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Yokohama F, Takaya Y, Ichikawa K, Nakayama R, Miki T, Toda H, Toh N, Miyoshi T, Nakamura K, Ito H. Association Between Aortic Valve Calcification and Severity of Concomitant Aortic Regurgitation in Patients With Severe Aortic Stenosis. Circ J 2024; 88:606-611. [PMID: 37045774 DOI: 10.1253/circj.cj-22-0746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
BACKGROUND Patients with severe aortic stenosis (AS) frequently have concomitant aortic regurgitation (AR), but the association between aortic valvular calcification (AVC) and the severity of AR remains unclear.Methods and Results: We retrospectively reviewed patients with severe AS who underwent transthoracic echocardiography and multidetector computed tomography (MDCT) within 1 month. The patients were divided into 3 groups according to the degree of concomitant AR. The association between AVC and the severity of concomitant AR was assessed in patients with severe AS. The study population consisted of 95 patients: 43 men and 52 women with a mean age of 82±7 years. Of the 95 patients with severe AS, 27 had no or trivial AR, 53 had mild AR, and 15 had moderate AR. The AVC score (AVCS) and AVC volume (AVCV) significantly increased as the severity of concomitant AR increased (P=0.014 for both), and similar findings were obtained for the AVCS and AVCV indexes (P=0.004 for both). CONCLUSIONS The severity of AR correlated with AVCS and AVCV measured by MDCT in patients with severe AS. AVC may cause concomitant AR, leading to worsening of disease condition.
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Affiliation(s)
- Fumi Yokohama
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences
| | - Yoichi Takaya
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences
| | - Keishi Ichikawa
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences
| | - Rie Nakayama
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences
| | - Takashi Miki
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences
| | - Hironobu Toda
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences
| | - Norihisa Toh
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences
| | - Toru Miyoshi
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences
| | - Kazufumi Nakamura
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences
| | - Hiroshi Ito
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences
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2
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Guddeti RR, Gill GS, Parekh JD, Jhand AS, Walters RW, Panaich SS, Goldsweig AM, Alla VM. Transcatheter Aortic Valve Implantation in Mixed Aortic Valve Disease: A Multicenter Study. Am J Cardiol 2023; 203:394-402. [PMID: 37517135 DOI: 10.1016/j.amjcard.2023.07.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 07/06/2023] [Accepted: 07/13/2023] [Indexed: 08/01/2023]
Abstract
Mixed aortic valve disease (MAVD), defined by the concurrent presence of aortic stenosis (AS) and insufficiency is frequently seen in patients who have undergone transcatheter aortic valve implantation (TAVI). However, studies comparing the outcomes of TAVI in MAVD versus isolated AS have demonstrated conflicting results. Therefore, we aim to assess the outcomes of TAVI in patients with MAVD in comparison with those with isolated severe AS. Patients who underwent native valve TAVI for severe AS at 3 tertiary care academic centers between January 2012 and December 2020 were included and categorized into 3 groups based on concomitant aortic insufficiency (AI) as follows: group 1, no AI; group 2, mild AI; and group 3, moderate to severe AI. Outcomes of interest included all-cause mortality and all-cause readmission rates at 30 days and 1 year. Other outcomes include bleeding, stroke, vascular complications, and the incidence of paravalvular leak at 30 days after the procedure. Of the 1,588 patients who underwent TAVI during the study period, 775 patients (49%) had isolated AS, 606 (38%) had mild AI, and 207 (13%) had moderate to severe AI. Society of Thoracic Surgeons risk scores were significantly different among the 3 groups (5% in group 1, 5.5% in group 2, and 6% in group 3, p = 0.003). Balloon-expandable valves were used in about 2/3 of the population. No statistically significant differences in 30-day or 1-year all-cause mortality and all-cause readmission rates were noted among the 3 groups. Post-TAVI paravalvular leak at follow-up was significantly lower in group 1 (2.3%) and group 2 (2%) compared with group 3 (5.6%) (p = 0.01). In summary, TAVI in MAVD is associated with comparable outcomes at 1 year compared with patients with isolated severe AS.
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Affiliation(s)
- Raviteja R Guddeti
- Division of Cardiovascular Diseases, Creighton University School of Medicine, Omaha, Nebraska
| | - Gauravpal S Gill
- Division of Cardiovascular Diseases, Creighton University School of Medicine, Omaha, Nebraska
| | - Jai D Parekh
- Division of Cardiovascular Diseases, University of Iowa, Iowa City, Iowa
| | - Aravdeep S Jhand
- Division of Cardiovascular Diseases, University of Nebraska Medical Center, Omaha, Nebraska
| | - Ryan W Walters
- Department of Clinical Research, Creighton University School of Medicine, Omaha, Nebraska
| | - Sidakpal S Panaich
- Division of Cardiovascular Diseases, University of Iowa, Iowa City, Iowa
| | - Andrew M Goldsweig
- Division of Cardiovascular Diseases, University of Nebraska Medical Center, Omaha, Nebraska
| | - Venkata Mahesh Alla
- Division of Cardiovascular Diseases, Creighton University School of Medicine, Omaha, Nebraska.
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3
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Bernard J, Jean G, Bienjonetti-Boudreau D, Jacques F, Tastet L, Salaun E, Clavel MA. Prognostic utility of N-terminal pro B-type natriuretic peptide ratio in mixed aortic valve disease. Open Heart 2023; 10:e002361. [PMID: 37474135 PMCID: PMC10357672 DOI: 10.1136/openhrt-2023-002361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 06/30/2023] [Indexed: 07/22/2023] Open
Abstract
OBJECTIVE We aimed to assess the incremental prognostic value of N-terminal-pro-B-type natriuretic peptide (Nt-proBNP) for risk stratification in mixed aortic valve disease (MAVD) patients. METHODS We included 556 (73±12 years, 37% women) consecutive patients with at least a moderate aortic stenosis (AS) or aortic regurgitation (AR) lesion with a concomitant AS or AR of any severity in whom Nt-proBNP was measured and expressed as its ratio (measured Nt-proBNP divided by the upper limit of normal Nt-proBNP for age and sex). The primary endpoint was all-cause mortality. RESULTS Baseline median Nt-proBNP ratio was 3.8 (IQR: 1.5-11.3), and the median follow-up was 5.6 years (4.8-6.1). Early aortic valve replacement (AVR) was performed within 3 months in 423 (76%) patients, while 133 (24%) remained initially under medical treatment. In comprehensive multivariable analyses, Nt-proBNP ratio was significantly associated with excess mortality (continuous variable: HR (95% CI): 1.24 (1.04 to 1.47), p=0.02; Nt-proBNP ratio ≥3: 2.41 (1.33 to 4.39), p=0.004). The independent prognostic value was also observed in patients with severe or non-severe AS/AR, and those treated by early-AVR (all p<0.04). Nt-proBNP ratio as continuous and dichotomic (≥3) variables showed incremental prognostic value (all net reclassification index >0.42, all p≤0.008). After early-AVR, Nt-proBNP ratio ≥3 was associated with higher 30-day mortality (9 (4%) vs 1 (0.5%), p=0.02). CONCLUSIONS In this series of MAVD patients, Nt-proBNP ratio was a powerful predictor of early and long-term mortality, even in patients with both non-severe AS/AR. Moreover, early-AVR may be an option for patients with Nt-proBNP ratio ≥3. Further randomised studies are needed to validate this last point.
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Affiliation(s)
- Jérémy Bernard
- Cardiology, Institut universitaire de cardiologie et de pneumologie de Québec - Université Laval, Quebec, Quebec, Canada
| | - Guillaume Jean
- Cardiology, Institut universitaire de cardiologie et de pneumologie de Québec - Université Laval, Quebec, Quebec, Canada
| | - David Bienjonetti-Boudreau
- Cardiology, Institut universitaire de cardiologie et de pneumologie de Québec - Université Laval, Quebec, Quebec, Canada
| | - Frédéric Jacques
- Cardiac Surgery, Institut universitaire de cardiologie et de pneumologie de Québec - Université Laval, Quebec, Quebec, Canada
| | - Lionel Tastet
- Cardiology, Institut universitaire de cardiologie et de pneumologie de Québec - Université Laval, Quebec, Quebec, Canada
| | - Erwan Salaun
- Cardiology, Institut universitaire de cardiologie et de pneumologie de Québec - Université Laval, Quebec, Quebec, Canada
| | - Marie-Annick Clavel
- Cardiology, Institut universitaire de cardiologie et de pneumologie de Québec - Université Laval, Quebec, Quebec, Canada
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4
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Egbe AC, Miranda WR, Anderson JH, Pellikka PA, Stephens EH, Andi K, Abozied O, Connolly HM. Left ventricular adaptation to aortic regurgitation in adults with repaired coarctation of aorta. Int J Cardiol 2023:S0167-5273(23)00650-2. [PMID: 37149005 DOI: 10.1016/j.ijcard.2023.04.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 04/05/2023] [Accepted: 04/30/2023] [Indexed: 05/08/2023]
Abstract
BACKGROUND Aortic regurgitation (AR) can develop in adults with repaired coarctation of aorta (COA), but there are limited data about left ventricular (LV) remodeling and clinical outcomes in this population. The purpose of the study was to compare LV remodeling (LV mass index [LVMI], LV ejection fraction [LVEF], and septal E/e') and onset of symptoms before aortic valve replacement, and LV reverse remodeling (%-change in LVMI, LVEF and E/e') after aortic valve replacement in patients with versus without repaired COA presenting with AR. METHODS Asymptomatic adults with repaired COA presenting with moderate/severe AR (AR-COA group) were matched 1:2 to asymptomatic adults without COA and similar severity of AR (control group). RESULTS Although both groups (AR-COA n = 52, and control n = 104) had similar age, sex, body mass index, aortic valve gradient, and AR severity, the AR-COA group had higher LVMI (124 ± 28 versus 102 ± 25 g/m2, p < 0.001) and E/e' (12.3 ± 2.3 versus 9.5 ± 2.1, p = 0.02) but similar LVEF (63 ± 9% versus 67 ± 10%, p = 0.4). COA diagnosis (adjusted HR 1.95, 95%CI 1.49-2.37, p < 0.001), older age, E/e', and LV hypertrophy were associated with onset of symptoms. Of 89 patients (AR-COA n = 41, and control n = 48) with echocardiographic data at 1-year post- aortic valve replacement, the AR-COA group had less regression of LVMI (-8% [95%CI -5 to -11] versus -17% [95%CI -15 to -21], p < 0.001) and E/e' (-5% [95% CI -3 to -7] versus -16% [95% CI -13 to -19], p < 0.001). CONCLUSIONS Patients with COA and AR had a more aggressive clinical course, and perhaps may require a different threshold for surgical intervention.
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Affiliation(s)
- Alexander C Egbe
- Cardiovascular Medicine, and Department of Cardiovascular Surgery, Mayo Clinic Rochester, MN 55905, United States of America.
| | - William R Miranda
- Cardiovascular Medicine, and Department of Cardiovascular Surgery, Mayo Clinic Rochester, MN 55905, United States of America
| | - Jason H Anderson
- Cardiovascular Medicine, and Department of Cardiovascular Surgery, Mayo Clinic Rochester, MN 55905, United States of America
| | - Patricia A Pellikka
- Cardiovascular Medicine, and Department of Cardiovascular Surgery, Mayo Clinic Rochester, MN 55905, United States of America
| | - Elizabeth H Stephens
- Cardiovascular Medicine, and Department of Cardiovascular Surgery, Mayo Clinic Rochester, MN 55905, United States of America
| | - Kartik Andi
- Cardiovascular Medicine, and Department of Cardiovascular Surgery, Mayo Clinic Rochester, MN 55905, United States of America
| | - Omar Abozied
- Cardiovascular Medicine, and Department of Cardiovascular Surgery, Mayo Clinic Rochester, MN 55905, United States of America
| | - Heidi M Connolly
- Cardiovascular Medicine, and Department of Cardiovascular Surgery, Mayo Clinic Rochester, MN 55905, United States of America
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5
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Nedadur R, Belzile D, Farrell A, Tsang W. Mixed aortic stenosis and regurgitation: a clinical conundrum. Heart 2023; 109:264-275. [PMID: 35609962 DOI: 10.1136/heartjnl-2021-320501] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 03/10/2022] [Indexed: 02/01/2023] Open
Abstract
Mixed aortic stenosis (AS) and aortic regurgitation (AR) is the most frequent concomitant valve disease worldwide and represents a heterogeneous population ranging from mild AS with severe AR to mild AR with severe AS. About 6.8% of patients with at least moderate AS will also have moderate or greater AR, and 17.9% of patients with at least moderate AR will suffer from moderate or greater AS. Interest in mixed AS/AR has increased, with studies demonstrating that patients with moderate mixed AS/AR have similar outcomes to those with isolated severe AS. The diagnosis and quantification of mixed AS/AR severity are predominantly echocardiography-based, but the combined lesions lead to significant limitations in the assessment. Aortic valve peak velocity is the best parameter to evaluate the combined haemodynamic impact of both lesions, with a peak velocity greater than 4.0 m/s suggesting severe mixed AS/AR. Moreover, symptoms, increased left ventricular wall thickness and filling pressures, and abnormal left ventricular global longitudinal strain likely identify high-risk patients who may benefit from closer follow-up. Although guidelines recommend interventions based on the predominant lesion, some patients could potentially benefit from earlier intervention. Once a patient is deemed to require intervention, for patients receiving transcatheter valves, the presence of mixed AS/AR could confer benefit to those at high risk of paravalvular leak. Overall, the current approach of managing patients based on the dominant lesion might be too reductionist and a more holistic approach including biomarkers and multimodality imaging cardiac remodelling and inflammation data might be more appropriate.
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Affiliation(s)
- Rashmi Nedadur
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - David Belzile
- Division of Cardiology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Ashley Farrell
- Library and Information Services, University Health Network, Toronto, Ontario, Canada
| | - Wendy Tsang
- Division of Cardiology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
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6
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Guddeti RR, Gill GS, Garcia-Garcia HM, Alla VM. Transcatheter aortic valve replacement in mixed aortic valve disease: a systematic review and meta-analysis. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2022; 8:169-176. [PMID: 34788825 DOI: 10.1093/ehjqcco/qcab080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 10/26/2021] [Accepted: 11/08/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Utilization of transcatheter aortic valve replacement (TAVR) has expanded from high-risk patients to intermediate- and select low-risk candidates with severe aortic stenosis (AS). TAVR is currently not indicated for patients with aortic insufficiency, and its outcomes in mixed aortic valve disease (MAVD) are unclear. METHODS A systematic search of PubMed, Medline, CINHAL, and Cochrane databases was performed to identify studies comparing TAVR outcomes in patients with AS vs. MAVD. Primary outcomes included 30-day and late all-cause mortality, and paravalvular regurgitation (PVR). Secondary outcomes were major bleeding, vascular complications, device implantation success, permanent pacemaker, and stroke. Pooled odds ratios (OR) and 95% confidence intervals (CIs) were calculated using Der Simonian-Laird random-effects model. RESULTS Six observational studies with 58 879 patients were included in the analysis. There was no significant difference in 30-day all-cause mortality [OR 1.03 (95% CI 0.92-1.15); P = 0.63], however, MAVD group had higher odds of moderate-to-severe PVR [1.81 (1.41-2.31); P < 0.01]. MAVD patients had lower odds of device implantation success [0.60 (0.40-0.91); P = 0.02] while other secondary outcomes were similar in the two groups. CONCLUSIONS TAVR in MAVD is associated with increased odds of paravalvular regurgitation and lower odds of device implantation success when compared to severe aortic stenosis.
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Affiliation(s)
- Raviteja R Guddeti
- Division of Cardiovascular Diseases, Creighton University School of Medicine, Omaha, NE 68154, USA.,Division of Cardiovascular Diseases, Minneapolis Heart Institute, Minneapolis, MN 55407, USA
| | - Gauravpal S Gill
- Division of Cardiovascular Diseases, Creighton University School of Medicine, Omaha, NE 68154, USA
| | - Hector M Garcia-Garcia
- Department of Medicine, Georgetown University, Washington, DC 20057, USA.,Division of Cardiovascular Medicine, MedStar Washington Hospital Center, Washington, DC 20010, USA
| | - Venkata Mahesh Alla
- Division of Cardiovascular Diseases, Creighton University School of Medicine, Omaha, NE 68154, USA
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7
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Mantovani F, Fanti D, Tafciu E, Fezzi S, Setti M, Rossi A, Ribichini F, Benfari G. When Aortic Stenosis Is Not Alone: Epidemiology, Pathophysiology, Diagnosis and Management in Mixed and Combined Valvular Disease. Front Cardiovasc Med 2021; 8:744497. [PMID: 34722676 PMCID: PMC8554031 DOI: 10.3389/fcvm.2021.744497] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 09/13/2021] [Indexed: 11/24/2022] Open
Abstract
Aortic stenosis (AS) may present frequently combined with other valvular diseases or mixed with aortic regurgitation, with peculiar physio-pathological and clinical implications. The hemodynamic interactions between AS in mixed or combined valve disease depend on the specific combination of valve lesions and may result in diagnostic pitfalls at echocardiography; other imaging modalities may be helpful. Indeed, diagnosis is challenging because several echocardiographic methods commonly used to assess stenosis or regurgitation have been validated only in patients with the single-valve disease. Moreover, in the developed world, patients with multiple valve diseases tend to be older and more fragile over time; also, when more than one valvular lesion needs to address the surgical risk rises together with the long-term risk of morbidity and mortality associated with multiple valve prostheses, and the likelihood and risk of reoperation. Therefore, when AS presents mixed or combined valve disease, the heart valve team must integrate various parameters into the diagnosis and management strategy, including suitability for single or multiple transcatheter valve procedures. This review aims to summarize the most critical pathophysiological mechanisms underlying AS when associated with mitral regurgitation, mitral stenosis, aortic regurgitation, and tricuspid regurgitation. We will focus on echocardiography, clinical implications, and the most important treatment strategies.
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Affiliation(s)
| | - Diego Fanti
- University of Verona, Section of Cardiology, Verona, Italy
| | - Elvin Tafciu
- University of Verona, Section of Cardiology, Verona, Italy
| | - Simone Fezzi
- University of Verona, Section of Cardiology, Verona, Italy
| | - Martina Setti
- University of Verona, Section of Cardiology, Verona, Italy
| | - Andrea Rossi
- University of Verona, Section of Cardiology, Verona, Italy
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8
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Petersen J, Kloth B, Iqbal S, Reichenspurner H, Geelhoed B, Schnabel R, Eschenhagen T, Christ T, Girdauskas E. Blunted beta-adrenoceptor-mediated inotropy in valvular cardiomyopathy: another piece of the puzzle in human aortic valve disease. Eur J Cardiothorac Surg 2021; 60:56-63. [PMID: 33619556 DOI: 10.1093/ejcts/ezab004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 11/29/2020] [Accepted: 12/15/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Heart failure induced by valvular cardiomyopathy occurs in a substantial proportion of patients undergoing heart valve surgery. We aimed (i) to quantify beta-adrenoceptor (beta-AR) function by measuring the inotropic effect of isoprenaline in left ventricular (LV) tissue and (ii) to correlate beta-AR-mediated inotropy with clinical markers of heart failure. METHODS A total of 179 LV myocardial samples were obtained from 104 consecutive patients who underwent aortic valve (AV) surgery between 2017 and 2019. Beta-ARs were stimulated by increasing the concentrations of isoprenaline, followed by a single high concentration of forskolin and calcium. Beta-AR sensitivity was estimated as the concentration to achieve half maximum effects (EC50). Maximum effect size was calculated as the relative beta-AR-mediated inotropic response compared to the force in the presence of high calcium [FISO/Ca (%)]. In vitro data were correlated with the clinical indicators of LV disease. RESULTS FISO/Ca was independent of age and sex and amounted to 79.6 ± 20.5%. In a multivariate regression model, we found a significant inverse association between FISO/Ca and preoperative left ventricular end-diastolic diameter increase per 10 mm (OR -9.24, 95% CI -16.66 to -1.82; P = 0.015). Furthermore, patients with end-stage heart failure showed a strong tendency towards more severe reduction of max beta-AR response, as indicated by reduced FISO/Ca in a multivariate model (OR -29.60, 95% CI -61.92 to 2.72; P = 0.055). CONCLUSIONS Our study indicates that in vitro myocardial contractility testing can quantify beta-AR dysfunction in patients with AV disease. We found a significant association between reduced beta-AR sensitivity and increased LV diameter, which may indicate a role of beta-AR dysfunction in the development of heart failure in patients with AV disease.
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Affiliation(s)
- Johannes Petersen
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, Hamburg, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Benjamin Kloth
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Shahria Iqbal
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Hermann Reichenspurner
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, Hamburg, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Bastian Geelhoed
- DZHK (German Centre for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Hamburg, Germany.,Department of Cardiology, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Renate Schnabel
- DZHK (German Centre for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Hamburg, Germany.,Department of Cardiology, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Thomas Eschenhagen
- DZHK (German Centre for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Hamburg, Germany.,Institute of Experimental Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Torsten Christ
- DZHK (German Centre for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Hamburg, Germany.,Institute of Experimental Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Evaldas Girdauskas
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, Hamburg, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
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9
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Unger P, Clavel MA. Mixed Aortic Valve Disease: A Diagnostic Challenge, a Prognostic Threat. STRUCTURAL HEART 2020. [DOI: 10.1080/24748706.2020.1817643] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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10
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Bhardwaj B, Cohen DJ, Vemulapalli S, Kosinski AS, Xiang Q, Li Z, Allen KB, Kapadia S, Aggarwal K, Sorajja P, Chhatriwalla AK. Outcomes of transcatheter aortic valve replacement for patients with severe aortic stenosis and concomitant aortic insufficiency: Insights from the TVT Registry. Am Heart J 2020; 228:57-64. [PMID: 32828047 DOI: 10.1016/j.ahj.2020.07.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 07/14/2020] [Indexed: 11/25/2022]
Abstract
AIMS Data regarding outcomes for patients with severe aortic stenosis (AS) with concomitant aortic insufficiency (AI), undergoing transcatheter aortic valve replacement (TAVR) are limited. This study aimed to analyze the prevalence of severe AS with concomitant AI among patients undergoing TAVR and outcomes of TAVR in this patient group. METHODS AND RESULTS Using data from the STS/ACC-TVT Registry, we identified patients with severe AS with or without concomitant AI who underwent TAVR between 2011 and 2016. Patients were categorized based on the severity of pre-procedural AI. Multivariable proportional hazards regression models were used to examine all-cause mortality and heart failure (HF) hospitalization at 1-year. Among 54,535 patients undergoing TAVR, 42,568 (78.1%) had severe AS with concomitant AI. Device success was lower in patients with severe AS with concomitant AI as compared with isolated AS. The presence of baseline AI was associated with lower 1 year mortality (HR 0.94 per 1 grade increase in AI severity; 95% CI, 0.91-0.98, P < .001) and HF hospitalization (HR 0.87 per 1 grade increase in AI severity; 95% CI, 0.84-0.91, P < .001). CONCLUSIONS Severe AS with concomitant AI is common among patients undergoing TAVR, and is associated with lower 1 year mortality and HF hospitalization. Future studies are warranted to better understand the mechanisms underlying this benefit. SHORT ABSTRACT In this nationally representative analysis from the United States, 78.1% of patients undergoing TAVR had severe AS with concomitant AI. Device success was lower in patients with severe AS with concomitant AI as compared with isolated AS. The presence of baseline AI was associated with lower 1 year mortality (HR 0.94 per 1 grade increase in AI severity; 95% CI, 0.91-0.98, P < .001) and HF hospitalization (HR 0.87 per 1 grade increase in AI severity; 95% CI, 0.84-0.91, P < .001).
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11
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Moderate Aortic Stenosis and Heart Failure With Reduced Ejection Fraction: Can Imaging Guide Us to Therapy? JACC Cardiovasc Imaging 2020; 12:172-184. [PMID: 30621989 DOI: 10.1016/j.jcmg.2018.10.021] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 10/17/2018] [Accepted: 10/18/2018] [Indexed: 11/21/2022]
Abstract
Clinical management of patients with only moderate aortic stenosis (AS) but symptoms of heart failure with a reduced left ventricular ejection fraction (HFrEF) is challenging. Current guidelines recommend clinical surveillance with multimodality imaging; aortic valve replacement (AVR) is deferred until the stenosis becomes severe. Given the known benefits of afterload reduction in management of patients with HFrEF, it has been hypothesized that AVR may be beneficial in patients with only moderate AS who present with HFrEF. In this article, we first review the current approach for management of patients with moderate AS and HFrEF based on close clinical and imaging surveillance with AVR delayed until AS is severe. We then discuss the case for transcatheter AVR (TAVR) earlier in the disease course, when AS is moderate, based on stress echocardiographic data. We conclude with a detailed summary of the TAVR UNLOAD (Transcatheter Aortic Valve Replacement to UNload the Left Ventricle in Patients With ADvanced Heart Failure) trial, in which patients with moderate AS and HFrEF are randomized to guideline-directed heart failure therapy alone versus guideline-directed heart failure therapy plus TAVR.
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12
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Ong G, Pibarot P. Combined aortic stenosis and regurgitation: double the trouble. Heart 2019; 105:1515-1522. [PMID: 31142591 DOI: 10.1136/heartjnl-2017-312303] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2018] [Revised: 01/30/2019] [Accepted: 04/18/2019] [Indexed: 11/03/2022] Open
Affiliation(s)
- Geraldine Ong
- Department of Cardiology, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Philippe Pibarot
- Department of Cardiology, Quebec Heart and Lung Institute, Quebec City, Quebec, Canada
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Philip JL, Zens T, Lozonschi L, De Oliveira NC, Osaki S, Kohmoto T, Akhter SA, Tang PC. Outcomes of surgical aortic valve replacement for mixed aortic valve disease. J Thorac Dis 2018; 10:4042-4051. [PMID: 30174847 DOI: 10.21037/jtd.2018.06.128] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background Mixed aortic valve disease (MAVD) is associated with a poorer natural history compared with isolated lesions. However, clinical and echocardiographic outcomes for aortic valve replacement (AVR) in mixed disease are less well understood. Methods Retrospective review of AVRs (n=1,011) from 2000-2016. Isolated AVR, AVR + coronary bypass, and AVR + limited ascending aortic replacement were included. Predominant aortic stenosis (AS) group was stratified into group 1 (n=660) with concomitant mild or less aortic insufficiency (AI), and group 2 (n=197) with accompanying moderate or greater AI. Predominant AI group was stratified using the same schema for concomitant AS into groups 3 (n=143) and 4 (n=53). Median follow-up was 3.1 and 4.4 years respectively for AS and AI groups. Results For the predominant AS group (n=857) preoperatively, group 2 had a larger preoperative left ventricular end diastolic diameter (LVESD) (51.0±8.4 vs. 48.6±7.2, P=0.02) and lower preoperative left ventricular ejection fraction (LVEF) (57.6% vs. 60.2%, P=0.043). No differences in left ventricular (LV) dimensions, LV or right ventricular (RV) function was evident at follow up (P>0.05). After propensity matching for age, operation, and comorbidities, there was no difference in survival (P=0.19). After propensity matching for the predominant AI group (n=196), survival was lower for group 4 compared to 3 (P=0.02). There were no differences in LV dimensions, LV or RV function preoperatively or on follow-up (P>0.05). Conclusions Predominant AS associated with higher AI grades had larger LV dimensions and worse LV function preoperatively. These differences resolve after AVR with equivalent survival. However, predominant AI with more severe AS had reduced survival despite AVR.
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Affiliation(s)
- Jennifer L Philip
- Department of Surgery, Division of General Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Tiffany Zens
- Department of Surgery, Division of General Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Lucian Lozonschi
- Department of Surgery, Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Nilto C De Oliveira
- Department of Surgery, Division of Cardiothoracic Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Satoru Osaki
- Department of Surgery, Division of Cardiothoracic Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Takushi Kohmoto
- Department of Surgery, Division of Cardiothoracic Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Shahab A Akhter
- Department of Cardiovascular Sciences, Division of Cardiac Surgery, East Carolina Heart Institute at East Carolina University, Greenville, North Carolina, USA
| | - Paul C Tang
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
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14
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Seeger J, Gonska B, Mörike J, Rottbauer W, Wöhrle J. Outcome of Patients with Mixed Aortic Valve Disease Undergoing Transfemoral Aortic Valve Replacement. STRUCTURAL HEART-THE JOURNAL OF THE HEART TEAM 2017. [DOI: 10.1080/24748706.2017.1348648] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Affiliation(s)
- Julia Seeger
- Department of Internal Medicine II, Cardiology, University of Ulm, Ulm, Germany
| | - Birgid Gonska
- Department of Internal Medicine II, Cardiology, University of Ulm, Ulm, Germany
| | - Johannes Mörike
- Department of Internal Medicine II, Cardiology, University of Ulm, Ulm, Germany
| | - Wolfgang Rottbauer
- Department of Internal Medicine II, Cardiology, University of Ulm, Ulm, Germany
| | - Jochen Wöhrle
- Department of Internal Medicine II, Cardiology, University of Ulm, Ulm, Germany
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