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Goliasch G, Kammerlander AA, Nitsche C, Dona C, Schachner L, Öztürk B, Binder C, Duca F, Aschauer S, Laufer G, Hengstenberg C, Bonderman D, Mascherbauer J. Syncope. JACC Cardiovasc Imaging 2019; 12:225-232. [DOI: 10.1016/j.jcmg.2018.09.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 09/17/2018] [Accepted: 09/19/2018] [Indexed: 11/26/2022]
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Colli A, Bizzotto E, Besola L, Gregori D, Toto F, Manzan E, Gerosa G. Risk stratification of severe aortic stenosis according to new guidelines: long term outcomes. J Thorac Dis 2018; 10:5833-5841. [PMID: 30505491 DOI: 10.21037/jtd.2018.09.152] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background Current ESC and ACC/AHA guidelines for the management of valvular heart disease assign a class Ia indication for aortic valve replacement (AVR) only to patients with symptomatic severe aortic valve stenosis and asymptomatic patients with depressed left ventricular ejection fraction (LVEF <50%) or positive exercise test. We examined the long-term outcomes for patients undergoing AVR for aortic stenosis over a 11-year period at our institution compared to current international guidelines for AVR. Methods Patients who had undergone isolated AVR for severe aortic valve stenosis between January 2001 and December 2012 were selected. The population was divided into subgroups based on preoperative LVEF (< or ≥50%) and on presence/absence of symptoms (NYHA =I or ≥II, respectively). Results We identified 607 patients with a median follow-up (FU) time of 5.75 years (IQR 3.24-8.00 years). The presence of symptoms did not have a significant impact on cardiovascular mortality (P=0.201). Patients with LVEF <50% displayed a higher long-term cardiovascular mortality rate (P=0.015). Multivariate analysis showed that preserved LVEF was a protective factor for asymptomatic patients (P=0.021), while preoperative LVEF did not affect the mortality rate in symptomatic patients (HR 0.88; 95% CI, 0.54-1.44). Correspondingly, asymptomatic patients with reduced LVEF were found to be at a higher risk of long-term mortality compared to the other groups (P=0.011). The only other independent risk factor for death was age (HR 6.46; 95% CI, 2.22-18.76). Conclusions According to our data, current international class I indications for symptomatic patients ensure good long-term survival, while class I indications for asymptomatic patients with reduced LVEF are associated with poor long-term survival. Our results suggest that early surgery should also be considered also for asymptomatic patients with preserved LVEF, particularly in cases of very low operative risk.
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Affiliation(s)
- Andrea Colli
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Eleonora Bizzotto
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Laura Besola
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Dario Gregori
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Francesca Toto
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Erica Manzan
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Gino Gerosa
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
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Song I, Ko SM, Yi JG, Chee HK, Kim JS. Differences in Aortic Valve and Left Ventricular Parameters Related to the Severity of Myocardial Fibrosis in Patients with Severe Aortic Valve Stenosis. PLoS One 2017; 12:e0170939. [PMID: 28129367 PMCID: PMC5271376 DOI: 10.1371/journal.pone.0170939] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 01/12/2017] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE This study investigated the morphological and functional characteristics of the aortic valve and the left ventricular (LV) systolic functional parameters and myocardial mass related to the severity of myocardial fibrosis (MF) in patients with severe aortic valve stenosis (AS). MATERIALS AND METHODS We retrospectively enrolled 81 patients (48 men; mean age: 59±12 years) with severe AS who underwent transthoracic echocardiography (TTE), cardiac computed tomography (CCT), and cardiovascular magnetic resonance (CMR) within 1 month and subsequent aortic valve surgery. Degree of MF was determined on delayed contrast-enhanced CMR with visual sub-segmental analysis-based quantification and was classified into three groups (no, mild, and severe) for identifying the differences in LV function and characteristics of the aortic valve. One-way ANOVA, Chi-square test or Fisher's exact test were used to compare variables of the three groups. Univariate multinomial logistic regression analysis was performed to determine the association between the severity of MF and variables on imaging modalities. RESULTS Of 81 patients, 34 (42%) had MF (mild, n = 18; severe, n = 16). Aortic valve calcium volume score on CCT, aortic valve area, LV mass index, LV end-diastolic volume index on CMR, presence of mild aortic regurgitation (AR), transaortic mean pressure gradient, and peak velocity on TTE were significantly different among the three groups and were associated with severity of MF on a univariate multinomial logistic regression analysis. Aortic valve calcium grade was different (p = 0.008) among the three groups but not associated with severity of MF (p = 0.375). CONCLUSIONS A multi-imaging approach shows that severe AS with MF is significantly associated with more severe calcific AS, higher LV end-diastolic volume, higher LV mass, and higher prevalence of mild AR.
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Affiliation(s)
- Inyoung Song
- Department of Radiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Sung Min Ko
- Department of Radiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Jeong Geun Yi
- Department of Radiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Hyun Keun Chee
- Department of Thoracic Surgery, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Jun Seok Kim
- Department of Thoracic Surgery, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
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Should We Reappraise Surgical Indications in Asymptomatic Severe High-Gradient Aortic Stenosis? JACC Cardiovasc Imaging 2017; 10:51-53. [DOI: 10.1016/j.jcmg.2016.06.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 06/16/2016] [Indexed: 11/18/2022]
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Banovic M, Brkovic V, Nedeljkovic I, Nedeljkovic M, Popovic D, Djordjevic-Dikic A, Ristic A, Nikolic S, Beleslin B. Diabetes mellitus and coronary microvascular function in asymptomatic patients with severe aortic stenosis and nonobstructed coronary arteries. Diab Vasc Dis Res 2016; 13:220-7. [PMID: 26993497 DOI: 10.1177/1479164115627107] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND AND AIM Coronary flow reserve is impaired in asymptomatic patients with aortic stenosis and has a prognostic value. We investigated whether the type II diabetes mellitus additionally impairs microvascular circulation assessed by coronary flow reserve in patients with asymptomatic severe aortic stenosis, normal left ventricular ejection fraction and nonobstructed coronary arteries. METHODS A total of 128 patients, mean age of 66.35 ± 10.51 (58.6% males), with severe aortic stenosis and normal left ventricular ejection fraction were enrolled in this study. Patients with diabetes mellitus, those who were treated for diabetes mellitus or had documentation confirming the diagnosis of diabetes mellitus, were considered. All patients underwent coronary angiography and had no obstructive coronary disease (defined as having no stenosis >50% in diameter), standard transthoracic Doppler-echocardiographic study and adenosine stress transthoracic echocardiography for coronary flow reserve measurement. RESULTS Diabetes mellitus was present in 26 patients (20.31%). There was no significant difference in aortic stenosis severity between diabetic and non-diabetic patients [aortic valve area (0.81 ± 0.18 vs 0.85 ± 0.15 cm(2)) and Vmax (4.20 ± 0.57 vs 4.21 ± 0.48 m/s)]. Mean coronary flow reserve in diabetic patients was 1.98 ± 0.48, while mean coronary flow reserve in non-diabetic patients was 2.64 ± 0.54 (p < 0.01). Diabetes mellitus was independent predictor of coronary flow reserve [B = -0.636, 95% confidence interval (-0.916 to -0.368), p < 0.001]. CONCLUSION Diabetes mellitus additionally impairs coronary microvascular function in asymptomatic patients with severe aortic stenosis and nonobstructed coronary arteries.
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Affiliation(s)
- Marko Banovic
- Departments of Non-Invasive Cardiology and Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia Belgrade Medical School, University of Belgrade, Belgrade, Serbia
| | - Voin Brkovic
- Departments of Non-Invasive Cardiology and Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia
| | - Ivana Nedeljkovic
- Departments of Non-Invasive Cardiology and Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia Belgrade Medical School, University of Belgrade, Belgrade, Serbia
| | - Milan Nedeljkovic
- Departments of Non-Invasive Cardiology and Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia Belgrade Medical School, University of Belgrade, Belgrade, Serbia
| | - Dejana Popovic
- Departments of Non-Invasive Cardiology and Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia
| | - Ana Djordjevic-Dikic
- Departments of Non-Invasive Cardiology and Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia Belgrade Medical School, University of Belgrade, Belgrade, Serbia
| | - Arsen Ristic
- Departments of Non-Invasive Cardiology and Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia Belgrade Medical School, University of Belgrade, Belgrade, Serbia
| | | | - Branko Beleslin
- Departments of Non-Invasive Cardiology and Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia Belgrade Medical School, University of Belgrade, Belgrade, Serbia
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Banovic M, Iung B, Bartunek J, Asanin M, Beleslin B, Biocina B, Casselman F, da Costa M, Deja M, Gasparovic H, Kala P, Labrousse L, Loncar Z, Marinkovic J, Nedeljkovic I, Nedeljkovic M, Nemec P, Nikolic SD, Pencina M, Penicka M, Ristic A, Sharif F, Van Camp G, Vanderheyden M, Wojakowski W, Putnik S. Rationale and design of the Aortic Valve replAcemenT versus conservative treatment in Asymptomatic seveRe aortic stenosis (AVATAR trial): A randomized multicenter controlled event-driven trial. Am Heart J 2016; 174:147-53. [PMID: 26995381 DOI: 10.1016/j.ahj.2016.02.001] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Accepted: 02/04/2016] [Indexed: 11/24/2022]
Abstract
Aortic valve replacement (AVR) therapy is an obvious choice for symptomatic severe aortic stenosis (AS) patients as it improves symptoms, left ventricular function, and survival. The treatment decisions and indication for AVR in asymptomatic patients with severe AS and normal left ventricular ejection fraction are less well established and the subject of ongoing debate. Many efforts have been made to define the best treatment option in asymptomatic AS patients with normal left ventricular ejection fraction. Retrospective and observational data imply that elective AVR for asymptomatic severe AS may lead to improvement in outcomes in comparison to surgery performed after onset of symptoms. The AVATAR trial will aim to assess outcomes among asymptomatic AS patients randomized to either elective early AVR or medical management with vigilant follow-up. In the latter group, AVR would be delayed until either the onset of symptoms or changes in predefined echocardiographic parameters. To the best of the authors' knowledge, it will be the first large prospective, randomized, controlled, multicenter clinical trial that will evaluate the safety and efficacy of elective AVR in this specific group of patients.
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Mrak M, Ambrožič J, Mušič Š, Terseglav S, Kontestabile B, Lakič N, Bunc M. Transcatheter aortic valve implantation in a cancer patient denied for surgical aortic valve replacement—a case report. Wien Klin Wochenschr 2016; 128:516-20. [DOI: 10.1007/s00508-016-0990-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 02/29/2016] [Indexed: 01/06/2023]
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Marko B, Voin B, Bosiljka VT, Ivana N, Danijela T, Ana M, Dejana P, Serjan N. Long-term risk stratification with low-dose dobutamine testing in asymptomatic low-flow patients with severe aortic stenosis and normal ejection fraction. Int J Cardiol 2014; 176:1275-7. [DOI: 10.1016/j.ijcard.2014.07.187] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2014] [Accepted: 07/27/2014] [Indexed: 11/16/2022]
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