J(H. Non-Diagnosis Decisions and Non-Treatment Decisions in Elderly Patients With Cardiovascular Diseases, Do They Differ? – A Systematic Review. J Am Med Dir Assoc 2012; 13:682-7. [PMID: 22705033 DOI: 10.1016/j.jamda.2012.05.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2012] [Revised: 05/14/2012] [Accepted: 05/14/2012] [Indexed: 11/25/2022]
|
31
|
Vahanian A, Alfieri O, Andreotti F, Antunes MJ, Barón-Esquivias G, Baumgartner H, Borger MA, Carrel TP, De Bonis M, Evangelista A, Falk V, Iung B, Lancellotti P, Pierard L, Price S, Schäfers HJ, Schuler G, Stepinska J, Swedberg K, Takkenberg J, Von Oppell UO, Windecker S, Zamorano JL, Zembala M, Bax JJ, Baumgartner H, Ceconi C, Dean V, Deaton C, Fagard R, Funck-Brentano C, Hasdai D, Hoes A, Kirchhof P, Knuuti J, Kolh P, McDonagh T, Moulin C, Popescu BA, Reiner Ž, Sechtem U, Sirnes PA, Tendera M, Torbicki A, Vahanian A, Windecker S, Popescu BA, Von Segesser L, Badano LP, Bunc M, Claeys MJ, Drinkovic N, Filippatos G, Habib G, Kappetein AP, Kassab R, Lip GY, Moat N, Nickenig G, Otto CM, Pepper J, Piazza N, Pieper PG, Rosenhek R, Shuka N, Schwammenthal E, Schwitter J, Mas PT, Trindade PT, Walther T. Guidelines on the management of valvular heart disease (version 2012). Eur J Cardiothorac Surg 2012; 42:S1-44. [DOI: 10.1093/ejcts/ezs455] [Citation(s) in RCA: 1024] [Impact Index Per Article: 85.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
|
32
|
Poelman JE, van der Werf RW, Douglas YL, van den Heuvel AFM, de Smet BJGL, Mariani MA. Percutaneous aortic valve replacement using a subclavian artery graft. Ann Thorac Surg 2012; 94:e95-6. [PMID: 23006722 DOI: 10.1016/j.athoracsur.2012.03.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2011] [Revised: 02/14/2012] [Accepted: 03/05/2012] [Indexed: 11/16/2022]
Abstract
Over the past few years transcatheter heart valve implantation (THI) has become an alternative treatment for aortic valve replacement. The THI does not require a midline sternotomy or cardiopulmonary bypass and can be performed through a transfemoral or a transapical approach. In case of severe peripheral vascular disease the transapical route is usually chosen. However, when the use of a small anterolateral thoracotomy is not preferred due to comorbidities, the subclavian artery can be considered as a third alternative route. This case report describes an approach for THI through the subclavian artery, by using a Dacron graft.
Collapse
Affiliation(s)
- Janny E Poelman
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | | | | | | | | | | |
Collapse
|
33
|
Vahanian A, Alfieri O, Andreotti F, Antunes MJ, Barón-Esquivias G, Baumgartner H, Borger MA, Carrel TP, De Bonis M, Evangelista A, Falk V, Iung B, Lancellotti P, Pierard L, Price S, Schäfers HJ, Schuler G, Stepinska J, Swedberg K, Takkenberg J, Von Oppell UO, Windecker S, Zamorano JL, Zembala M, Baumgartner H, Ceconi C, Dean V, Deaton C, Fagard R, Funck-Brentano C, Hasdai D, Hoes A, Kirchhof P, Knuuti J, Kolh P, McDonagh T, Moulin C, Popescu BA, Reiner Ž, Sechtem U, Sirnes PA, Tendera M, Torbicki A, Vahanian A, Windecker S, Popescu BA, Von Segesser L, Badano LP, Bunc M, Claeys MJ, Drinkovic N, Filippatos G, Habib G, Kappetein AP, Kassab R, Lip GY, Moat N, Nickenig G, Otto CM, Pepper J, Piazza N, Pieper PG, Rosenhek R, Shuka N, Schwammenthal E, Schwitter J, Mas PT, Trindade PT, Walther T. Guidelines on the management of valvular heart disease (version 2012). Eur Heart J 2012; 33:2451-96. [PMID: 22922415 DOI: 10.1093/eurheartj/ehs109] [Citation(s) in RCA: 2622] [Impact Index Per Article: 218.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
-
- Service de Cardiologie, Hospital Bichat AP-HP, 46 rue Henri Huchard, 75018 Paris, France.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
34
|
Birim Ö, Heuvelman HJ, Piazza N, Bogers AJJC, Kappetein AP. What do we know about the natural history of severe symptomatic aortic valve stenosis? Interv Cardiol 2012. [DOI: 10.2217/ica.12.5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
|
35
|
Nistri S, Faggiano P, Olivotto I, Papesso B, Bordonali T, Vescovo G, Dei Cas L, Cecchi F, Bonow RO. Hemodynamic progression and outcome of asymptomatic aortic stenosis in primary care. Am J Cardiol 2012; 109:718-23. [PMID: 22154322 DOI: 10.1016/j.amjcard.2011.10.035] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2011] [Revised: 10/13/2011] [Accepted: 10/13/2011] [Indexed: 11/27/2022]
Abstract
The prognostic relevance of a rapid rate of hemodynamic progression of aortic stenosis (AS) has been predominantly investigated in tertiary centers. We reviewed the clinical and echocardiographic data from 153 asymptomatic patients with AS (age 77 ± 9 years; 65% men), with normal left ventricular function and paired echocardiograms ≥4 months apart (mean 2.9 ± 2.1 years), evaluated in a nonreferral echocardiographic laboratory. The severity of AS was graded by the peak aortic velocity (Vmax) and progression was classified as slow or fast according to a cutoff value of 0.3 m/s increase annually. The end points were all-cause mortality and a composite of all-cause mortality and aortic valve replacement (AVR). At baseline, 135 patients (88%) had mild-to-moderate and 18 (12%) severe AS. Of the 153 patients, 49 (32%) showed fast progression (0.61 ± 0.32 m/s/yr) and 104 (68%) had slow progression (0.10 ± 0.16 m/s/yr). Among the 144 patients (94%) with clinical follow-up data, 40 died and 48 underwent AVR. The mortality rate was greater than that of the general population (p <0.001). On multivariate analysis, the independent predictors of mortality were the yearly change in Vmax (hazard ratio [HR] 13.352 per m/s increase, 95% confidence interval [CI] 5.136 to 34.713, p <0.001) and age (HR 1.122 per year, 95% CI 1.0728 to 1.735, p <0.001). The predictors of the composite end point of death and AVR were the yearly change in Vmax (HR 12.307, 95% CI 6.024 to 25.140, p <0.001) and Vmax on the initial echocardiogram (HR 2.684, 95% CI 1.921 to 3.750, p <0.001). In conclusion, primary care patients with asymptomatic AS are usually elderly and frequently develop rapid hemodynamic progression, which independently predicts, not only AVR, but also overall mortality.
Collapse
|
36
|
Malaisrie SC, Tuday E, Lapin B, Wang E, Lee R, McGee EC, Davidson C, McCarthy PM. Transcatheter aortic valve implantation decreases the rate of unoperated aortic stenosis. Eur J Cardiothorac Surg 2011; 40:43-8. [PMID: 21232970 DOI: 10.1016/j.ejcts.2010.11.031] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2010] [Revised: 11/08/2010] [Accepted: 11/11/2010] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE Aortic valve replacement (AVR) is the standard treatment for severe, symptomatic aortic stenosis (AS). However, many patients are not referred for surgery and fewer undergo AVR. Transcatheter aortic valve implantation (TAVI) has emerged as a solution for high-risk AS patients. We sought to measure the impact of TAVI on the undertreatment of AS. METHODS Patients with AS were identified by retrospective medical record review and evaluation of echocardiograms were performed in a single-center tertiary-care institution. A total of 179, 183, 214, and 265 patients had AS in 2006, 2007, 2008, and 2009, respectively, with the introduction of TAVI occurring in 2008 and continuing through 2009. The primary endpoints were the rates of unoperated AS and surgical referral. RESULTS The rates of unoperated AS were 50.6% before TAVI and 40.7% after TAVI (p = 0.002). Referral rates to surgery were 63.6% before TAVI and 74.1% after TAVI (p = 0.003). Reasons for nonreferral were patient-family decision, perceived high operative risk, and the presence of comorbidities. Operative mortality was 3.7% and not statistically significant different between years. Three-year patient survival was 82.5% in the AVS group and 43.9% in the UNOP group (p < 0.001). CONCLUSIONS The introduction of TAVI was associated with an increase in surgical referrals and a decrease in the rate of unoperated AS. This positive impact was due to increases in both TAVI and AVR volume. Increased volume was not associated with worse patient survival. A significant population of patients with AS are still treated medically.
Collapse
Affiliation(s)
- S Chris Malaisrie
- Division of Cardiac Surgery, Northwestern University, Feinberg School of Medicine, Bluhm Cardiovascular Institute at Northwestern Memorial Hospital, Chicago, IL, USA.
| | | | | | | | | | | | | | | |
Collapse
|
37
|
Transcatheter aortic valve implantation: evidence on safety and efficacy compared with medical therapy. A systematic review of current literature. Clin Res Cardiol 2010; 100:265-76. [PMID: 21165626 DOI: 10.1007/s00392-010-0268-x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2010] [Accepted: 12/02/2010] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Transcatheter aortic valve implantation (TAVI) promises effective treatment for high-risk elderly patients with symptomatic severe aortic stenosis (AS). However, the adoption of TAVI must be justified and guarantee long-term performance. Systematic reviews are a core methodology in evidence-based health economics for judging medical effectiveness. In this work, the methodology was applied to provide objective evidence on the efficacy and safety of TAVI at 1-year follow-up and to assess whether TAVI confers a survival benefit compared with medical therapy. METHODS In accordance with the toolkit of the "German Scientific Working Group Technology Assessment for Health Care" (GSWG), a systematic literature review on the safety and efficacy of TAVI procedures was conducted in major bibliographic databases to identify all relevant publications. Preestablished inclusion criteria were defined. An initial screening of identified articles regarding titles and abstracts was followed by a full-text screening. Data from eligible articles were extracted and evaluated according to GSWG checklists followed by a qualitative synthesis of information. RESULTS The systematic literature search identified 12 primary publications (derived from 1,849 citations) for TAVI [number of patients (n) = 1,049] and 11 publications (derived from 189 citations) for medical therapy of AS (n = 946) that fulfilled the inclusion criteria. Mean overall procedural success rate for included TAVI interventions was 93.3%. Mean combined procedural, post-procedural, and cumulative in-hospital/30-day mortality was 11.4% (n = 116; range 5.3-23%). 1 year after TAVI, the mean overall survival rate was 75.9% (range 64.1-87%) compared with 62.4% (range 40-84.8%) for medically treated patients (p value < 0.01). 1-year survival after TAVI for patients treated with transvascular (TV) procedures was higher than after transapical (TA) procedures (79.2 vs. 73.6%) (p value = 0.04). At 1-year follow-up, the improved valvular function remained stable, and there was a trend towards an improved ventricular function. CONCLUSION Based on the best available data, in patients with symptomatic severe AS, TAVI demonstrates an improved 1-year survival compared with medical treatment. The survival benefit of TV-TAVI over medical therapy elucidated from this systematic literature review is +16.8% and therefore, in good congruence with the recently published results from the randomized PARTNER US trial (+20%).
Collapse
|
38
|
Antunes MJ. Editorial comment. Eur J Cardiothorac Surg 2009; 35:958-9. [DOI: 10.1016/j.ejcts.2009.02.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2009] [Revised: 02/14/2009] [Accepted: 02/16/2009] [Indexed: 11/24/2022] Open
|