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Springhetti P, Tomaselli M, Clavel MA. Measuring the aortic valvular area: Key challenges in aortic stenosis assessment. Int J Cardiol 2024; 414:132410. [PMID: 39097150 DOI: 10.1016/j.ijcard.2024.132410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2024] [Accepted: 07/29/2024] [Indexed: 08/05/2024]
Affiliation(s)
- Paolo Springhetti
- Institut Universitaire de Cardiologie et de Pneumologie, Université Laval, Québec, Canada.
| | - Michele Tomaselli
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Marie-Annick Clavel
- Institut Universitaire de Cardiologie et de Pneumologie, Université Laval, Québec, Canada
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Sugiyama Y, Miyashita H, Ochiai T, Shishido K, Jalanko M, Yamanaka F, Vähäsilta T, Saito S, Laine M, Moriyama N. Haemodynamic and clinical outcomes at 5 years according to predicted prosthesis-patient mismatch after transcatheter aortic valve replacement. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024:S1553-8389(24)00541-4. [PMID: 38944598 DOI: 10.1016/j.carrev.2024.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Revised: 06/11/2024] [Accepted: 06/11/2024] [Indexed: 07/01/2024]
Abstract
BACKGROUND/PURPOSE Although the impact of predicted prosthesis-patient mismatch (PPMP) on outcomes after surgical aortic valve replacement is well established, studies on PPMP in transcatheter aortic valve replacement (TAVR) are limited. This study investigated the effects of PPMp on haemodynamic and 5-year clinical outcomes after TAVR. METHODS/MATERIALS We analysed 1733 patients who underwent TAVR. PPMp was defined using two different methods: 1) normal reference values of the effective orifice area for each valve type and size indexed to body surface area (PPMp1; n = 1733) and 2) reference values for aortic annulus area or perimeter assessed with pre-procedural computed tomography indexed to body surface area (PPMp2; n = 1227). The primary endpoint was the composite of all-cause death and/or rehospitalisation for heart failure at 5 years. RESULTS The incidence of PPMp1 was 11.7 % and 0.8 % in moderate and severe cases, respectively. PPMp2 was classified as either moderate (3.8 %) or severe (0 %). Rates of residual mean aortic gradient ≥20 mmHg significantly increased depending on PPMp1 severity (no PPMp1: 3.1 % vs. moderate PPMp1: 26.8 % vs. severe PPMp1: 53.9 %, p < 0.0001) and PPMp2 (no PPMp2: 4.1 % vs. moderate PPMp2: 12.8 %, p = 0.0049). Neither of PPMP methods were associated with the composite outcome in total cohort; however, PPMP1 was significantly related to worse clinical outcomes at 5 years among patients with reduced left ventricular ejection fraction (LVEF) in multivariate analysis (HR: 1.87; 95 % CI: 1.02-3.43). CONCLUSIONS The impact of PPMP on TAVR clinical outcomes may not be negligible in patients with low LVEF.
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Affiliation(s)
- Yoichi Sugiyama
- Department of Cardiology and Catheterization Laboratories, Shonan Kamakura General Hospital, Okamoto 1370-1, Kamakura City, Kanagawa 247-8533, Japan; Department of Cardiology, Heart and Lung Center, Helsinki University and Helsinki University Central Hospital, Haartmaninkatu 4, 00290 Helsinki, Finland
| | - Hirokazu Miyashita
- Department of Cardiology and Catheterization Laboratories, Shonan Kamakura General Hospital, Okamoto 1370-1, Kamakura City, Kanagawa 247-8533, Japan
| | - Tomoki Ochiai
- Department of Cardiology and Catheterization Laboratories, Shonan Kamakura General Hospital, Okamoto 1370-1, Kamakura City, Kanagawa 247-8533, Japan
| | - Koki Shishido
- Department of Cardiology and Catheterization Laboratories, Shonan Kamakura General Hospital, Okamoto 1370-1, Kamakura City, Kanagawa 247-8533, Japan
| | - Mikko Jalanko
- Department of Cardiology, Heart and Lung Center, Helsinki University and Helsinki University Central Hospital, Haartmaninkatu 4, 00290 Helsinki, Finland
| | - Futoshi Yamanaka
- Department of Cardiology and Catheterization Laboratories, Shonan Kamakura General Hospital, Okamoto 1370-1, Kamakura City, Kanagawa 247-8533, Japan
| | - Tommi Vähäsilta
- Department of Cardiology, Heart and Lung Center, Helsinki University and Helsinki University Central Hospital, Haartmaninkatu 4, 00290 Helsinki, Finland
| | - Shigeru Saito
- Department of Cardiology and Catheterization Laboratories, Shonan Kamakura General Hospital, Okamoto 1370-1, Kamakura City, Kanagawa 247-8533, Japan
| | - Mika Laine
- Department of Cardiology, Heart and Lung Center, Helsinki University and Helsinki University Central Hospital, Haartmaninkatu 4, 00290 Helsinki, Finland
| | - Noriaki Moriyama
- Department of Cardiology and Catheterization Laboratories, Shonan Kamakura General Hospital, Okamoto 1370-1, Kamakura City, Kanagawa 247-8533, Japan.
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Reil JC, Marquetand C, Busch-Tilge C, Ivannikova M, Rudolph V, Aboud A, Ensminger S, Schäfers HJ, Stierle U, Reil GH. Functional interaction of aortic valve and ascending aorta in patients after valve-sparing procedures. Sci Rep 2023; 13:15340. [PMID: 37714924 PMCID: PMC10504237 DOI: 10.1038/s41598-023-42068-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 09/05/2023] [Indexed: 09/17/2023] Open
Abstract
Pressure recovery (PR) is essential part of the post stenotic fluid mechanics and depends on the ratio of EOA/AA, the effective aortic valve orifice area (EOA) and aortic cross-sectional area (AA). In patients with advanced ascending aortic aneurysm and mildly diseased aortic valves, the effect of AA on pressure recovery and corresponding functional aortic valve opening area (ELCO) was evaluated before and after valve-sparing surgery (Dacron graft implantation). 66 Patients with ascending aortic aneurysm (mean aortic diameter 57 +/- 10 mm) and aortic valve-sparing surgery (32 reimplantation technique (David), 34 remodeling technique (Yacoub)) were routinely investigated by Doppler echocardiography. Dacron graft with a diameter between 26 and 34 mm were implanted. EOA was significantly declined after surgery (3.4 +/- 0.8 vs. 2.6 +/- 0.9cm2; p < 0.001). Insertion of Dacron prosthesis resulted in a significant reduction of AA (26.7 +/- 10.2 vs. 6.8 +/- 1.1cm2; p < 0.001) with increased ratio of EOA/AA (0.14 +/- 0.05 vs. 0.40 +/- 0.1; p < 0.001) and pressure recovery index (PRI; 0.24 +/- 0.08 vs. 0.44 +/- 0.06; p < 0.0001). Despite reduction of EOA, ELCO (= EOA corrected for PR) increased from 4.0 +/- 1.1 to 5.0 +/- 3.1cm2 (p < 0.01) with reduction in transvalvular LV stroke work (1005 +/- 814 to 351 +/- 407 mmHg × ml, p < 0.001) after surgery. These effects were significantly better in patients with Yacoub technique than with the David operation. The hemodynamic findings demonstrate a valve-vessel interaction almost entirely caused by a marked reduction in the ascending AA with significant PR gain. The greater hemodynamic benefit of the Yacoub technique due to higher EOA values compared to the David technique was evident and may be of clinical relevance.
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Affiliation(s)
- Jan-Christian Reil
- Klinik für Allgemeine und Interventionelle Kardiolgie, Herz-und Diabetes-Zentrum Nordrhein-Westphalen, Georgstrasse 11, 32545, Bad Oeynhausen, Germany.
- Klinik für Herzchirurgie, Universitäres Herzzentrum Lübeck, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, Lübeck, Germany.
| | - Christoph Marquetand
- Medizinische Klinik II, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitäres Herzzentrum Lübeck, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, Lübeck, Germany
| | - Claudia Busch-Tilge
- Klinik für Herzchirurgie, Universitäres Herzzentrum Lübeck, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, Lübeck, Germany
| | - Maria Ivannikova
- Klinik für Allgemeine und Interventionelle Kardiolgie, Herz-und Diabetes-Zentrum Nordrhein-Westphalen, Georgstrasse 11, 32545, Bad Oeynhausen, Germany
| | - Volker Rudolph
- Klinik für Allgemeine und Interventionelle Kardiolgie, Herz-und Diabetes-Zentrum Nordrhein-Westphalen, Georgstrasse 11, 32545, Bad Oeynhausen, Germany
| | - Anas Aboud
- Klinik für Herzchirurgie, Universitäres Herzzentrum Lübeck, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, Lübeck, Germany
| | - Stephan Ensminger
- Klinik für Herzchirurgie, Universitäres Herzzentrum Lübeck, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, Lübeck, Germany
| | - Hans-Joachim Schäfers
- Klinik für Herz-und Thoraxchirurgie, Universitätsklinkum des Saarlandes, Kirrberger Strasse, 66421, Homburg, Saar, Germany
| | - Ulrich Stierle
- Klinik für Herzchirurgie, Universitäres Herzzentrum Lübeck, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, Lübeck, Germany
| | - Gert-Hinrich Reil
- Universitätsklinik für Innere Medizin - Kardiologie, Klinikum Oldenburg, Rahel Strauss Strasse 10, Oldenburg, Germany
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Velders BJJ, Groenwold RHH, Ajmone Marsan N, Kappetein AP, Wijngaarden RAFDLV, Braun J, Klautz RJM, Vriesendorp MD. Improving accuracy in diagnosing aortic stenosis severity: An in-depth analysis of echocardiographic measurement error through literature review and simulation study. Echocardiography 2023; 40:892-902. [PMID: 37519290 DOI: 10.1111/echo.15664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 07/10/2023] [Accepted: 07/23/2023] [Indexed: 08/01/2023] Open
Abstract
AIMS The present guidelines advise replacing the aortic valve for individuals with severe aortic stenosis (AS) based on various echocardiographic parameters. Accurate measurements are essential to avoid misclassification and unnecessary interventions. The objective of this study was to evaluate the influence of measurement error on the echocardiographic evaluation of the severity of AS. METHODS AND RESULTS A systematic review was performed to examine whether measurement errors are reported in studies focusing on the prognostic value of peak aortic jet velocity (Vmax ), mean pressure gradient (MPG), and effective orifice area (EOA) in asymptomatic patients with AS. Out of the 37 studies reviewed, 17 (46%) acknowledged the existence of measurement errors, but none of them utilized methods to address them. Secondly, the magnitude of potential errors was collected from available literature for use in clinical simulations. Interobserver variability ranged between 0.9% and 8.3% for Vmax and MPG but was higher for EOA (range 7.7%-12.7%), indicating lower reliability. Assuming a circular left ventricular outflow tract area led to a median underestimation of EOA by 23% compared to planimetry by other modalities. A clinical simulation resulted in the reclassification of 42% of patients, shifting them from a diagnosis of severe AS to moderate AS. CONCLUSIONS Measurement errors are underreported in studies on echocardiographic assessment of AS severity. These errors can lead to misclassification and misdiagnosis. Clinicians and scientists should be aware of the implications for accurate clinical decision-making and assuring research validity.
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Affiliation(s)
- Bart J J Velders
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Rolf H H Groenwold
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Biomedical Data Science, Leiden University Medical Center, Leiden, The Netherlands
| | - Nina Ajmone Marsan
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Arie-Pieter Kappetein
- Global Clinical Operations, Coronary and Structural Heart, Medtronic, Maastricht, The Netherlands
| | | | - Jerry Braun
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Robert J M Klautz
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Michiel D Vriesendorp
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
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Akinmolayemi O, Ozdemir D, Pibarot P, Zhao Y, Leipsic J, Douglas PS, Jaber WA, Weissman NJ, Blanke P, Hahn RT. Clinical and Echocardiographic Characteristics of Flow-Based Classification Following Balloon-Expandable Transcatheter Heart Valve in PARTNER Trials. JACC Cardiovasc Imaging 2023; 16:1-9. [PMID: 36599555 DOI: 10.1016/j.jcmg.2022.05.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 04/25/2022] [Accepted: 05/19/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND Current expected normal echocardiographic measures of transcatheter heart valve (THV) function were derived from pooled cohorts of the randomized trials; however, THV function by flow state before or following transcatheter aortic valve replacement (TAVR) has not been previously reported. OBJECTIVES This study sought to assess the expected normal echocardiographic hemodynamics for the balloon-expandable THV grouped by stroke volume index (SVI). METHODS Patients with severe aortic stenosis enrolled in PARTNER (Placement of Aortic Transcatheter Valves) 1 (high/extreme surgical risk), PARTNER 2 (intermediate surgical risk), or PARTNER 3 (low surgical risk) trials with complete core laboratory echocardiography were included. Patients were grouped by low-flow (SVILOW <35 mL/m2) and normal-flow (SVINORMAL ≥35 mL/m2). Mean gradient, effective orifice area (EOA), and Doppler velocity index (DVI) were collected at baseline and at 30 days post-TAVR. Prosthesis-patient mismatch (PPM) was both calculated and predicted from normative data, using defined criteria. RESULTS In the entire population (N = 4,991), mean age was 81.8 years, 58% of patients were male, and 42% had low flow. Compared with patients with baseline SVINORMAL, those with SVILOW were more likely to be male; have more comorbidities; and lower left ventricular ejection fraction, mean gradient, and EOA. Post-TAVR, SVILOW increased to SVINORMAL in 17.3% and SVINORMAL decreased to SVILOW in 12.3% of patients. Using baseline SVI, follow-up EOA, mean gradient, and DVI for patients with SVILOW tended to be lower than for patients with SVINORMAL. Using the post-TAVR SVI, follow-up EOA, mean gradient, and DVI were significantly lower for patients with SVILOW than for those with SVINORMAL (P < 0.001 for all). The incidence of calculated, but not predicted, severe PPM was higher in patients with low flow than it was in patients with normal flow, suggesting pseudo-PPM in the presence of low flow. CONCLUSIONS This study demonstrates that flow affects THV hemodynamics and both baseline and follow-up SVI should be considered when predicting THV hemodynamics prior to TAVR, as well as assessing valve function following valve implantation.
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Affiliation(s)
- Oludamilola Akinmolayemi
- Columbia University Irving Medical Center/New York Presbyterian Hospital, New York, New York, USA
| | - Denizhan Ozdemir
- Columbia University Irving Medical Center/New York Presbyterian Hospital, New York, New York, USA
| | - Philippe Pibarot
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Department of Medicine, Laval University, Québec City, Québec, Canada
| | - Yanglu Zhao
- Edwards Lifescience, Irvine, California, USA
| | - Jonathon Leipsic
- University of British Columbia and St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Pamela S Douglas
- Division of Cardiovascular Medicine, Duke University Medical Center and Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Wael A Jaber
- Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | | | - Philipp Blanke
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Department of Medicine, Laval University, Québec City, Québec, Canada
| | - Rebecca T Hahn
- Columbia University Irving Medical Center/New York Presbyterian Hospital, New York, New York, USA.
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Guzzetti E, Annabi MS, Pibarot P, Clavel MA. Multimodality Imaging for Discordant Low-Gradient Aortic Stenosis: Assessing the Valve and the Myocardium. Front Cardiovasc Med 2020; 7:570689. [PMID: 33344514 PMCID: PMC7744378 DOI: 10.3389/fcvm.2020.570689] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 10/12/2020] [Indexed: 01/29/2023] Open
Abstract
Aortic stenosis (AS) is a disease of the valve and the myocardium. A correct assessment of the valve disease severity is key to define the need for aortic valve replacement (AVR), but a better understanding of the myocardial consequences of the increased afterload is paramount to optimize the timing of the intervention. Transthoracic echocardiography remains the cornerstone of AS assessment, as it is universally available, and it allows a comprehensive structural and hemodynamic evaluation of both the aortic valve and the rest of the heart. However, it may not be sufficient as a significant proportion of patients with severe AS presents with discordant grading (i.e., an AVA ≤ 1 cm2 and a mean gradient <40 mmHg) which raises uncertainty about the true severity of AS and the need for AVR. Several imaging modalities (transesophageal or stress echocardiography, computed tomography, cardiovascular magnetic resonance, positron emission tomography) exist that allow a detailed assessment of the stenotic aortic valve and the myocardial remodeling response. This review aims to provide an updated overview of these multimodality imaging techniques and seeks to highlight a practical approach to help clinical decision making in the challenging group of patients with discordant low-gradient AS.
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Affiliation(s)
- Ezequiel Guzzetti
- Institut Universitaire de Cardiologie et de Pneumologie de Québec (Quebec Heart & Lung Institute), Quebec, QC, Canada
| | - Mohamed-Salah Annabi
- Institut Universitaire de Cardiologie et de Pneumologie de Québec (Quebec Heart & Lung Institute), Quebec, QC, Canada
| | - Philippe Pibarot
- Institut Universitaire de Cardiologie et de Pneumologie de Québec (Quebec Heart & Lung Institute), Quebec, QC, Canada
| | - Marie-Annick Clavel
- Institut Universitaire de Cardiologie et de Pneumologie de Québec (Quebec Heart & Lung Institute), Quebec, QC, Canada
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Contemporary Imaging of Aortic Stenosis. Heart Lung Circ 2019; 28:1310-1319. [PMID: 31266725 DOI: 10.1016/j.hlc.2019.05.177] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 04/29/2019] [Accepted: 05/17/2019] [Indexed: 12/26/2022]
Abstract
Degenerative or fibrocalcific aortic stenosis (AS) is now the most common native valvular heart disease assessed and managed by cardiologists in developed countries. Transthoracic echocardiography remains the quintessential imaging modality for the non-invasive characterisation of AS due to its widespread availability, superior assessment of flow haemodynamics, and a wealth of prognostic data accumulated over decades of clinical utility and research applications. With expanding technologies and increasing availability of treatment options such as transcatheter aortic valve replacements, in addition to conventional surgical approaches, accurate and precise assessment of AS severity is critical to guide decisions for and timing of interventions. Despite clear guideline echocardiographic parameters demarcating severe AS, discrepancies between transvalvular velocities, gradients, and calculated valve areas are commonly encountered in clinical practice. This often results in diagnostically challenging cases with significant implications. Greater emphasis must be placed on the quality of performance of basic two dimensional (2D) and Doppler measurements (attention to detail ensuring accuracy and precision), incorporating ancillary haemodynamic surrogates, understanding study- or patient-specific confounders, and recognising the role and limitations of stress echocardiography in the subgroups of low-flow low-gradient AS. A multiparametric approach, along with the incorporation of multimodality imaging (cardiac computed tomography or magnetic resonance imaging) in certain scenarios, is now mandatory to avoid incorrect misclassification of severe AS. This is essential to ensure appropriate selection of patients who would most benefit from interventions on the aortic valve to relieve the afterload mismatch resulting from truly severe valvular stenosis.
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Jover E, Fagnano M, Angelini G, Madeddu P. Cell Sources for Tissue Engineering Strategies to Treat Calcific Valve Disease. Front Cardiovasc Med 2018; 5:155. [PMID: 30460245 PMCID: PMC6232262 DOI: 10.3389/fcvm.2018.00155] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 10/10/2018] [Indexed: 12/15/2022] Open
Abstract
Cardiovascular calcification is an independent risk factor and an established predictor of adverse cardiovascular events. Despite concomitant factors leading to atherosclerosis and heart valve disease (VHD), the latter has been identified as an independent pathological entity. Calcific aortic valve stenosis is the most common form of VDH resulting of either congenital malformations or senile “degeneration.” About 2% of the population over 65 years is affected by aortic valve stenosis which represents a major cause of morbidity and mortality in the elderly. A multifactorial, complex and active heterotopic bone-like formation process, including extracellular matrix remodeling, osteogenesis and angiogenesis, drives heart valve “degeneration” and calcification, finally causing left ventricle outflow obstruction. Surgical heart valve replacement is the current therapeutic option for those patients diagnosed with severe VHD representing more than 20% of all cardiac surgeries nowadays. Tissue Engineering of Heart Valves (TEHV) is emerging as a valuable alternative for definitive treatment of VHD and promises to overcome either the chronic oral anticoagulation or the time-dependent deterioration and reintervention of current mechanical or biological prosthesis, respectively. Among the plethora of approaches and stablished techniques for TEHV, utilization of different cell sources may confer of additional properties, desirable and not, which need to be considered before moving from the bench to the bedside. This review aims to provide a critical appraisal of current knowledge about calcific VHD and to discuss the pros and cons of the main cell sources tested in studies addressing in vitro TEHV.
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Affiliation(s)
- Eva Jover
- Bristol Medical School (Translational Health Sciences), Bristol Heart Institute, University of Bristol, Bristol, United Kingdom
| | - Marco Fagnano
- Bristol Medical School (Translational Health Sciences), Bristol Heart Institute, University of Bristol, Bristol, United Kingdom
| | - Gianni Angelini
- Bristol Medical School (Translational Health Sciences), Bristol Heart Institute, University of Bristol, Bristol, United Kingdom
| | - Paolo Madeddu
- Bristol Medical School (Translational Health Sciences), Bristol Heart Institute, University of Bristol, Bristol, United Kingdom
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Karahanoglu E, Altinboga O, Akpinar F, Demirdag E, Ozdemirci S, Akyol A, Yalvac S. Nifedipine increases fetoplacental perfusion. J Perinat Med 2017; 45:51-55. [PMID: 27387329 DOI: 10.1515/jpm-2016-0072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 06/03/2016] [Indexed: 11/15/2022]
Abstract
AIM Our aim is to evaluate the effect of nifedipine on fetoplacental hemodynamic parameters. METHODS A retrospective study was conducted at a tertiary center with 30 patients for whom nifedipine treatment was used as a tocolytic therapy for preterm labor. Initiation of this treatment was at 31.6±2.5 weeks of gestation. We combined the pulse Doppler imaging parameters with grayscale imaging via the Bernoulli theorem, which is called the "continuity equation", to get the fetoplacental perfusion (FPP). Evaluated parameters were the resistance index (RI), the pulsatility index (PI), systole/diastole ratios (S/D), the velocity-time integral of the umbilical artery (VTI), the radius of the umbilical artery, the peak systolic velocity and the mean pressure gradient in the umbilical artery. From these parameters, the FPP was acquired. RESULTS We found that the RI, the PI and the S/D ratio did not change after treatment with nifedipine. The mean pressure gradient, the VTI and the peak systolic velocity increased after treatment with nifedipine. Nifedipine increases FPP from 166±73.81 beat.cm3/min to 220±83.3 beat.cm3/min. DISCUSSION Although nifedipine had no effect on the PI, the RI or the S/D, it increased the mean pressure gradient, the VTI and FPP.
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Transcatheter aortic valves produce unphysiological flows which may contribute to thromboembolic events: An in-vitro study. J Biomech 2016; 49:4080-4089. [PMID: 27836502 PMCID: PMC5179499 DOI: 10.1016/j.jbiomech.2016.10.050] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Revised: 10/04/2016] [Accepted: 10/29/2016] [Indexed: 11/21/2022]
Abstract
PURPOSE Transcatheter aortic valve implantation (TAVI) has been associated with large incidence of ischemic events, whose sources are still unclear. In fact, sub-acute complications cannot be directly related to the severity of the calcification in the host tissues, nor with catheter manipulation during the implant. A potential cause could be local flow perturbations introduced by the implantation approach, resulting in thrombo-embolic consequences. In particular, contrary to the surgical approach, TAVI preserves the presence of the native leaflets, which are expanded in the paravalvular space inside the Valsalva sinuses. The purpose of this study is to verify if this configuration can determine hemodynamic variations which may promote blood cell aggregation and thrombus formation. METHODS The study was performed in vitro, on idealized models of the patient anatomy before and after TAVI, reproducing a range of physiological operating conditions on a pulse duplicator. The fluid dynamics in the Valsalva sinuses was analyzed and characterized using phase resolved Particle Image Velocimetry. RESULTS Comparison of the flow downstream the valve clearly indicated major alterations in the fluid mechanics after TAVI, characterized by unphysiological conditions associated with extended stagnation zones at the base of the sinuses. CONCLUSION The prolonged stasis observed in the Valsalva sinuses for the configuration modelling the presence of transcatheter aortic valves provides a fluid dynamic environment favourable for red blood cell aggregation and thrombus formation, which may justify some of the recently reported thromboembolic and ischemic events. This suggests the adoption of anticoagulation therapies following TAVI, and some caution in the patients׳ selection.
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Abstract
BACKGROUND 3D stereolithographic printing can be used to convert high-resolution computed tomography images into life-size physical models. We sought to apply 3D printing technologies to develop patient-specific models of the anatomic and functional characteristics of severe aortic valve stenosis. METHODS AND RESULTS Eight patient-specific models of severe aortic stenosis (6 tricuspid and 2 bicuspid) were created using dual-material fused 3D printing. Tissue types were identified and segmented from clinical computed tomography image data. A rigid material was used for printing calcific regions, and a rubber-like material was used for soft tissue structures of the outflow tract, aortic root, and noncalcified valve cusps. Each model was evaluated for its geometric valve orifice area, echocardiographic image quality, and aortic stenosis severity by Doppler and Gorlin methods under 7 different in vitro stroke volume conditions. Fused multimaterial 3D printed models replicated the focal calcific structures of aortic stenosis. Doppler-derived measures of peak and mean transvalvular gradient correlated well with reference standard pressure catheters across a range of flow conditions (r=0.988 and r=0.978 respectively, P<0.001). Aortic valve orifice area by Gorlin and Doppler methods correlated well (r=0.985, P<0.001). Calculated aortic valve area increased a small amount for both methods with increasing flow (P=0.002). CONCLUSIONS By combing the technologies of high-spatial resolution computed tomography, computer-aided design software, and fused dual-material 3D printing, we demonstrate that patient-specific models can replicate both the anatomic and functional properties of severe degenerative aortic valve stenosis.
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Chahal NS, Drakopoulou M, Gonzalez-Gonzalez AM, Manivarmane R, Khattar R, Senior R. Resting Aortic Valve Area at Normal Transaortic Flow Rate Reflects True Valve Area in Suspected Low-Gradient Severe Aortic Stenosis. JACC Cardiovasc Imaging 2015; 8:1133-1139. [DOI: 10.1016/j.jcmg.2015.04.021] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 03/23/2015] [Accepted: 04/02/2015] [Indexed: 10/23/2022]
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Burwash IG. Echocardiographic Evaluation of Aortic Stenosis - Normal Flow and Low Flow Scenarios. Eur Cardiol 2014; 9:92-99. [PMID: 30310493 PMCID: PMC6159432 DOI: 10.15420/ecr.2014.9.2.92] [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] [Received: 10/10/2014] [Accepted: 11/11/2014] [Indexed: 02/07/2023] Open
Abstract
The echocardiographic evaluation of the patient with aortic stenosis (AS) has evolved in recent years, beyond confirming the diagnosis and measuring the resting mean pressure gradient or valve area. New echocardiographic approaches have developed to address the clinical dilemmas related to discordant haemodynamic data, asymptomatic haemodynamically severe AS and low-flow, low-gradient AS in order to better evaluate the disease severity, enhance the risk stratification of patients and provide important prognostic information. This article reviews the echocardiographic evaluation of the AS patient and focuses on the echocardiographic assessment of the haemodynamic severity, the prediction of clinical outcome and the use of echocardiography to guide patient management in the presence of normal flow and low flow scenarios.
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Affiliation(s)
- Ian G Burwash
- University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
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Garcia J, Markl M, Schnell S, Allen B, Entezari P, Mahadevia R, Chris Malaisrie S, Pibarot P, Carr J, Barker AJ. Evaluation of aortic stenosis severity using 4D flow jet shear layer detection for the measurement of valve effective orifice area. Magn Reson Imaging 2014; 32:891-8. [PMID: 24865143 PMCID: PMC4099275 DOI: 10.1016/j.mri.2014.04.017] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Revised: 04/16/2014] [Accepted: 04/17/2014] [Indexed: 12/13/2022]
Abstract
AIMS The objective of this study was to evaluate the potential of 4D flow MRI to assess valve effective orifice area (EOA) in patients with aortic stenosis as determined by the jet shear layer detection (JSLD) method. METHODS AND RESULTS An in-vitro stenosis phantom was used for validation and in-vivo imaging was performed in 10 healthy controls and 40 patients with aortic stenosis. EOA was calculated by the JSLD method using standard 2D phase contrast MRI (PC-MRI) and 4D flow MRI measurements (EOAJSLD-2D and EOAJSLD-4D, respectively). As a reference standard, the continuity equation was used to calculate EOA (EOACE) with the 2D PC-MRI velocity field and compared to the EOAJSLD measurements. The in-vitro results exhibited excellent agreement between flow theory (EOA=0.78cm(2)) and experimental measurement (EOAJSLD-4D=0.78±0.01cm(2)) for peak velocities ranging from 0.9 to 3.7m/s. In-vivo results showed good correlation and agreement between EOAJSLD-2D and EOACE (r=0.91, p<0.001; bias: -0.01±0.38cm(2); agreement limits: 0.75 to -0.77cm(2)), and between EOAJSLD-4D and EOACE (r=0.95, p<0.001; bias: -0.09±0.26cm(2); limits: 0.43 to -0.62cm(2)). CONCLUSION This study demonstrates the feasibility of measuring EOAJSLD using 4D flow MRI. The technique allows for optimization of the EOA measurement position by visualizing the 3D vena contracta, and avoids potential sources of EOACE measurement variability.
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Affiliation(s)
- Julio Garcia
- Radiology, Northwestern University, Chicago, USA; Medicine, Laval University, Quebec, Canada.
| | - Michael Markl
- Radiology, Northwestern University, Chicago, USA; Biomedical Engineering, Northwestern University, Chicago, USA
| | | | | | | | | | - S Chris Malaisrie
- Division of Cardiothoracic Surgery, Northwestern University, Chicago, USA
| | | | - James Carr
- Radiology, Northwestern University, Chicago, USA
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Hemodynamic performance during exercise of the new St. Jude Trifecta aortic bioprosthesis: results from a French multicenter study. J Am Soc Echocardiogr 2014; 27:590-7. [PMID: 24656322 DOI: 10.1016/j.echo.2014.01.022] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2013] [Indexed: 11/24/2022]
Abstract
BACKGROUND Initial experience with the new St. Jude Trifecta pericardial aortic stented bioprosthesis shows an excellent resting hemodynamic profile. Little is known about changes in the hemodynamic profile of the Trifecta valve during exercise. METHODS Between February 2011 and November 2012, 85 patients (49 men; mean age, 76 ± 7 years) with severe symptomatic aortic stenosis who underwent aortic valve replacement with the Trifecta bioprosthesis at three centers in France (Amiens, Rennes, and Angers) underwent quantitative Doppler echocardiographic at rest, during low-level exercise (25 W), and during peak exercise (68 ± 21 W), 6 months after aortic valve replacement. RESULTS Mean peak transvalvular aortic velocity, mean transvalvular gradient, and mean left ventricular ejection fraction for all valve sizes were 211 ± 35 cm/sec, 10 ± 3 mm Hg, and 62 ± 10% at rest; 237 ± 48 cm/sec, 13 ± 4 mm Hg, and 64 ± 10% during low-level exercise; and 248 ± 70 cm/sec, 15 ± 5 mm Hg, and 67 ± 10% during peak exercise, respectively. Mean effective orifice area was 1.84 ± 0.42 cm(2) at rest, 1.86 ± 0.84 cm(2) (P = .92) during low-level exercise, and 1.95 ± 0.62 cm(2) (P = .49) during peak exercise. The prevalence of prosthesis-patient mismatch was low in the overall series (23%) and increased to 30% for the smallest valve sizes (19 and 21 mm). CONCLUSIONS The new Trifecta bioprosthesis provides an excellent hemodynamic profile both at rest and during exercise. This type of valve could be an appropriate choice in patients with small aortic annular diameters, to avoid prosthesis-patient mismatch.
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Garcia J, Capoulade R, Le Ven F, Gaillard E, Kadem L, Pibarot P, Larose É. Discrepancies between cardiovascular magnetic resonance and Doppler echocardiography in the measurement of transvalvular gradient in aortic stenosis: the effect of flow vorticity. J Cardiovasc Magn Reson 2013; 15:84. [PMID: 24053194 PMCID: PMC3848817 DOI: 10.1186/1532-429x-15-84] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Accepted: 09/03/2013] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Valve effective orifice area EOA and transvalvular mean pressure gradient (MPG) are the most frequently used parameters to assess aortic stenosis (AS) severity. However, MPG measured by cardiovascular magnetic resonance (CMR) may differ from the one measured by transthoracic Doppler-echocardiography (TTE). The objectives of this study were: 1) to identify the factors responsible for the MPG measurement discrepancies by CMR versus TTE in AS patients; 2) to investigate the effect of flow vorticity on AS severity assessment by CMR; and 3) to evaluate two models reconciling MPG discrepancies between CMR/TTE measurements. METHODS Eight healthy subjects and 60 patients with AS underwent TTE and CMR. Strouhal number (St), energy loss (EL), and vorticity were computed from CMR. Two correction models were evaluated: 1) based on the Gorlin equation (MPG(CMR-Gorlin)); 2) based on a multivariate regression model (MPG(CMR-Predicted)). RESULTS MPGCMR underestimated MPGTTE (bias = -6.5 mmHg, limits of agreement from -18.3 to 5.2 mmHg). On multivariate regression analysis, St (p = 0.002), EL (p = 0.001), and mean systolic vorticity (p < 0.001) were independently associated with larger MPG discrepancies between CMR and TTE. MPG(CMR-Gorlin) and MPGTTE correlation and agreement were r = 0.7; bias = -2.8 mmHg, limits of agreement from -18.4 to 12.9 mmHg. MPG(CMR-Predicted) model showed better correlation and agreement with MPGTTE (r = 0.82; bias = 0.5 mmHg, limits of agreement from -9.1 to 10.2 mmHg) than measured MPGCMR and MPG(CMR-Gorlin). CONCLUSION Flow vorticity is one of the main factors responsible for MPG discrepancies between CMR and TTE.
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Affiliation(s)
- Julio Garcia
- Québec Heart and Lung Institute, Laval University, Québec, Canada
- Laboratory of Cardiovascular Fluid Dynamics, Concordia University, Montréal, Canada
- Department of Radiology, Northwestern University, Chicago, USA
| | - Romain Capoulade
- Québec Heart and Lung Institute, Laval University, Québec, Canada
| | - Florent Le Ven
- Québec Heart and Lung Institute, Laval University, Québec, Canada
| | - Emmanuel Gaillard
- Department of Mechanical Engineering, McGill University, Montréal, Canada
| | - Lyes Kadem
- Laboratory of Cardiovascular Fluid Dynamics, Concordia University, Montréal, Canada
| | - Philippe Pibarot
- Québec Heart and Lung Institute, Laval University, Québec, Canada
| | - Éric Larose
- Québec Heart and Lung Institute, Laval University, Québec, Canada
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Chopard R, Meneveau N, Plastaras P, Janin S, Seronde MF, Ecarnot F, Schiele F. Invasive assessment of doubtful aortic stenosis by measuring simultaneous transaortic gradient with a pressure wire. Am J Cardiol 2013; 111:1772-7. [PMID: 23540549 DOI: 10.1016/j.amjcard.2013.02.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2012] [Revised: 02/12/2013] [Accepted: 02/12/2013] [Indexed: 11/16/2022]
Abstract
Two-dimensional transthoracic echocardiography (2D-TTE) is the reference technique for evaluating aortic stenosis (AS) but may be unreliable in some cases. We aimed to assess whether the use of a pressure wire to measure simultaneous transaortic gradient and aortic valve area (AVA) could be helpful in patients in whom initial noninvasive evaluations were considered doubtful for AS. Fifty-seven patients (mean age 76 years; 39 men) underwent cardiac catheterization with single arterial access for assessment of AVA with the Gorlin and Gorlin formula. Transaortic pressure was obtained by 2 invasive methods: (1) conventional pullback method (PM) from the left ventricle toward the aorta and (2) simultaneous method (SM) with transaortic pressure simultaneously recorded with a 0.014-inch pressure wire introduced into the left ventricle and with a diagnostic catheter placed in the ascending aorta. Reasons for inaccurate assessment by 2D-TTE were low flow states (88%) and/or atrial fibrillation (79%). Agreement for severe AS defined by AVA <0.6 cm²/m² between SM and 2D-TTE and between SM and PM was fair, with kappa coefficients of 0.38 (95% confidence interval [CI] 0.14-0.75) and 0.36 (95% CI 0.22-0.7) respectively; agreement was poor between 2D-TTE and PM (kappa: 0.23; 95% CI 0.002-0.36). SM led to a reclassification of the severity of AS in 9 patients (15.8%) compared with 2D-TTE and in 11 patients (19.3%) compared with PM. In conclusion, invasive evaluation of doubtful AS by measuring simultaneous transaortic gradient using a pressure wire may provide an attractive method that can lead to a change in therapeutic strategy in a substantial proportion of patients.
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Affiliation(s)
- Romain Chopard
- Department of Cardiology, University Hospital Jean Minjoz, University of Franche-Comte, EA 3920, Besançon, France.
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Lauten J, Rost C, Breithardt OA, Seligmann C, Klinghammer L, Daniel WG, Flachskampf FA. Invasive Hemodynamic Characteristics of Low Gradient Severe Aortic Stenosis Despite Preserved Ejection Fraction. J Am Coll Cardiol 2013; 61:1799-808. [DOI: 10.1016/j.jacc.2013.02.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2012] [Revised: 01/29/2013] [Accepted: 02/03/2013] [Indexed: 02/06/2023]
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Garcia J, Marrufo OR, Rodriguez AO, Larose E, Pibarot P, Kadem L. Cardiovascular magnetic resonance evaluation of aortic stenosis severity using single plane measurement of effective orifice area. J Cardiovasc Magn Reson 2012; 14:23. [PMID: 22480269 PMCID: PMC3366866 DOI: 10.1186/1532-429x-14-23] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2011] [Accepted: 04/06/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Transthoracic echocardiography (TTE) is the standard method for the evaluation of the severity of aortic stenosis (AS). Valve effective orifice area (EOA) measured by the continuity equation is one of the most frequently used stenotic indices. However, TTE measurement of aortic valve EOA is not feasible or not reliable in a significant proportion of patients. Cardiovascular magnetic resonance (CMR) has emerged as a non-invasive alternative to evaluate EOA using velocity measurements. The objectives of this study were: 1) to validate a new CMR method using jet shear layer detection (JSLD) based on acoustical source term (AST) concept to estimate the valve EOA; 2) to introduce a simplified JSLD method not requiring vorticity field derivation. METHODS AND RESULTS We performed an in vitro study where EOA was measured by CMR in 4 fixed stenoses (EOA = 0.48, 1.00, 1.38 and 2.11 cm²) under the same steady flow conditions (4-20 L/min). The in vivo study included eight (8) healthy subjects and 37 patients with mild to severe AS (0.72 cm² ≤ EOA ≤ 1.71 cm²). All subjects underwent TTE and CMR examinations. EOA was determinated by TTE with the use of continuity equation method (TTE(CONT)). For CMR estimation of EOA, we used 3 methods: 1) Continuity equation (CMR(CONT)); 2) Shear layer detection (CMR(JSLD)), which was computed from the velocity field of a single CMR velocity profile at the peak systolic phase; 3) Single plane velocity truncation (CMR(SPVT)), which is a simplified version of CMR(JSLD) method. There was a good agreement between the EOAs obtained in vitro by the different CMR methods and the EOA predicted from the potential flow theory. In the in vivo study, there was good correlation and concordance between the EOA measured by the TTE(CONT) method versus those measured by each of the CMR methods: CMR(CONT) (r = 0.88), CMR(JSLD) (r = 0.93) and CMR(SPVT) (r = 0.93). The intra- and inter- observer variability of EOA measurements was 5 ± 5% and 9 ± 5% for TTE(CONT), 2 ± 1% and 7 ± 5% for CMR(CONT), 7 ± 5% and 8 ± 7% for CMR(JSLD), 1 ± 2% and 3 ± 2% for CMR(SPVT). When repeating image acquisition, reproducibility of measurements was 10 ± 8% and 12 ± 5% for TTE(CONT), 9 ± 9% and 8 ± 8% for CMR(CONT), 6 ± 5% and 7 ± 4% for CMR(JSLD) and 3 ± 2% and 2 ± 2% for CMR(SPVT). CONCLUSION There was an excellent agreement between the EOA estimated by the CMR(JSLD) or CMR(SPVT) methods and: 1) the theoretical EOA in vitro, and 2) the TTE(CONT) EOA in vivo. The CMR(SPVT) method was superior to the TTE and other CMR methods in terms of measurement variability. The novel CMR-based methods proposed in this study may be helpful to corroborate stenosis severity in patients for whom Doppler-echocardiography exam is inconclusive.
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Affiliation(s)
- Julio Garcia
- Québec Heart & Lung Institute, Laval University, Québec, Canada
- Laboratory of Cardiovascular Fluid Dynamics, Concordia University, Montréal, Canada
| | - Oscar R Marrufo
- Department of Electrical Engineering, Universidad Autonoma Metropolitana, Mexico, DF, Mexico
| | - Alfredo O Rodriguez
- Department of Electrical Engineering, Universidad Autonoma Metropolitana, Mexico, DF, Mexico
| | - Eric Larose
- Québec Heart & Lung Institute, Laval University, Québec, Canada
| | | | - Lyes Kadem
- Laboratory of Cardiovascular Fluid Dynamics, Concordia University, Montréal, Canada
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Levy F, Luc Monin J, Rusinaru D, Petit-Eisenmann H, Lelguen C, Chauvel C, Adams C, Metz D, Leleu F, Gueret P, Tribouilloy C. Valvuloarterial impedance does not improve risk stratification in low-ejection fraction, low-gradient aortic stenosis: results from a multicentre study. EUROPEAN JOURNAL OF ECHOCARDIOGRAPHY 2011; 12:358-63. [DOI: 10.1093/ejechocard/jer022] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Mahmood F, Fritsch M, Maslow A. Unanticipated mild-to-moderate aortic stenosis during coronary artery bypass graft surgery: scope of the problem and its echocardiographic evaluation. J Cardiothorac Vasc Anesth 2009; 23:869-77. [PMID: 19589698 DOI: 10.1053/j.jvca.2009.03.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2008] [Indexed: 11/11/2022]
Affiliation(s)
- Feroze Mahmood
- Department of Anesthesia and Critical Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA.
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Khaw AV, von Bardeleben RS, Strasser C, Mohr-Kahaly S, Blankenberg S, Espinola-Klein C, Münzel TF, Schnabel R. Direct measurement of left ventricular outflow tract by transthoracic real-time 3D-echocardiography increases accuracy in assessment of aortic valve stenosis. Int J Cardiol 2008; 136:64-71. [PMID: 18657334 DOI: 10.1016/j.ijcard.2008.04.070] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2007] [Revised: 01/11/2008] [Accepted: 04/23/2008] [Indexed: 11/19/2022]
Abstract
BACKGROUND Evaluation of aortic valve stenosis is a major clinical application of echocardiography. The widely employed continuity equation requires determination of the left ventricular outflow tract (LVOT) area. We aimed at testing whether direct area measurement in a volume data set is superior to conventional calculation from the LVOT diameter. METHODS We performed LVOT measurement in 20 normal subjects and 83 patients with moderate to severe aortic stenosis with a transthoracic real-time three-dimensional echocardiography (3D-TTE) technique in two systolic frames. The off-line 3D-evaluation allows full choice of section planes within the acquired volume data set. The aortic valve area was calculated from systolic LVOT areas. These results were compared to area values obtained by M-mode LVOT-diameters (area=pi(*)(d/2)(2)). In addition, the calculated aortic valve orifices were compared to invasive measurements or direct planimetry in the transthoracic or transesophageal examination. RESULTS Two independent observers found a reduction in LVOT area during systole (p<0.001). Often a more ellipsoid-like shaped LVOT resulted at end-systole which was shown by a reduction (p<0.001) of the LVOT longitudinal to oblique axis ratio. 3D-TTE determination of aortic valve orifice areas (mean difference: -0.04+/-0.09 cm(2)) showed a lesser deviation from the invasively or planimetrically measured areas than conventionally calculated LVOT areas (mean difference: -0.1+/-0.1 cm(2)) using the continuity equation (p<0.001). CONCLUSIONS The tested transthoracic 3D-echocardiography technique offers non-invasive measurement of the LVOT and aortic valve area based on the continuity equation during systole and thus improves accuracy and, additionally, agreement of aortic valvular area determination with invasive and direct measurements.
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Affiliation(s)
- Alexander V Khaw
- Neurovascular Research, Department of Neurology, Ernst-Moritz-Arndt University of Greifswald, Germany
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Bottio T, Tarzia V, Rizzoli G, Gerosa G. Valve prostheses evaluation: it is a complex scenario and not only a matter of gradient. Ann Thorac Surg 2008; 86:691; author reply 691-2. [PMID: 18640370 DOI: 10.1016/j.athoracsur.2007.12.059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2007] [Revised: 11/13/2007] [Accepted: 12/20/2007] [Indexed: 11/18/2022]
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Poh KK, Levine RA, Solis J, Shen L, Flaherty M, Kang YJ, Guerrero JL, Hung J. Assessing aortic valve area in aortic stenosis by continuity equation: a novel approach using real-time three-dimensional echocardiography. Eur Heart J 2008; 29:2526-35. [PMID: 18263866 DOI: 10.1093/eurheartj/ehn022] [Citation(s) in RCA: 111] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
AIMS Two-dimensional echocardiographic (2DE) continuity-equation derived aortic valve area (AVA) in aortic stenosis (AS) relies on non-simultaneous measurement of left ventricular outflow tract (LVOT) velocity and geometric assumptions of LVOT area, which can amplify error, especially in upper septal hypertrophy (USH). We hypothesized that real-time three-dimensional echocardiography (RT3DE) can improve accuracy of AVA by directly measuring LVOT stroke volume (SV) in one window. METHODS AND RESULTS RT3DE colour Doppler and 2DE were acquired in 68 AS patients (74 +/- 12 yrs) prospectively. SV was derived from flow obtained from a sampling curve placed orthogonal to LVOT (Tomtec Imaging). Agreement between continuity-equation derived AVA by RT3DE (AVA(3D-SV)) and 2DE (AVA(2D)) and predictors of discrepancies were analysed. Validation of LVOT SV was performed by aortic flow probe in a sheep model with balloon inflation of septum to mimic USH. There was only modest correlation between AVA(2D) and AVA(3D-SV) (r = 0.71, difference 0.11 +/- 0.23 cm(2)). The degree of USH was significantly associated with difference in AVA calculation (r = 0.4, P = 0.005). In experimentally distorted LVOT geometry in sheep, RT3DE correlated better with flow probe assessment (r = 0.96, P < 0.001) than 2DE (r = 0.71, P = 0.006). CONCLUSION RT3DE colour Doppler-derived LVOT SV in the calculation of AVA by continuity equation is more accurate than 2D, including in situations such as USH, common in the elderly, which modify LVOT geometry.
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Affiliation(s)
- Kian Keong Poh
- Division of Cardiology, Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
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Bottio T, Gerosa G. Conflicting Echocardiographic Evaluations of Supra-Annular Tissue Valves: A Mystery Not Yet Resolved. Ann Thorac Surg 2007; 84:713-4. [PMID: 17643679 DOI: 10.1016/j.athoracsur.2007.02.072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2007] [Revised: 01/01/2007] [Accepted: 02/23/2007] [Indexed: 11/29/2022]
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Gerosa G, Tarzia V, Rizzoli G, Bottio T. Reply to the Editor. J Thorac Cardiovasc Surg 2007. [DOI: 10.1016/j.jtcvs.2006.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Abstract
PURPOSE OF REVIEW Valve replacement improves symptoms and survival in symptomatic severe aortic stenosis. Low-flow, low-gradient aortic stenosis, however, is an especially challenging subset as valve replacement has a significant risk, and may fail to alleviate symptoms or improve left ventricular function. This article reviews the potential problems in evaluating aortic stenosis severity in low-flow, low-gradient aortic stenosis, the utility of dobutamine challenge to identify patients most likely to benefit from surgery, and the factors predicting patient outcome. RECENT FINDINGS Low-flow, low-gradient aortic stenosis consists of a heterogeneous group of patients with 'true' severe aortic stenosis, in whom afterload mismatch results from a severely stenotic valve; and 'pseudo-severe' aortic stenosis, where the valve is only mildly or moderately stenotic, but appears severe due to limitations in determining disease severity under low-flow conditions. Valve replacement is likely to benefit the former group, but may have little benefit to the latter. Dobutamine challenge can distinguish 'true' and 'pseudo-severe' aortic stenosis, and can evaluate contractile reserve, one of the strongest predictors of patient outcome. Strategies to avoid prosthesis-patient mismatch should be considered to optimize postoperative outcome. SUMMARY Dobutamine challenge can identify low-flow, low-gradient aortic stenosis patients most likely to benefit from valve replacement and provides important prognostic information on the operative risks and long-term outcome.
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Affiliation(s)
- Ian G Burwash
- Department of Medicine, Division of Cardiology, University of Ottawa Heart Institute, University of Ottawa, Ontario, Canada.
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DeMaria AN, Ben-Yehuda O, Feld GK, Ginsburg GS, Greenberg BH, Lew WYW, Lima JAC, Maisel AS, Narula J, Sahn DJ, Tsimikas S. Highlights of the Year in JACC2006. J Am Coll Cardiol 2007; 49:509-27. [PMID: 17258099 DOI: 10.1016/j.jacc.2006.12.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2006] [Accepted: 12/05/2006] [Indexed: 12/15/2022]
Affiliation(s)
- Anthony N DeMaria
- Cardiology Division, University of California-San Diego, 92103-9000, USA.
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Rahimtoola SH. The Year in Valvular Heart Disease. J Am Coll Cardiol 2007; 49:361-74. [PMID: 17239719 DOI: 10.1016/j.jacc.2006.11.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2006] [Revised: 11/02/2006] [Accepted: 11/06/2006] [Indexed: 01/02/2023]
Affiliation(s)
- Shahbudin H Rahimtoola
- Griffith Center, Division of Cardiovascular Medicine, Department of Medicine, LAC + USC Medical Center, Keck School of Medicine at USC, Los Angeles, California 90033, USA
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Abstract
Aortic valve stenosis has already reached endemic proportions in Western countries. As the prognosis of low-flow aortic valve stenosis under medical treatment is dismal, surgery is recommended in most patients. Preoperative dobutamine stress testing may help to assess surgical risk, but there is no strong scientific evidence to deny surgery based exclusively on the results of this test. The problems associated with clinical decision making in this condition are reviewed.
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Affiliation(s)
- J Bermejo
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain.
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