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Carrión-Sánchez I, Zamorano JL. Multivalvular diseases: look beyond the valves-no way home. Eur Heart J Cardiovasc Imaging 2024:jeae226. [PMID: 39259523 DOI: 10.1093/ehjci/jeae226] [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: 09/13/2024] Open
Affiliation(s)
- Irene Carrión-Sánchez
- Cardiology Department, University Hospital Ramón y Cajal, M-607 KM 9,100, 28034 Madrid, Spain
- Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), M-607 KM 9, 100, 28034 Madrid, Spain
| | - José Luis Zamorano
- Cardiology Department, University Hospital Ramón y Cajal, M-607 KM 9,100, 28034 Madrid, Spain
- Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), M-607 KM 9, 100, 28034 Madrid, Spain
- CIBERCV Instituto de Salud Carlos III (ISCIII), Monforte de Lemos, 3-5, 28029 Madrid, Spain
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Sooriyakanthan M, Graham FJ, Ho N, Leong-Poi H, Tsang W. Alterations in Left Atrial and Ventricular Coupling in Mixed Aortic Valve Disease. Eur Heart J Cardiovasc Imaging 2024:jeae199. [PMID: 39119781 DOI: 10.1093/ehjci/jeae199] [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: 02/28/2024] [Revised: 07/05/2024] [Accepted: 08/07/2024] [Indexed: 08/10/2024] Open
Abstract
AIMS To characterize left atrial (LA) and left ventricular (LV) function and atrioventricular (AV) coupling in patients with moderate mixed aortic valve disease (MMAVD) against those with isolated moderate or severe aortic valve disease and controls. METHODS & RESULTS Retrospective LA and LV peak longitudinal strain (LS) analysis were performed on 260 patients (46 MMAVD, 81 moderate aortic stenosis (AS), 50 severe AS, 48 moderate aortic regurgitation (AR), and 35 severe AR) and 66 controls. Peak LV and LA LS and AV coupling, assessed by combined peak LA and LV strain, was compared between the groups. ANOVA and 2-sided t-tests were used and a p-value of <0.01 was considered significant.LV strain was significantly lower in those with MMAVD compared to controls and those with moderate or severe isolated AR but comparable to those with moderate or severe AS (-17.1±1.1% MMAVD vs. -17.7±1.5% moderate AS p=0.02; vs. -17.0%±1.5% severe AS, p=0.74). AV coupling was significantly lower in those with MMAVD compared to controls and those with moderate AS or AR but comparable to those with severe AS or AR (47.1±6.8% MMAVD vs. 45.1±5.6% severe AS, p=0.13; vs. 50.4±9% severe AR, p=0.07). CONCLUSIONS Impairments in AV coupling are comparable for patients with MMAVD and those with severe isolated AS or AR. Impairments in LV GLS in MMAVD mirror those found in severe AS. These findings suggest that haemodynamic consequences and adverse remodelling are similar for patients with MMAVD and isolated severe disease.
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Affiliation(s)
- Maala Sooriyakanthan
- Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Fraser J Graham
- Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, United Kingdom
| | - Natalie Ho
- The Scarborough Health Network, Toronto, Canada
| | | | - Wendy Tsang
- Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
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Jahangiri M, Prendergast B. Management of bicuspid aortic valve disease in the transcatheter aortic valve implantation era. Heart 2024:heartjnl-2024-324054. [PMID: 39117383 DOI: 10.1136/heartjnl-2024-324054] [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: 06/06/2024] [Accepted: 07/23/2024] [Indexed: 08/10/2024] Open
Abstract
In an era of rapidly expanding use of transcatheter aortic valve implantation (TAVI), the management of patients with bicuspid aortic valve (BAV) disease is far less well established than in those with trileaflet anatomy. Results of isolated surgical aortic valve replacement are excellent in suitable patients, and surgery also allows treatment of concomitant pathology of the aortic root and ascending aorta that is frequently encountered in this cohort. Conversely, TAVI provides an excellent alternative in older patients who may be unsuitable for surgery, although outcomes in BAV disease have only been reported in relatively small non-randomised series. Here, we discuss the pertinent literature on this topic and outline contemporary interventional treatment options in this challenging setting.
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Affiliation(s)
- Marjan Jahangiri
- Department of Cardiac Surgery, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Bernard Prendergast
- Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, UK
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Kochav JD, Takayama H, Goldstone A, Kalfa D, Bacha E, Rosenbaum M, Lewis MJ. Left ventricular reverse remodeling after aortic valve replacement or repair in bicuspid aortic valve with moderate or greater aortic regurgitation. JTCVS OPEN 2024; 19:47-60. [PMID: 39015468 PMCID: PMC11247208 DOI: 10.1016/j.xjon.2024.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 02/22/2024] [Accepted: 03/08/2024] [Indexed: 07/18/2024]
Abstract
Objective Bicuspid aortic valve (AV) patients with aortic regurgitation (AR) differ from tricuspid AV patients given younger age, greater left ventricle (LV) compliance, and more prevalent aortic stenosis (AS). Bicuspid AV-specific data to guide timing of AV replacement or repair are lacking. Methods Adults with bicuspid AV and moderate or greater AR who underwent aortic valve replacement or repair at our center were studied. The presurgical echocardiogram, and echocardiograms within 3 years postoperatively were evaluated for LV geometry/function, and AV function. Semiquantitative AS/AR assessment was performed in all patients with adequate imaging. Results One hundred thirty-five patients (85% men, aged 44.5 ± 15.9 years) were studied (63% pure AR, 37% mixed AS/AR). Following aortic valve replacement or repair, change in LV end-diastolic dimension and change in LV end-diastolic volume were associated with preoperative LV end-diastolic dimension (β = 0.62 Δcm/cm; 95% CI, 0.43-0.73 Δcm/cm; P < .001), and LV end-diastolic volume (β = 0.6 ΔmL/mL; 95% CI, 0.4-0.7 ΔmL/mL; P < .001), respectively, each independent of AR/AS severity (P = not significant). Baseline LV size predicted postoperative normalization (LV end-diastolic dimension: odds ratio, 3.75/cm; 95% CI, 1.61-8.75/cm, LV end-diastolic volume: odds ratio, 1.01/mL; 95% CI, 1.004-1.019/mL, both P values < .01) whereas AR/AS severity did not (P = not significant). Indexed LV end diastolic volume outperformed LV end-diastolic dimension in predicting postoperative LV normalization (area under the curve = 0.74 vs 0.61) with optimal diagnostic cutoffs of 99 mL/m2 and 6.1 cm, respectively. Postoperative indexed LV end diastolic volume dilatation was associated with increased risk of death, transplant/ventricular assist device, ventricular arrhythmia, and reoperation (hazard ratio, 6.1; 95% CI, 1.7-21.5; P < .01). Conclusions Remodeling extent following surgery in patients with bicuspid AV and AR relates to preoperative LV size independent of valve disease phenotype or severity. Many patients with LV end-diastolic dimension below current surgical thresholds did not normalize LV size. LV volumetric assessment offered superior diagnostic performance for predicting residual LV dilatation, and postoperative indexed LV end diastolic volume dilatation was associated with adverse prognosis.
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Affiliation(s)
- Jonathan D. Kochav
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Hiroo Takayama
- Division of Cardiothoracic and Vascular Surgery, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Andrew Goldstone
- Division of Cardiothoracic and Vascular Surgery, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - David Kalfa
- Division of Cardiothoracic and Vascular Surgery, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Emile Bacha
- Division of Cardiothoracic and Vascular Surgery, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Marlon Rosenbaum
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Matthew J. Lewis
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
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5
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Wang C, Hu X, Luo S, Sun Y, Yang B, Zheng S, Chen J, Fu M, Fan R, Li J, Luo J. Assess the Outcomes of Transcatheter Aortic Valve Replacement in Bicuspid Valve with Mixed Disease versus Predominant Aortic Stenosis. Clin Interv Aging 2024; 19:695-703. [PMID: 38711477 PMCID: PMC11070846 DOI: 10.2147/cia.s447272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 04/04/2024] [Indexed: 05/08/2024] Open
Abstract
Purpose In mixed aortic valve disease (MAVD), the results of transcatheter aortic valve replacement (TAVR) are conflicting. There is limited data on the outcomes of TAVR in patients with bicuspid aortic valve (BAV) and MAVD. The objective of this study is to compare outcomes after TAVR in BAV patients with MAVD and predominant aortic stenosis (PAS). Patients and Methods Patients with BAV who underwent TAVR between January 2016 and April 2023 were included. The primary outcome was device success. The secondary endpoints were periprocedural mortality and other complications as defined by the Valve Academic Research Consortium-3 (VARC-3). Propensity score matching was used to minimize potential confounding. Results A total of 262 patients were included in this study, 83 of whom had MAVD. The median age was 72 years, and 55.7% were male. The baseline comorbidity risk files were comparable between the two groups. Patients with MAVD had more mitral regurgitation, tricuspid regurgitation and pulmonary hypertension, larger annular and left ventricular outflow tract dimensions, and more severe calcification than PAS. In the unmatched population, MAVD patients had similar device success rate (69.9% vs 79.9%, P=0.075) and 30-day mortality (3.6% vs 3.4%, P=1) compared to PAS. Propensity score matching resulted in 66 patient pairs. Device success rate were still comparable in the matched population. Other clinical outcomes, including stroke, bleeding (type 2-4), major vascular complications, acute kidney injury (stage 2-4) and permanent pacemaker implantation, were comparable between the two groups. Multivariable logistic regression analysis did not show MAVD to be an independent negative predictor of device success. At one year, survival was similar between patients with MAVD and those with PAS. Conclusion For the bicuspid valve, patients with MAVD had a more challenging anatomy. MAVD patients associated with comparable 30-day clinical outcomes after TAVR compared to PAS patients in patients with BAV.
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Affiliation(s)
- Changjin Wang
- Department of Cardiology, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, People’s Republic of China
| | - Xiaolu Hu
- Department of Cardiology, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, People’s Republic of China
- School of Medicine South China University of Technology, Guangzhou, People’s Republic of China
| | - Songyuan Luo
- Department of Cardiology, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, People’s Republic of China
| | - Yinghao Sun
- Department of Cardiology, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, People’s Republic of China
| | - Bangyuan Yang
- Department of Cardiology, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, People’s Republic of China
| | - Shengneng Zheng
- Department of Radiology, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, People’s Republic of China
| | - Jiaohua Chen
- Department of Cardiology, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, People’s Republic of China
| | - Ming Fu
- Department of Cardiology, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, People’s Republic of China
| | - Ruixin Fan
- Department of Cardiac Surgery, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, People’s Republic of China
| | - Jie Li
- Department of Cardiology, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, People’s Republic of China
| | - Jianfang Luo
- Department of Cardiology, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, People’s Republic of China
- School of Medicine South China University of Technology, Guangzhou, People’s Republic of China
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Patel KP, McKenna M, Thornton GD, Vandermolen S, Abdulelah ZA, Awad W, Baumbach A, Mathur A, Treibel TA, Lloyd G, Mullen MJ, Bhattacharyya S. Predictors of outcome in patients with moderate mixed aortic valve disease. Heart 2024; 110:740-748. [PMID: 38148159 DOI: 10.1136/heartjnl-2023-323321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 12/13/2023] [Indexed: 12/28/2023] Open
Abstract
OBJECTIVES Grading the severity of moderate mixed aortic stenosis and regurgitation (MAVD) is challenging and the disease poorly understood. Identifying markers of haemodynamic severity will improve risk stratification and potentially guide timely treatment. This study aims to identify prognostic haemodynamic markers in patients with moderate MAVD. METHODS Moderate MAVD was defined as coexisting moderate aortic stenosis (aortic valve area (AVA) 1.0-1.5 cm2) and moderate aortic regurgitation (vena contracta (VC) 0.3-0.6 cm). Consecutive patients diagnosed between 2015 and 2019 were included from a multicentre registry. The primary composite outcome of death or heart failure hospitalisation was evaluated among these patients. Demographics, comorbidities, echocardiography and treatment data were assessed for their prognostic significance. RESULTS 207 patients with moderate MAVD were included, aged 78 (66-84) years, 56% male sex, AVA 1.2 (1.1-1.4) cm2 and VC 0.4 (0.4-0.5) cm. Over a follow-up of 3.5 (2.5-4.7) years, the composite outcome was met in 89 patients (43%). Univariable associations with the primary outcome included older age, previous myocardial infarction, previous cerebrovascular event, atrial fibrillation, New York Heart Association >2, worse renal function, tricuspid regurgitation ≥2 and mitral regurgitation ≥2. Markers of biventricular systolic function, cardiac remodelling and transaortic valve haemodynamics demonstrated an inverse association with the primary composite outcome. In multivariable analysis, peak aortic jet velocity (Vmax) was independently and inversely associated with the composite outcome (HR: 0.63, 95% CI 0.43 to 0.93; p=0.021) in an adjusted model along with age (HR: 1.05, 95% CI 1.03 to 1.08; p<0.001), creatinine (HR: 1.002, 95% CI 1.001 to 1.003; p=0.005), previous cerebrovascular event (85% vs 42%; HR: 3.04, 95% CI 1.54 to 5.99; p=0.001) and left ventricular ejection fraction (LVEF) (HR: 0.97, 95% CI 0.95 to 0.99; p=0.007). Patients with Vmax ≤2.8 m/s and LVEF ≤50% (n=27) had the worst outcome compared with the rest of the population (72% vs 41%; HR: 3.87, 95% CI 2.20 to 6.80; p<0.001). CONCLUSIONS Patients with truly moderate MAVD have a high incidence of death and heart failure hospitalisation (43% at 3.5 (2.5-4.7) years). Within this group, a high-risk group characterised by disproportionately low aortic Vmax (≤2.8 m/s) and adverse remodelling (LVEF ≤50%) have the worst outcomes.
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Affiliation(s)
- Kush P Patel
- Institute of Cardiovascular Science, University College London, London, UK
- Barts Heart Centre, West Smithfield, London, UK
| | | | - George D Thornton
- Institute of Cardiovascular Science, University College London, London, UK
- Barts Heart Centre, West Smithfield, London, UK
| | - Sebastian Vandermolen
- Institute of Cardiovascular Science, University College London, London, UK
- The William Harvey Research Institute, Queen Mary University, London, UK
| | | | - Wael Awad
- Barts Heart Centre, West Smithfield, London, UK
| | - Andreas Baumbach
- Barts Heart Centre, West Smithfield, London, UK
- The William Harvey Research Institute, Queen Mary University, London, UK
| | - Anthony Mathur
- Barts Heart Centre, West Smithfield, London, UK
- The William Harvey Research Institute, Queen Mary University, London, UK
| | - Thomas A Treibel
- Institute of Cardiovascular Science, University College London, London, UK
- Barts Heart Centre, West Smithfield, London, UK
| | - Guy Lloyd
- Barts Heart Centre, West Smithfield, London, UK
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Saijo Y, Kusunose K, Takahashi T, Yamada H, Sata M, Sato K, Albakaa N, Ishizu T, Seo Y. Impact of Transcatheter Aortic Valve Replacement on Cardiac Reverse Remodeling and Prognosis in Mixed Aortic Valve Disease. J Am Heart Assoc 2024; 13:e033289. [PMID: 38362873 PMCID: PMC11010113 DOI: 10.1161/jaha.123.033289] [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: 11/24/2023] [Accepted: 01/23/2024] [Indexed: 02/17/2024]
Abstract
BACKGROUND The management of mixed aortic valve disease (MAVD), defined as the concomitant presence of aortic stenosis (AS) and aortic regurgitation, remains a clinical challenging. The present study assessed the impact of transcatheter aortic valve replacement (TAVR) on cardiac geometry and prognosis in patients with MAVD. METHODS AND RESULTS A retrospective multicenter TAVR registry was conducted, including patients who underwent TAVR for severe symptomatic AS between January 2015 and March 2019. Patients were subdivided into 2 groups according to concomitant presence of moderate or more severe aortic regurgitation as the MAVD group, and with mild or less severe aortic regurgitation as the isolated AS group. The primary outcome was a composite of cardiovascular death and rehospitalization due to cardiovascular causes. A total of 1742 patients (isolated AS, 1522 patients; MAVD, 220 patients) were included (84.0±5.2 years). Although MAVD exhibited significantly larger left ventricular volumes and higher left ventricular mass index at the TAVR procedure than isolated AS (respectively, P<0.001), MAVD showed a greater improvement of left ventricular volumes and left ventricular mass index after TAVR (respectively, P≤0.001). During a median follow-up of 747 days, 301 patients achieved the primary event. The prognosis post-TAVR was comparable between the 2 groups (log-rank P=0.65). Even after adjustment using propensity score matching to reduce the potential bias between the 2 groups, similar results were obtained for the entire cohort. CONCLUSIONS Despite more advanced cardiac remodeling in MAVD at the time of TAVR compared with isolated AS, a greater improvement of cardiac reverse remodeling was found in MAVD, and the prognosis following TAVR was comparable between the 2 groups.
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Affiliation(s)
- Yoshihito Saijo
- Cardiovascular Department Tokushima University Hospital Tokushima Japan
| | - Kenya Kusunose
- Department of Cardiovascular Medicine, Nephrology and Neurology University of the Ryukyus Okinawa Japan
| | | | - Hirotsugu Yamada
- Cardiovascular Department Tokushima University Hospital Tokushima Japan
| | - Masataka Sata
- Cardiovascular Department Tokushima University Hospital Tokushima Japan
| | - Kimi Sato
- Department of Cardiology, Faculty of Medicine University of Tsukuba Japan
| | - Noor Albakaa
- Department of Cardiology, Faculty of Medicine University of Tsukuba Japan
| | - Tomoko Ishizu
- Department of Cardiology, Faculty of Medicine University of Tsukuba Japan
| | - Yoshihiro Seo
- Department of Cardiology Nagoya City University Graduate School of Medical Sciences Nagoya Japan
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8
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Egbe AC, Pellikka PA, Connolly HM, Borlaug BA. Abnormal Right Ventricular-Pulmonary Arterial Coupling in Patients With Coarctation of Aorta Presenting With Aortic Stenosis. JACC Cardiovasc Imaging 2024:S1936-878X(24)00034-2. [PMID: 38340137 DOI: 10.1016/j.jcmg.2023.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 12/04/2023] [Accepted: 12/21/2023] [Indexed: 02/12/2024]
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Tanriverdi Z. Importance of the Aortic Regurgitation in Patients With Mixed Aortic Valve Disease Treated by TAVI: Friend or Foe? Am J Cardiol 2023; 206:357-359. [PMID: 37735057 DOI: 10.1016/j.amjcard.2023.08.115] [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: 08/06/2023] [Revised: 08/13/2023] [Accepted: 08/20/2023] [Indexed: 09/23/2023]
Affiliation(s)
- Zulkif Tanriverdi
- Department of Cardiology, Faculty of Medicine, Harran University, Sanliurfa, Turkey.
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10
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Dayawansa NH, Noaman S, Teng LE, Htun NM. Transcatheter Aortic Valve Therapy for Bicuspid Aortic Valve Stenosis. J Cardiovasc Dev Dis 2023; 10:421. [PMID: 37887868 PMCID: PMC10607300 DOI: 10.3390/jcdd10100421] [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: 09/11/2023] [Revised: 10/01/2023] [Accepted: 10/07/2023] [Indexed: 10/28/2023] Open
Abstract
Transcatheter aortic valve implantation (TAVI) has become first-line treatment for older adults with severe aortic stenosis (AS), however, patients with bicuspid aortic valve (BAV) have been traditionally excluded from randomised trials and guidelines. As familiarity and proficiency of TAVI operators have improved, case-series and observational data have demonstrated the feasibility of successful TAVI in bicuspid aortic valve aortic stenosis (BAV-AS), however, patients with BAV-AS have several distinct characteristics that influence the likelihood of TAVI success. This review aims to summarise the pathophysiology and classification of BAV, published safety data, anatomical challenges and procedural considerations essential for pre-procedural planning, patient selection and procedural success of TAVI in BAV.
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Affiliation(s)
- Nalin H. Dayawansa
- Alfred Health, Melbourne, VIC 3004, Australia; (N.H.D.); (S.N.); (L.E.T.)
- Department of Medicine, Central Clinical School, Monash University, Melbourne, VIC 3004, Australia
- Baker Heart & Diabetes Institute, Melbourne, VIC 3004, Australia
| | - Samer Noaman
- Alfred Health, Melbourne, VIC 3004, Australia; (N.H.D.); (S.N.); (L.E.T.)
- Western Health, St Albans, VIC 3021, Australia
| | - Lung En Teng
- Alfred Health, Melbourne, VIC 3004, Australia; (N.H.D.); (S.N.); (L.E.T.)
| | - Nay Min Htun
- Alfred Health, Melbourne, VIC 3004, Australia; (N.H.D.); (S.N.); (L.E.T.)
- Peninsula Health, Frankston, VIC 3199, Australia
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11
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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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12
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Onishi H, Izumo M, Ouchi T, Yuki H, Naganuma T, Nakao T, Nakamura S. Clinical impact of aortic valve replacement in patients with moderate mixed aortic valve disease. Front Cardiovasc Med 2023; 10:1259188. [PMID: 37692041 PMCID: PMC10484795 DOI: 10.3389/fcvm.2023.1259188] [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: 07/15/2023] [Accepted: 08/07/2023] [Indexed: 09/12/2023] Open
Abstract
Background Information is scarce regarding the clinical implications of aortic valve replacement (AVR) for patients suffering from moderate mixed aortic valve disease (MAVD), characterized by a combination of moderate aortic stenosis (AS) and regurgitation (AR). The objective of this retrospective study was to explore the clinical effects of AVR in individuals with moderate MAVD. Methods We examined the clinical data from patients with moderate MAVD and preserved left ventricular ejection fraction, who had undergone echocardiography in the period spanning from 2010 to 2018. Moderate AS was defined as aortic valve area index of 0.60-0.85 cm2/m2 and peak velocity of 3.0-4.0 m/s. Moderate AR was defined as a vena contracta width of 3.0-6.0 mm. The primary endpoint was a composite of all-cause death and heart failure hospitalization. Results Among 88 patients (mean age, 74.4 ± 6.8 years; 48.9%, men), 44 (50.0%) required AVR during a median follow-up period of 3.3 years (interquartile range, 0.5-4.9). Mean values of specific aortic valve variables are as follows: aortic valve area index, 0.64 ± 0.04 cm2/m2; peak velocity, 3.40 ± 0.30 m/s; and vena contracta width, 4.1 ± 0.7 mm. The primary endpoint occurred in 32 (36.4%) patients during a median follow-up duration of 5.3 years (interquartile range, 3.2-8.0). Multivariable analysis revealed that AVR was significantly associated with the endpoint (hazard ratio, 0.248; 95% confidence interval, 0.107-0.579; p = 0.001) after adjusting for age, B-type natriuretic peptide, and the Charlson comorbidity index. Patients who underwent AVR during follow-up had significantly lower incidence rates of the endpoint than those managed with medical treatment (10.2% vs. 44.1% at 5 years; p < 0.001). Conclusions Approximately half of the patients diagnosed with moderate MAVD eventually necessitated AVR throughout the period of observation, leading to positive clinical results. Vigilant tracking of these patients and watchful monitoring for signs requiring AVR during this time frame are essential.
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Affiliation(s)
- Hirokazu Onishi
- Department of Cardiology, New Tokyo Hospital, Chiba, Japan
- Department of Cardiology, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Masaki Izumo
- Department of Cardiology, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Toru Ouchi
- Department of Cardiology, New Tokyo Hospital, Chiba, Japan
| | - Haruhito Yuki
- Department of Cardiology, New Tokyo Hospital, Chiba, Japan
| | - Toru Naganuma
- Department of Cardiology, New Tokyo Hospital, Chiba, Japan
| | - Tatsuya Nakao
- Department of Cardiovascular Surgery, New Tokyo Hospital, Chiba, Japan
| | - Sunao Nakamura
- Department of Cardiology, New Tokyo Hospital, Chiba, Japan
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13
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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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14
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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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15
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Ugwu JK, Kandah DR, Ndulue JK, Ebiem OP, Ugwu-Erugo JN, Hamilton R, Osei K, Taskesen T, Shivapour DM, Chawla A, Marcus RH. Comparative Outcomes of TAVR in Mixed Aortic Valve Disease and Aortic Stenosis: A Meta-analysis. Cardiol Ther 2023; 12:143-157. [PMID: 36567395 PMCID: PMC9986165 DOI: 10.1007/s40119-022-00293-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 11/28/2022] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION Transcatheter aortic valve replacement (TAVR) has become a suitable alternative to surgical aortic valve replacement (SAVR) for the treatment of symptomatic severe aortic stenosis (AS). A high proportion of patients with AS have mixed aortic valve disease (MAVD) with mild or more concurrent aortic regurgitation (AR). Differential outcomes of TAVR among patients with AS and MAVD have not been well characterized. We compared 1-year mortalities following TAVR among patients with MAVD and AS. METHODS We conducted a meta-analysis of studies published in PubMed/Medline. The primary outcome was 1-year all-cause mortality following TAVR among patients with MAVD vs. AS. Secondary endpoints were: (1) incidence of AR within 30 days following TAVR (post TAVR AR); and (2) 1-year all-cause mortality within each group stratified according to severity of post TAVR AR. RESULTS Nine studies involving 9505 participants were included in the analysis. At 1 year following TAVR, mortality was lower in MAVD than in AS; HR 0.89, 95% CI 0.81-0.98. The mortality advantage increased when pre-TAVR AR was moderate or more; HR 0.84, 95% CI 0.72-0.99. The mortality advantage was attenuated after correction for publication bias. There was a higher risk of post TAVR AR in the MAVD group; OR 1.51, 95% CI 1.20-1.90 but the impact on mortality of moderate vs. mild post TAVR AR was greater among patients with AS than in patients with MAVD HR 1.67 95% CI 0.89-3.14 vs. 0.93 95% CI 0.47-1.85. CONCLUSIONS Patients with MAVD have similar or improved survival 1 year after TAVR compared to those with AS.
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Affiliation(s)
- Justin K Ugwu
- Department of Cardiovascular Medicine, MercyOne Des Moines Medical Center, 1111 6Th Ave, Des Moines, IA, 50314, United States of America.
| | - Daniel R Kandah
- Internal Medicine Residency, MercyOne Des Moines Medical Center, Des Moines, IA, United States of America
| | - Jideofor K Ndulue
- Providence Medical Group, Chehalis Family Medicine, Chehalis, WA, United States of America
| | - Okechukwu P Ebiem
- Department of Hospital Medicine, Miami Valley Hospital, Dayton, OH, United States of America
| | | | - Russell Hamilton
- Department of Cardiovascular Medicine, MercyOne Des Moines Medical Center, 1111 6Th Ave, Des Moines, IA, 50314, United States of America
| | - Kofi Osei
- Department of Cardiovascular Medicine, MercyOne Des Moines Medical Center, 1111 6Th Ave, Des Moines, IA, 50314, United States of America
| | - Tuncay Taskesen
- Department of Cardiovascular Medicine, MercyOne Des Moines Medical Center, 1111 6Th Ave, Des Moines, IA, 50314, United States of America
| | - Daniel M Shivapour
- Department of Cardiovascular Medicine, MercyOne Des Moines Medical Center, 1111 6Th Ave, Des Moines, IA, 50314, United States of America
| | - Atul Chawla
- Department of Cardiovascular Medicine, MercyOne Des Moines Medical Center, 1111 6Th Ave, Des Moines, IA, 50314, United States of America
| | - Richard H Marcus
- Department of Cardiovascular Medicine, MercyOne Des Moines Medical Center, 1111 6Th Ave, Des Moines, IA, 50314, United States of America
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16
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Bhogal S, Rogers T, Aladin A, Ben-Dor I, Cohen JE, Shults CC, Wermers JP, Weissman G, Satler LF, Reardon MJ, Yakubov SJ, Waksman R. TAVR in 2023: Who Should Not Get It? Am J Cardiol 2023; 193:1-18. [PMID: 36857839 DOI: 10.1016/j.amjcard.2023.01.040] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 01/10/2023] [Accepted: 01/21/2023] [Indexed: 03/03/2023]
Abstract
Since the first transcatheter delivery of an aortic valve prosthesis was performed by Cribier et al in 2002, the picture of aortic stenosis (AS) therapeutics has changed dramatically. Initiated from an indication of inoperable to high surgical risk, extending to intermediate and low risk, transcatheter aortic valve replacement (TAVR) is now an approved treatment for patients with severe, symptomatic AS across all the risk categories. The current evidence supports TAVR as a frontline therapy for treating severe AS. The crucial question remains concerning the subset of patients who still are not ideal candidates for TAVR because of certain inherent anatomic, nonmodifiable, and procedure-specific factors. Therefore, in this study, we focus on these scenarios and reasons for referring selected patients for surgical aortic valve replacement in 2023.
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Affiliation(s)
- Sukhdeep Bhogal
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, District of Columbia
| | - Toby Rogers
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, District of Columbia; Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Amer Aladin
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, District of Columbia
| | - Itsik Ben-Dor
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, District of Columbia
| | - Jeffrey E Cohen
- Department of Cardiac Surgery, MedStar Washington Hospital Center, Washington, District of Columbia
| | - Christian C Shults
- Department of Cardiac Surgery, MedStar Washington Hospital Center, Washington, District of Columbia
| | - Jason P Wermers
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, District of Columbia
| | - Gaby Weissman
- Department of Cardiology, MedStar Washington Hospital Center, Washington, District of Columbia
| | - Lowell F Satler
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, District of Columbia
| | - Michael J Reardon
- DeBakey Heart and Vascular Center, Houston Methodist, Houston, Texas
| | - Steven J Yakubov
- Department of Cardiology, McConnell Heart Hospital at Riverside Methodist Hospital, Columbus, Ohio
| | - Ron Waksman
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, District of Columbia.
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17
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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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18
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Pandian NG, Kim JK, Arias-Godinez JA, Marx GR, Michelena HI, Chander Mohan J, Ogunyankin KO, Ronderos RE, Sade LE, Sadeghpour A, Sengupta SP, Siegel RJ, Shu X, Soesanto AM, Sugeng L, Venkateshvaran A, Campos Vieira ML, Little SH. Recommendations for the Use of Echocardiography in the Evaluation of Rheumatic Heart Disease: A Report from the American Society of Echocardiography. J Am Soc Echocardiogr 2023; 36:3-28. [PMID: 36428195 DOI: 10.1016/j.echo.2022.10.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Acute rheumatic fever and its chronic sequela, rheumatic heart disease (RHD), pose major health problems globally, and remain the most common cardiovascular disease in children and young people worldwide. Echocardiography is the most important diagnostic tool in recognizing this preventable and treatable disease and plays an invaluable role in detecting the presence of subclinical disease needing prompt therapy or follow-up assessment. This document provides recommendations for the comprehensive use of echocardiography in the diagnosis and therapeutic intervention of RHD. Echocardiographic diagnosis of RHD is made when typical findings of valvular and subvalvular abnormalities are seen, including commissural fusion, leaflet thickening, and restricted leaflet mobility, with varying degrees of calcification. The mitral valve is predominantly affected, most often leading to mitral stenosis. Mixed valve disease and associated cardiopulmonary pathology are common. The severity of valvular lesions and hemodynamic effects on the cardiac chambers and pulmonary artery pressures should be rigorously examined. It is essential to take advantage of all available modalities of echocardiography to obtain accurate anatomic and hemodynamic details of the affected valve lesion(s) for diagnostic and strategic pre-treatment planning. Intraprocedural echocardiographic guidance is critical during catheter-based or surgical treatment of RHD, as is echocardiographic surveillance for post-intervention complications or disease progression. The role of echocardiography is indispensable in the entire spectrum of RHD management.
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Affiliation(s)
| | - Jin Kyung Kim
- University of California, Irvine, Irvine, California
| | | | | | | | | | | | | | | | - Anita Sadeghpour
- MedStar Health Research Institute, Washington, District of Columbia
| | | | | | | | - Amiliana M Soesanto
- Universitas Indonesia/National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
| | - Lissa Sugeng
- North Shore University Hospital, Manhasset, New York
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19
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Ahmad Y, Agarwal V, Williams ML, Wang DD, Reardon MJ, Cavalcante JL, Makkar R, Forrest JK. Imaging, Treatment Options, Patient Selection, and Outcome Considerations for Patients With Bicuspid Aortic Valve Disease. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2022; 1:100506. [PMID: 39132366 PMCID: PMC11307905 DOI: 10.1016/j.jscai.2022.100506] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 09/12/2022] [Accepted: 09/14/2022] [Indexed: 08/13/2024]
Abstract
Transcatheter aortic valve replacement has emerged as a safe and effective alternative to surgical aortic valve replacement for patients with severe symptomatic aortic stenosis across the spectrum of surgical risks based on a series of foundational randomized clinical trials. Of note, patients with bicuspid aortic valve (BAV) disease were excluded from all these pivotal randomized trials, leaving a significant knowledge gap because BAVs are commonly encountered in patients referred for aortic valve surgery or intervention. In this comprehensive review, we aim to provide heart teams with a detailed insight into how to approach patients with BAV disease, focusing on imaging and characterization of bicuspid valves, an overview of surgical approaches, and an understanding of the current data behind the role of transcatheter aortic valve replacement for patients with BAV disease.
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Affiliation(s)
- Yousif Ahmad
- Division of Cardiology, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Vratika Agarwal
- Division of Cardiology, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Matthew L. Williams
- Division of Cardiac Surgery, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Dee Dee Wang
- Division of Cardiology, Center for Structural Heart Disease, Henry Ford Hospital, Detroit, Michigan
| | | | - João L. Cavalcante
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Raj Makkar
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - John K. Forrest
- Division of Cardiology, Yale School of Medicine, Yale University, New Haven, Connecticut
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20
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Ito S, Oh JK. Aortic Stenosis: New Insights in Diagnosis, Treatment, and Prevention. Korean Circ J 2022; 52:721-736. [PMID: 36217595 PMCID: PMC9551229 DOI: 10.4070/kcj.2022.0234] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 09/07/2022] [Indexed: 12/02/2022] Open
Abstract
Aortic stenosis (AS) is one of the most common valvular heart diseases and the number of patients with AS is expected to increase globally as the older population is growing fast. Since the majority of patients are elderly, AS is no longer a simple valvular heart disease of left ventricular outflow obstruction but is accompanied by other cardiac and comorbid conditions. Because of the significant variations of the disease, identifying patients at high risk and even earlier detection of patients with AS before developing symptomatic severe AS is becoming increasingly important. With the proven of efficacy and safety of transcatheter aortic valve replacement (TAVR) in the severe AS population, there is a growing interest in applying TAVR in those with less than severe AS. A medical therapy to reduce or prevent the progression in AS is actively investigated by several randomized control trials. In this review, we will summarize the most recent findings in AS and discuss potential future management strategies of patients with AS.
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Affiliation(s)
- Saki Ito
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jae K Oh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA.
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21
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Hecht S, Butcher SC, Pio SM, Kong WKF, Singh GK, Ng ACT, Perry R, Poh KK, Almeida AG, González A, Shen M, Yeo TC, Shanks M, Popescu BA, Gay LG, Fijałkowski M, Liang M, Tay E, Marsan NA, Selvanayagam J, Pinto F, Zamorano JL, Evangelista A, Delgado V, Bax JJ, Pibarot P. Impact of Left Ventricular Ejection Fraction on Clinical Outcomes in Bicuspid Aortic Valve Disease. J Am Coll Cardiol 2022; 80:1071-1084. [PMID: 36075677 DOI: 10.1016/j.jacc.2022.06.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 06/13/2022] [Accepted: 06/21/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND The prognostic impact of left ventricular ejection fraction (LVEF) in patients with bicuspid aortic valve (BAV) disease has not been previously studied. OBJECTIVES The purpose of this study was to determine the prognostic impact of LVEF in BAV patients according to the type of aortic valve dysfunction. METHODS We retrospectively analyzed the data collected in 2,672 patients included in an international registry of patients with BAV. Patients were classified according to the type of aortic valve dysfunction: isolated aortic stenosis (AS) (n = 749), isolated aortic regurgitation (AR) (n = 554), mixed aortic valve disease (MAVD) (n = 190), or no significant aortic valve dysfunction (n = 1,179; excluded from this analysis). The study population was divided according to LVEF strata to investigate its impact on clinical outcomes. RESULTS The risk of all-cause mortality and the composite endpoint of aortic valve replacement or repair (AVR) and all-cause mortality increased when LVEF was <60% in the whole cohort as well as in the AS and AR groups, and when LVEF was <55% in MAVD group. In multivariable analysis, LVEF strata were significantly associated with increased rate of mortality (LVEF 50%-59%: HR: 1.83 [95% CI: 1.09-3.07]; P = 0.022; LVEF 30%-49%: HR: 1.97 [95% CI: 1.13-3.41]; P = 0.016; LVEF <30%: HR: 4.20 [95% CI: 2.01-8.75]; P < 0.001; vs LVEF 60%-70%, reference group). CONCLUSIONS In BAV patients, the risk of adverse clinical outcomes increases significantly when the LVEF is <60%. These findings suggest that LVEF cutoff values proposed in the guidelines to indicate intervention should be raised from 50% to 60% in AS or AR and 55% in MAVD.
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Affiliation(s)
- Sébastien Hecht
- Quebec Heart and Lung Institute, Laval University, Quebec, Quebec, Canada
| | - Steele C Butcher
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands; Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Stephan M Pio
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - William K F Kong
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands; Department of Cardiology, National University Heart Centre, National University Health System, Singapore, Singapore
| | - Gurpreet K Singh
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Arnold C T Ng
- Department of Cardiology, Princess Alexandra Hospital, The University of Queensland, Brisbane, Queensland, Australia
| | - Rebecca Perry
- Department of Cardiovascular Medicine, Flinders Medical Centre, Bedford Park, Adelaide, South Australia, Australia
| | - Kian Keong Poh
- Department of Cardiology, National University Heart Centre, National University Health System, Singapore, Singapore
| | - Ana G Almeida
- Cardiology Department, Santa Maria University Hospital (CHLN), CAML, CCUL, Lisbon School of Medicine of the Universidade de Lisboa, Lisbon, Portugal
| | - Ariana González
- Department of Cardiology, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - Mylène Shen
- Quebec Heart and Lung Institute, Laval University, Quebec, Quebec, Canada
| | - Tiong Cheng Yeo
- Department of Cardiology, National University Heart Centre, National University Health System, Singapore, Singapore
| | - Miriam Shanks
- Division of Cardiology, University of Alberta, Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Bogdan A Popescu
- University of Medicine and Pharmacy "Carol Davila"-Euroecolab, Institute of Cardiovascular Diseases "Prof. Dr C. C. Iliescu," Bucharest, Romania
| | - Laura Galian Gay
- Department of Cardiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Marcin Fijałkowski
- First Department of Cardiology, Medical University of Gdansk, Gdansk, Poland
| | - Michael Liang
- Department of Cardiology, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Edgar Tay
- Department of Cardiology, National University Heart Centre, National University Health System, Singapore, Singapore
| | - Nina Ajmone Marsan
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Joseph Selvanayagam
- Department of Cardiovascular Medicine, Flinders Medical Centre, Bedford Park, Adelaide, South Australia, Australia
| | - Fausto Pinto
- Cardiology Department, Santa Maria University Hospital (CHLN), CAML, CCUL, Lisbon School of Medicine of the Universidade de Lisboa, Lisbon, Portugal
| | - Jose L Zamorano
- Department of Cardiology, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - Arturo Evangelista
- Department of Cardiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Victoria Delgado
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands; Heart Center, University of Turku and Turku University Hospital, Turku, Finland.
| | - Philippe Pibarot
- Quebec Heart and Lung Institute, Laval University, Quebec, Quebec, Canada.
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22
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Onishi H, Naganuma T, Izumo M, Ouchi T, Yuki H, Mitomo S, Nakamura S. Prognostic relevance of B-type natriuretic peptide in patients with moderate mixed aortic valve disease. ESC Heart Fail 2022; 9:2474-2483. [PMID: 35543340 PMCID: PMC9288736 DOI: 10.1002/ehf2.13946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 03/29/2022] [Accepted: 04/06/2022] [Indexed: 12/03/2022] Open
Abstract
AIMS Data on B-type natriuretic peptide (BNP) levels and adverse outcomes in patients with moderate mixed aortic valve disease (MAVD), defined as moderate aortic stenosis (AS) and regurgitation (AR), are scarce. Therefore, this study investigated the impact of BNP on the clinical outcomes in such patients. METHODS AND RESULTS Clinical data from 81 patients (mean age, 74.1 ± 6.8 years; 50.6%, men) treated for moderate MAVD and left ventricular ejection fraction (LVEF) ≥ 50% during 2010-2018 were retrospectively analysed. Specific echocardiographic data of the study patients were LVEF of 57.8 ± 5.0%, aortic valve index of 0.64 ± 0.04 cm2 /m2 , peak aortic valve velocity of 3.38 ± 0.29 m/s, and AR vena contracta width of 4.2 ± 0.7 mm. The median BNP level was 61.4 pg/mL (interquartile range, 29.7-109.9). The primary endpoint was a composite of all-cause death, heart failure hospitalization, and aortic valve replacement, and its cumulative incidence at 5 years was 57.7%. Multivariable analysis revealed that age (hazard ratio, 1.079; 95% confidence interval, 1.028-1.133; P = 0.002) and BNP levels (hazard ratio, 1.028; 95% confidence interval, 1.003-1.053; P = 0.027) were significantly related to the endpoint; specifically, BNP > 61.4 pg/mL had significantly higher incidence rates of the endpoint than those with a BNP ≤ 61.4 pg/mL (70.3% vs. 45.5% at 5 years; P = 0.018). Compared with patients with BNP ≤ 61.4 pg/mL, those with BNP > 61.4 pg/mL had significantly worse left ventricular global longitudinal strain (-17.1 ± 3.6% vs. -18.7 ± 2.6%; P = 0.029), along with higher left ventricular mass index (116.9 ± 27.8 g/m2 vs. 103.5 ± 19.7 g/m2 ; P = 0.014), relative wall thickness (0.45 ± 0.07 vs. 0.42 ± 0.05; P = 0.022), left atrial volume index (46.0 ± 28.4 mL/m2 vs. 31.4 ± 10.3 mL/m2 ; P = 0.003), pulmonary artery systolic pressure (32.6 ± 9.7 mmHg vs. 28.2 ± 4.7 mmHg; P = 0.011), and prevalence of moderate or greater tricuspid regurgitation (15.0% vs. 0.0%; P = 0.012). CONCLUSIONS Patients with moderate MAVD are at higher risk of unfavourable clinical outcomes, and age and BNP are independently related to the occurrence of adverse events. High BNP levels may reflect extravalvular cardiac damage in patients with moderate MAVD.
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Affiliation(s)
- Hirokazu Onishi
- Department of CardiologyNew Tokyo Hospital1271 Wanagaya, MatsudoChiba270‐2232Japan
- Division of Cardiology, Department of Internal MedicineSt. Marianna University School of MedicineKanagawaJapan
| | - Toru Naganuma
- Department of CardiologyNew Tokyo Hospital1271 Wanagaya, MatsudoChiba270‐2232Japan
| | - Masaki Izumo
- Division of Cardiology, Department of Internal MedicineSt. Marianna University School of MedicineKanagawaJapan
| | - Toru Ouchi
- Department of CardiologyNew Tokyo Hospital1271 Wanagaya, MatsudoChiba270‐2232Japan
| | - Haruhito Yuki
- Department of CardiologyNew Tokyo Hospital1271 Wanagaya, MatsudoChiba270‐2232Japan
| | - Satoru Mitomo
- Department of CardiologyNew Tokyo Hospital1271 Wanagaya, MatsudoChiba270‐2232Japan
| | - Sunao Nakamura
- Department of CardiologyNew Tokyo Hospital1271 Wanagaya, MatsudoChiba270‐2232Japan
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23
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Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Rafael Sádaba J, Tribouilloy C, Wojakowski W. Guía ESC/EACTS 2021 sobre el diagnóstico y tratamiento de las valvulopatías. Rev Esp Cardiol 2022. [DOI: 10.1016/j.recesp.2021.11.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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24
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Appa H, Park K, Bezuidenhout D, van Breda B, de Jongh B, de Villiers J, Chacko R, Scherman J, Ofoegbu C, Swanevelder J, Cousins M, Human P, Smith R, Vogt F, Podesser BK, Schmitz C, Conradi L, Treede H, Schröfel H, Fischlein T, Grabenwöger M, Luo X, Coombes H, Matskeplishvili S, Williams DF, Zilla P. The Technological Basis of a Balloon-Expandable TAVR System: Non-occlusive Deployment, Anchorage in the Absence of Calcification and Polymer Leaflets. Front Cardiovasc Med 2022; 9:791949. [PMID: 35310972 PMCID: PMC8928444 DOI: 10.3389/fcvm.2022.791949] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Accepted: 01/18/2022] [Indexed: 12/14/2022] Open
Abstract
Leaflet durability and costs restrict contemporary trans-catheter aortic valve replacement (TAVR) largely to elderly patients in affluent countries. TAVR that are easily deployable, avoid secondary procedures and are also suitable for younger patients and non-calcific aortic regurgitation (AR) would significantly expand their global reach. Recognizing the reduced need for post-implantation pacemakers in balloon-expandable (BE) TAVR and the recent advances with potentially superior leaflet materials, a trans-catheter BE-system was developed that allows tactile, non-occlusive deployment without rapid pacing, direct attachment of both bioprosthetic and polymer leaflets onto a shape-stabilized scallop and anchorage achieved by plastic deformation even in the absence of calcification. Three sizes were developed from nickel-cobalt-chromium MP35N alloy tubes: Small/23 mm, Medium/26 mm and Large/29 mm. Crimp-diameters of valves with both bioprosthetic (sandwich-crosslinked decellularized pericardium) and polymer leaflets (triblock polyurethane combining siloxane and carbonate segments) match those of modern clinically used BE TAVR. Balloon expansion favors the wing-structures of the stent thereby creating supra-annular anchors whose diameter exceeds the outer diameter at the waist level by a quarter. In the pulse duplicator, polymer and bioprosthetic TAVR showed equivalent fluid dynamics with excellent EOA, pressure gradients and regurgitation volumes. Post-deployment fatigue resistance surpassed ISO requirements. The radial force of the helical deployment balloon at different filling pressures resulted in a fully developed anchorage profile of the valves from two thirds of their maximum deployment diameter onwards. By combining a unique balloon-expandable TAVR system that also caters for non-calcific AR with polymer leaflets, a powerful, potentially disruptive technology for heart valve disease has been incorporated into a TAVR that addresses global needs. While fulfilling key prerequisites for expanding the scope of TAVR to the vast number of patients of low- to middle income countries living with rheumatic heart disease the system may eventually also bring hope to patients of high-income countries presently excluded from TAVR for being too young.
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Affiliation(s)
- Harish Appa
- Strait Access Technologies (SAT), University of Cape Town, Cape Town, South Africa
| | - Kenneth Park
- Strait Access Technologies (SAT), University of Cape Town, Cape Town, South Africa
| | - Deon Bezuidenhout
- Strait Access Technologies (SAT), University of Cape Town, Cape Town, South Africa
- Cardiovascular Research Unit, University of Cape Town, Cape Town, South Africa
| | - Braden van Breda
- Strait Access Technologies (SAT), University of Cape Town, Cape Town, South Africa
| | - Bruce de Jongh
- Strait Access Technologies (SAT), University of Cape Town, Cape Town, South Africa
| | - Jandré de Villiers
- Strait Access Technologies (SAT), University of Cape Town, Cape Town, South Africa
| | - Reno Chacko
- Strait Access Technologies (SAT), University of Cape Town, Cape Town, South Africa
| | - Jacques Scherman
- Cardiovascular Research Unit, University of Cape Town, Cape Town, South Africa
- Chris Barnard Division for Cardiothoracic Surgery, University of Cape Town, Cape Town, South Africa
| | - Chima Ofoegbu
- Cardiovascular Research Unit, University of Cape Town, Cape Town, South Africa
- Chris Barnard Division for Cardiothoracic Surgery, University of Cape Town, Cape Town, South Africa
| | - Justiaan Swanevelder
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, South Africa
| | - Michael Cousins
- Strait Access Technologies (SAT), University of Cape Town, Cape Town, South Africa
| | - Paul Human
- Cardiovascular Research Unit, University of Cape Town, Cape Town, South Africa
- Chris Barnard Division for Cardiothoracic Surgery, University of Cape Town, Cape Town, South Africa
| | - Robin Smith
- Strait Access Technologies (SAT), University of Cape Town, Cape Town, South Africa
| | - Ferdinand Vogt
- Deparment of Cardiac Surgery, Artemed Clinic Munich South, Munich, Germany
- Department of Cardiac Surgery, Klinikum Nürnberg, Paracelsus Medical University, Nuremberg, Germany
| | - Bruno K. Podesser
- Center for Biomedical Research, Medical University of Vienna, Vienna, Austria
| | - Christoph Schmitz
- Auto Tissue Berlin, Berlin, Germany
- Department of Cardiac Surgery, University of Munich, Munich, Germany
| | - Lenard Conradi
- Department of Cardiovascular Surgery, University Heart Center, Hamburg, Germany
| | - Hendrik Treede
- Department of Cardiac and Vascular Surgery, University Hospital, Mainz, Germany
| | - Holger Schröfel
- Department of Cardiovascular Surgery, University Heart Center, Freiburg, Germany
| | - Theodor Fischlein
- Department of Cardiac Surgery, Klinikum Nürnberg, Paracelsus Medical University, Nuremberg, Germany
| | - Martin Grabenwöger
- Department of Cardiovascular Surgery, Vienna North Hospital, Vienna, Austria
| | - Xinjin Luo
- Department of Cardiac Sugery, Fu Wai Hospital, Peking Union Medical College, Beijing, China
| | - Heather Coombes
- Strait Access Technologies (SAT), University of Cape Town, Cape Town, South Africa
| | | | - David F. Williams
- Strait Access Technologies (SAT), University of Cape Town, Cape Town, South Africa
- Wake Forest Institute of Regenerative Medicine, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Peter Zilla
- Strait Access Technologies (SAT), University of Cape Town, Cape Town, South Africa
- Cardiovascular Research Unit, University of Cape Town, Cape Town, South Africa
- Chris Barnard Division for Cardiothoracic Surgery, University of Cape Town, Cape Town, South Africa
- Cape Heart Centre, University of Cape Town, Cape Town, South Africa
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25
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Galusko V, Thornton G, Jozsa C, Sekar B, Aktuerk D, Treibel TA, Petersen SE, Ionescu A, Ricci F, Khanji MY. Aortic regurgitation management: a systematic review of clinical practice guidelines and recommendations. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2022; 8:113-126. [PMID: 35026012 DOI: 10.1093/ehjqcco/qcac001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 01/05/2022] [Indexed: 11/13/2022]
Abstract
Guidelines for the diagnosis and management of aortic regurgitation (AR) contain recommendations that do not always match. We systematically reviewed clinical practice guidelines and summarized similarities and differences in the recommendations as well as gaps in evidence on the management of AR. We searched MEDLINE and Embase (1 January 2011 to 1 September 2021), Google Scholar, and websites of relevant organizations for contemporary guidelines that were rigorously developed as assessed by the Appraisal of Guidelines for Research and Evaluation II tool. Three guidelines met our inclusion criteria. There was consensus on the definition of severe AR and use of echocardiography and of multimodality imaging for diagnosis, with emphasis on comprehensive assessment by the heart valve team to assess suitability and choice of intervention. Surgery is indicated in all symptomatic patients and aortic valve replacement is the cornerstone of treatment. There is consistency in the frequency of follow-up of patients, and safety of non-cardiac surgery in patients without indications for surgery. Discrepancies exist in recommendations for 3D imaging and the use of global longitudinal strain and biomarkers. Cut-offs for left ventricular ejection fraction and size for recommending surgery in severe asymptomatic AR also vary. There are no specific AR cut-offs for high-risk surgery and the role of percutaneous intervention is yet undefined. Recommendations on the treatment of mixed valvular disease are sparse and lack robust prospective data.
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Affiliation(s)
- Victor Galusko
- Department of Cardiology, King's College Hospital, London SE5 9RS, UK
| | - George Thornton
- Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London EC1A 7BE, UK
- Institute of Cardiovascular Science, University College London, London WC1E 6DD, UK
| | - Csilla Jozsa
- Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London EC1A 7BE, UK
- Department of Cardiology, Newham University Hospital, Barts Health NHS Trust, Glen Road, London E13 8SL, UK
| | - Baskar Sekar
- Department of Cardiology, Gloucestershire Hospitals NHS Foundation Trust, Gloucester GL1 3NN, UK
| | - Dincer Aktuerk
- Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London EC1A 7BE, UK
| | - Thomas A Treibel
- Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London EC1A 7BE, UK
- Institute of Cardiovascular Science, University College London, London WC1E 6DD, UK
| | - Steffen E Petersen
- Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London EC1A 7BE, UK
- NIHR Barts Biomedical Research Centre, William Harvey Research Institute, Queen Mary University of London, London EC1A 7BE, UK
| | - Adrian Ionescu
- Morriston Hospital, UK Cardiac Regional Centre, Swansea Bay Health Board, Swansea SA6 6NL, UK
| | - Fabrizio Ricci
- Department of Neuroscience, Imaging and Clinical Sciences, 'G.d'Annunzio' University of Chieti-Pescara, 66100 Chieti, Italy
- Department of Clinical Sciences, Lund University, Jan Waldenströms gata 35, -205 02, Malmö, Sweden
- Casa di Cura Villa Serena, 65013 Città Sant'Angelo, Pescara, Italy
| | - Mohammed Y Khanji
- Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London EC1A 7BE, UK
- Department of Cardiology, Newham University Hospital, Barts Health NHS Trust, Glen Road, London E13 8SL, UK
- NIHR Barts Biomedical Research Centre, William Harvey Research Institute, Queen Mary University of London, London EC1A 7BE, UK
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26
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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: 11] [Impact Index Per Article: 5.5] [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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27
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Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W. 2021 ESC/EACTS Guidelines for the management of valvular heart disease. EUROINTERVENTION 2022; 17:e1126-e1196. [PMID: 34931612 PMCID: PMC9725093 DOI: 10.4244/eij-e-21-00009] [Citation(s) in RCA: 146] [Impact Index Per Article: 73.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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28
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Butcher SC, Pio SM, Kong WKF, Singh GK, Ng ACT, Perry R, Sia CH, Poh KK, Almeida AG, González A, Shen M, Yeo TC, Shanks M, Popescu BA, Galian Gay L, Fijałkowski M, Liang M, Tay E, Ajmone Marsan N, Selvanayagam J, Pinto F, Zamorano JL, Pibarot P, Evangelista A, Bax JJ, Delgado V. Left ventricular remodelling in bicuspid aortic valve disease. Eur Heart J Cardiovasc Imaging 2021; 23:1669-1679. [PMID: 34966913 DOI: 10.1093/ehjci/jeab284] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 12/13/2021] [Indexed: 11/12/2022] Open
Abstract
AIMS Characterization of left ventricular (LV) geometric pattern and LV mass could provide an important insight into the pathophysiological adaptations of the LV to pressure and/or volume overload in patients with bicuspid aortic valve (BAV) and significant (≥moderate) aortic valve (AV) disease. This study aimed to characterize LV remodelling and its prognostic impact in patients with BAV according to the predominant type of valvular dysfunction. METHODS AND RESULTS In this international, multicentre BAV registry, 1345 patients [51.0 (37.0-63.0) years, 71% male] with significant AV disease were identified. Patients were classified as having isolated aortic stenosis (AS) (n = 669), isolated aortic regurgitation (AR) (n = 499) or mixed aortic valve disease (MAVD) (n = 177). LV hypertrophy was defined as a LV mass index >115 g/m2 in males and >95 g/m2 in females. LV geometric pattern was classified as (i) normal geometry: no LV hypertrophy, relative wall thickness (RWT) ≤0.42, (ii) concentric remodelling: no LV hypertrophy, RWT >0.42, (iii) concentric hypertrophy: LV hypertrophy, RWT >0.42, and (iv) eccentric hypertrophy: LV hypertrophy, RWT ≤0.42. Patients were followed-up for the endpoints of event-free survival (defined as a composite of AV repair/replacement and all-cause mortality) and all-cause mortality. Type of AV dysfunction was related to significant variations in LV remodelling. Higher LV mass index, i.e. LV hypertrophy, was independently associated with the composite endpoint for patients with isolated AS [hazard ratio (HR) 1.08 per 25 g/m2, 95% confidence interval (CI) 1.00-1.17, P = 0.046] and AR (HR 1.19 per 25 g/m2, 95% CI 1.11-1.29, P < 0.001), but not for those with MAVD. The presence of concentric remodelling, concentric hypertrophy and eccentric hypertrophy were independently related to the composite endpoint in patients with isolated AS (HR 1.54, 95% CI 1.06-2.23, P = 0.024; HR 1.68, 95% CI 1.17-2.42, P = 0.005; HR 1.59, 95% CI 1.03-2.45, P = 0.038, respectively), while concentric hypertrophy and eccentric hypertrophy were independently associated with the combined endpoint for those with isolated AR (HR 2.49, 95% CI 1.35-4.60, P = 0.004 and HR 3.05, 95% CI 1.71-5.45, P < 0.001, respectively). There was no independent association observed between LV remodelling and the combined endpoint for patients with MAVD. CONCLUSIONS LV hypertrophy or remodelling were independently associated with the composite endpoint of AV repair/replacement and all-cause mortality for patients with isolated AS and isolated AR, although not for patients with MAVD.
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Affiliation(s)
- Steele C Butcher
- Department of Cardiology, Leiden University Medical Center, Heart Lung Center, Albinusdreef 2, 2300 RC Leiden, The Netherlands.,Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, 197 Wellington St, Perth WA 6000, Australia
| | - Stephan M Pio
- Department of Cardiology, Leiden University Medical Center, Heart Lung Center, Albinusdreef 2, 2300 RC Leiden, The Netherlands
| | - William K F Kong
- Department of Cardiology, Leiden University Medical Center, Heart Lung Center, Albinusdreef 2, 2300 RC Leiden, The Netherlands.,Department of Cardiology, National University Heart Centre, National University Health System, 5 Lower Kent Ridge Rd, Singapore 119074, Singapore
| | - Gurpreet K Singh
- Department of Cardiology, Leiden University Medical Center, Heart Lung Center, Albinusdreef 2, 2300 RC Leiden, The Netherlands
| | - Arnold C T Ng
- Department of Cardiology, Princess Alexandra Hospital, The University of Queensland, Brisbane, 199 Ipswich Rd, Woolloongabba QLD 4102, Australia
| | - Rebecca Perry
- Department of Cardiovascular Medicine, Flinders Medical Centre, Flinders Dr, Bedford Park SA 5042, Adelaide, Australia
| | - Ching-Hui Sia
- Department of Cardiology, National University Heart Centre, National University Health System, 5 Lower Kent Ridge Rd, Singapore 119074, Singapore
| | - Kian Keong Poh
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, Singapore 117597, Singapore
| | - Ana G Almeida
- Cardiology Department, Santa Maria University Hospital (CHLN), CAML, CCUL, Lisbon School of Medicine of the Universidade de Lisboa, Av. Prof. Egas Moniz MB, 1649-028 Lisboa, Portugal
| | - Ariana González
- Department of Cardiology, Hospital Universitario Ramón y Cajal, M-607, 9, 100, 28034 Madrid, Spain
| | - Mylène Shen
- Quebec Heart and Lung Institute, Laval University, 2725 Ch Ste-Foy, Québec, QC G1V 4G5, Canada
| | - Tiong Cheng Yeo
- Department of Cardiology, National University Heart Centre, National University Health System, 5 Lower Kent Ridge Rd, Singapore 119074, Singapore
| | - Miriam Shanks
- Division of Cardiology, University of Alberta, Mazankowski Alberta Heart Institute, 11220 83 Ave NW, Edmonton, AB T6G 2B7, Canada
| | - Bogdan A Popescu
- University of Medicine and Pharmacy 'Carol Davila'-Euroecolab, Institute of Cardiovascular Diseases 'Prof. Dr. C. C. Iliescu', Bulevardul Eroii Sanitari 8, București 050474, Romania
| | - Laura Galian Gay
- Department of Cardiology, Hospital Universitari Vall d'Hebrón, Passeig de la Vall d'Hebron, 119, 08035 Barcelona, Spain
| | - Marcin Fijałkowski
- First Department of Cardiology, Medical University of Gdansk, Marii Skłodowskiej-Curie 3a, 80-210 Gdańsk, Poland
| | - Michael Liang
- Department of Cardiology, National University Heart Centre, National University Health System, 5 Lower Kent Ridge Rd, Singapore 119074, Singapore.,Department of Cardiology, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore 768828, Singapore
| | - Edgar Tay
- Department of Cardiology, Princess Alexandra Hospital, The University of Queensland, Brisbane, 199 Ipswich Rd, Woolloongabba QLD 4102, Australia
| | - Nina Ajmone Marsan
- Department of Cardiology, Leiden University Medical Center, Heart Lung Center, Albinusdreef 2, 2300 RC Leiden, The Netherlands
| | - Joseph Selvanayagam
- Department of Cardiovascular Medicine, Flinders Medical Centre, Flinders Dr, Bedford Park SA 5042, Adelaide, Australia
| | - Fausto Pinto
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, Singapore 117597, Singapore
| | - Jose L Zamorano
- Cardiology Department, Santa Maria University Hospital (CHLN), CAML, CCUL, Lisbon School of Medicine of the Universidade de Lisboa, Av. Prof. Egas Moniz MB, 1649-028 Lisboa, Portugal
| | - Philippe Pibarot
- Department of Cardiology, Hospital Universitario Ramón y Cajal, M-607, 9, 100, 28034 Madrid, Spain
| | - Arturo Evangelista
- University of Medicine and Pharmacy 'Carol Davila'-Euroecolab, Institute of Cardiovascular Diseases 'Prof. Dr. C. C. Iliescu', Bulevardul Eroii Sanitari 8, București 050474, Romania
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, Heart Lung Center, Albinusdreef 2, 2300 RC Leiden, The Netherlands.,Heart Center, University of Turku and Turku University Hospital, Kiinamyllynkatu 4-8, 20521 Turku, Finland
| | - Victoria Delgado
- Department of Cardiology, Leiden University Medical Center, Heart Lung Center, Albinusdreef 2, 2300 RC Leiden, The Netherlands
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29
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Egbe AC, Oh JK, Pellikka PA. Cardiac Remodeling and Disease Progression in Patients With Repaired Coarctation of Aorta and Aortic Stenosis. Circ Cardiovasc Imaging 2021; 14:1091-1099. [PMID: 34932381 DOI: 10.1161/circimaging.121.013383] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Valvulo-arterial impedance (Zva) is used for assessment of left ventricular (LV) global pressure load in patients with aortic stenosis (AS) and impaired arterial compliance. Because patients with repaired coarctation of aorta (COA) have impaired arterial compliance, we hypothesized that COA patients with greater than or equal to moderate AS (AS-COA group) will have higher Zva, symptomatic progression, and cardiovascular events, as compared to non-COA patients with similar AS severity (AS group). METHODS Propensity matching (1:1) of 71 AS-COA and 71 AS patients based on age, sex, body mass index, and aortic valve mean gradient (cohort 1). Of 172 patients, 117 patients (AS-COA [n=62]; AS [n=55]) underwent aortic valve replacement, cohort 2. Cohort 1 was used to assess the relationship between preoperative Zva, cardiac remodeling, and symptomatic progression, while cohort 2 was used to assess the relationship between postoperative Zva, LV mass index regression (reduction in LV mass index after aortic valve replacement), and cardiovascular events. RESULTS The AS-COA group had higher Zva (4.2±0.6 versus 3.5±0.4 mm Hg/mL·m2, P<0.001), more advanced cardiac remodeling, and higher 5-year incidence of symptomatic progression (85% versus 51%, P<0.001). Preoperative Zva was independently associated with cardiac remodeling (r=0.66, P<0.001) and symptomatic progression (hazard ratio, 1.06 [1.02-1.10], per mm Hg/mL·m2 increase in Zva). The AS-COA group had higher postoperative Zva (3.3±0.5 versus 2.4±0.4 mm Hg/mL·m2, P<0.001), less robust LV mass index regression at 1-year post-aortic valve replacement, and higher 5-year incidence of cardiovascular events. Postoperative Zva was independently associated with LV mass index regression (r=-0.46, P<0.001) and cardiovascular events (hazard ratio, 1.06 [1.02-1.10], per mm Hg/mL·m2 increase in Zva). CONCLUSIONS Adults with AS-COA had higher LV global pressure load, cardiac remodeling, symptomatic progression, and cardiovascular events as compared to non-COA patients with similar severity of AS. Zva can identify patients at risk for adverse outcomes, and perhaps should be used for risk stratification with regards to timing of aortic valve replacement.
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Affiliation(s)
- Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN
| | - Jae K Oh
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN
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30
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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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31
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Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W. 2021 ESC/EACTS Guidelines for the management of valvular heart disease. Eur J Cardiothorac Surg 2021; 60:727-800. [PMID: 34453161 DOI: 10.1093/ejcts/ezab389] [Citation(s) in RCA: 316] [Impact Index Per Article: 105.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
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32
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Engel Gonzalez P, Kumbhani DJ. Treatment of Bicuspid Aortic Valve Stenosis Using Transcatheter Heart Valves. Interv Cardiol Clin 2021; 10:541-552. [PMID: 34593116 DOI: 10.1016/j.iccl.2021.06.002] [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] [Indexed: 06/13/2023]
Abstract
The paucity of data regarding the use of transcatheter aortic valve replacement (TAVR) in bicuspid aortic valve (BAV) anatomy due to exclusion from pivotal studies and lack of studies assessing the long-term outcomes and valve performance continue to present a significant challenge as we expand TAVR to patients with BAV anatomy. This article discusses the important anatomic and clinical considerations in the selection and management of patients with BAV with TAVR and reviews the emerging evidence that increasingly suggests this procedure is safe, device success is excellent, and procedural outcomes are improving.
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Affiliation(s)
- Pedro Engel Gonzalez
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA. https://twitter.com/engelpedro
| | - Dharam J Kumbhani
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA.
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33
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Lim MS, Strange G, Playford D, Stewart S, Celermajer DS. Characteristics of Bicuspid Aortic Valve Disease and Stenosis: The National Echo Database of Australia. J Am Heart Assoc 2021; 10:e020785. [PMID: 34459236 PMCID: PMC8649243 DOI: 10.1161/jaha.121.020785] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Bicuspid aortic valve (BAV) is the most common congenital heart disease in adults but is clinically heterogeneous. We aimed to describe the echocardiographic characteristics of BAV and compare patients with BAV with moderate‐to‐severe aortic stenosis (AS) with those with tricuspid aortic valve (TAV) stenosis. Methods and Results Using the National Echo Database of Australia, patients in whom BAV was identified were studied. Those with moderate‐to‐severe AS (mean gradient >20 mm Hg [BAV‐AS]) were compared with those with TAV and moderate‐to‐severe AS (TAV‐AS). Of 264 159 adults whose aortic valve morphology was specified, 4783 (1.8%) had confirmed BAV (aged 49.6±17.4 years, 69% men). Of these, 42% had no AS, and 46% had no aortic regurgitation. Moderate‐to‐severe AS was detected in a greater proportion of patients with BAV with a recorded mean gradient (n=1112, 34%) compared with those with TAV (n=4377, 4%; P<0.001). Patients with BAV‐AS were younger (aged 55.3±16.7 years versus 77.3±11.0 years; P<0.001), and where measured had larger ascending aortic diameters (37±8 mm versus 35±5 mm; P<0.001). Age and sex‐adjusted mortality risk was significantly lower in patients with BAV‐AS (hazard ratio, 0.53; 95% CI, 0.45–0.63; P<0.001). Conclusions In this large study of patients across the spectrum of BAV disease, the largest proportion had no significant valvulopathy or aortopathy. Compared with those with TAV‐AS, patients with BAV were more likely to have moderate‐to‐severe AS, have larger ascending aortas, and were over 2 decades younger at the time of AS diagnosis. Despite this, patients with BAV appear to have a more favorable prognosis when AS develops, compared with those with TAV‐AS. Registration URL: www.anzctr.org.au/; Unique identifier: ACTRN12617001387314.
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Affiliation(s)
- Michelle S Lim
- University of SydneySydney Medical SchoolFaculty of Medicine and Health Camperdown New South Wales Australia.,Department of Cardiology Royal Prince Alfred Hospital Camperdown New South Wales Australia
| | - Geoff Strange
- University of SydneySydney Medical SchoolFaculty of Medicine and Health Camperdown New South Wales Australia.,University of Notre Dame Fremantle Western Australia Australia.,Heart Research Institute Sydney New South Wales Australia
| | - David Playford
- University of Notre Dame Fremantle Western Australia Australia
| | - Simon Stewart
- Torrens University Australia Adelaide South Australia Australia
| | - David S Celermajer
- University of SydneySydney Medical SchoolFaculty of Medicine and Health Camperdown New South Wales Australia.,Department of Cardiology Royal Prince Alfred Hospital Camperdown New South Wales Australia.,Heart Research Institute Sydney New South Wales Australia
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Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W. 2021 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J 2021; 43:561-632. [PMID: 34453165 DOI: 10.1093/eurheartj/ehab395] [Citation(s) in RCA: 2318] [Impact Index Per Article: 772.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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35
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Ngiam JN, Chew NW, Pramotedham T, Tan BYQ, Sia CH, Loh PH, Ruan W, Tay E, Kong WK, Yeo TC, Poh KK. Implications of Coexisting Aortic Regurgitation in Patients With Aortic Stenosis. JACC: ASIA 2021; 1:105-111. [PMID: 36338366 PMCID: PMC9627873 DOI: 10.1016/j.jacasi.2021.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 05/05/2021] [Accepted: 05/06/2021] [Indexed: 12/03/2022]
Abstract
Background Aortic regurgitation (AR) is a common comorbidity in patients with aortic stenosis (AS), but coexisting AR has often been excluded from major clinical studies on AS. The impact of coexisting AR on the natural history of AS has not been well-described. Objectives The authors compared clinical outcomes in medically managed patients with moderate-to-severe AS with or without coexisting AR. Methods Consecutive patients (N = 1,188) with index echocardiographic diagnosis of moderate-to-severe AS (aortic valve area <1.5 cm2) were studied. All patients were medically managed and were divided into those with coexisting AR (at least moderate severity) and those without. Adverse composite clinical outcomes were defined as mortality or admissions for congestive cardiac failure on subsequent follow-up. The authors compared differences in clinical profile and outcomes between the groups. Results There were 88 patients (7.4%) with coexisting AR and AS. These patients did not differ significantly in age, but had lower body mass index (22.9 ± 3.8 vs 25.3 ± 5.1 kg/m2), lower diastolic blood pressure (68.7 ± 10.7 vs 72.2 ± 12.3 mm Hg), larger end-diastolic volume index (68.8 ± 18.8 vs 60.4 ± 17.8 mL/m2) and larger left ventricular mass index (118.6 ± 36.4 vs 108.9 ± 33.1 g/m2). The prevalence of cardiovascular risk factors did not differ significantly. Coexisting AR was associated with increased incidence of adverse outcomes (log-rank 4.20; P = 0.040). On multivariable Cox regression, coexisting AR remained independently associated with adverse outcomes (HR: 1.36; 95% CI: 1.02-1.82) after adjusting for age, AS severity, left ventricular ejection fraction, and year of study. Conclusions In patients with AS, coexisting AR was associated with changes in echocardiographic profile and adverse outcomes.
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Affiliation(s)
| | - Nicholas W.S. Chew
- Department of Cardiology, National University Heart Centre Singapore, National University Health System, Singapore
| | | | | | - Ching-Hui Sia
- Department of Cardiology, National University Heart Centre Singapore, National University Health System, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Poay Huan Loh
- Department of Cardiology, National University Heart Centre Singapore, National University Health System, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Wen Ruan
- Department of Cardiology, National Heart Centre Singapore, Singapore
| | - Edgar Tay
- Department of Cardiology, National University Heart Centre Singapore, National University Health System, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - William K.F. Kong
- Department of Cardiology, National University Heart Centre Singapore, National University Health System, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Tiong-Cheng Yeo
- Department of Cardiology, National University Heart Centre Singapore, National University Health System, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Kian-Keong Poh
- Department of Cardiology, National University Heart Centre Singapore, National University Health System, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Address for correspondence: A/Prof Poh Kian-Keong, Department of Cardiology, National University Heart Centre, National University Health System, Singapore, 1E Kent Ridge Rd, NUHS Tower Block, Level 9, Singapore 119228.
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36
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2020 ACC/AHA guideline for the management of patients with valvular heart disease: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Thorac Cardiovasc Surg 2021; 162:e183-e353. [PMID: 33972115 DOI: 10.1016/j.jtcvs.2021.04.002] [Citation(s) in RCA: 90] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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37
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Harris AW, Bach DS. Mixed Aortic Valve Disease and Strain: Unraveling the Myocardial Response. JACC Cardiovasc Imaging 2021; 14:1335-1337. [PMID: 33865765 DOI: 10.1016/j.jcmg.2021.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 02/09/2021] [Indexed: 11/17/2022]
Affiliation(s)
- Andrew W Harris
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - David S Bach
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA.
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38
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Saijo Y, Isaza N, Conic JZ, Desai MY, Johnston D, Roselli EE, Grimm RA, Svensson LG, Kapadia S, Obuchowski NA, Griffin BP, Popović ZB. Left Ventricular Longitudinal Strain in Characterization and Outcome Assessment of Mixed Aortic Valve Disease Phenotypes. JACC Cardiovasc Imaging 2021; 14:1324-1334. [PMID: 33744141 DOI: 10.1016/j.jcmg.2021.01.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 01/15/2021] [Accepted: 01/20/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The aims of this study were to characterize the interplay between mixed aortic valve disease (MAVD) phenotypes (defined by concomitant severities of aortic stenosis and aortic regurgitation) and left ventricular global longitudinal strain (LV-GLS), and to assess the prognostic utility of LV-GLS in MAVD. BACKGROUND Little is known about the way LV-GLS separates MAVD phenotypes and if it is associated with their outcomes. METHODS This observational cohort study evaluated 783 consecutive adult patients with left ventricular ejection fraction ≥50% and MAVD, which was defined as coexisting with at least moderate aortic stenosis and at least moderate aortic regurgitation. We measured the conventional echocardiographic variables and average LV-GLS from apical long, 2- and 4-chamber views. The primary endpoint was all-cause mortality. RESULTS Mean age of patients was 69 ± 15 years, and 58% were male. Mean LV-GLS was -14.7 ± 2.9%. In total, 458 patients (59%) underwent aortic valve replacement at a median period of 50 days (25th to 75th percentile range: 6 to 560 days). During a median follow-up period of 5.6 years (25th to 75th percentile range: 1.8 to 9.4 years), 391 patients (50%) died. When stratified patients into tertiles according to LV-GLS values, patients with worse LV-GLS had worse outcomes (p < 0.001). LV-GLS was independently associated with mortality (hazard ratio: 1.09; 95% confidential intervals: 1.04 to 1.14; p < 0.001), with the relationship between LV-GLS and mortality being linear. CONCLUSIONS LV-GLS is associated with all-cause mortality. LV-GLS may be useful for risk stratification in patients with MAVD.
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Affiliation(s)
- Yoshihito Saijo
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Nicolas Isaza
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Julijana Z Conic
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Milind Y Desai
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Douglas Johnston
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Richard A Grimm
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Lars G Svensson
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Samir Kapadia
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Nancy A Obuchowski
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Brian P Griffin
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Zoran B Popović
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA.
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39
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Vincent F, Ternacle J, Denimal T, Shen M, Redfors B, Delhaye C, Simonato M, Debry N, Verdier B, Shahim B, Pamart T, Spillemaeker H, Schurtz G, Pontana F, Thourani VH, Pibarot P, Van Belle E. Transcatheter Aortic Valve Replacement in Bicuspid Aortic Valve Stenosis. Circulation 2021; 143:1043-1061. [PMID: 33683945 DOI: 10.1161/circulationaha.120.048048] [Citation(s) in RCA: 90] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
After 15 years of successive randomized, controlled trials, indications for transcatheter aortic valve replacement (TAVR) are rapidly expanding. In the coming years, this procedure could become the first line treatment for patients with a symptomatic severe aortic stenosis and a tricuspid aortic valve anatomy. However, randomized, controlled trials have excluded bicuspid aortic valve (BAV), which is the most frequent congenital heart disease occurring in 1% to 2% of the total population and representing at least 25% of patients 80 years of age or older referred for aortic valve replacement. The use of a less invasive transcatheter therapy in this elderly population became rapidly attractive, and approximately 10% of patients currently undergoing TAVR have a BAV. The U.S. Food and Drug Administration and the "European Conformity" have approved TAVR for low-risk patients regardless of the aortic valve anatomy whereas international guidelines recommend surgical replacement in BAV populations. Given this progressive expansion of TAVR toward younger and lower-risk patients, heart teams are encountering BAV patients more frequently, while the ability of this therapy to treat such a challenging anatomy remains uncertain. This review will address the singularity of BAV anatomy and associated technical challenges for the TAVR procedure. We will examine and summarize available clinical evidence and highlight critical knowledge gaps regarding TAVR utilization in BAV patients. We will provide a comprehensive overview of the role of computed tomography scans in the diagnosis, and classification of BAV and TAVR procedure planning. Overall, we will offer an integrated framework for understanding the current role of TAVR in the treatment of bicuspid aortic stenosis and for guiding physicians in clinical decision-making.
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Affiliation(s)
- Flavien Vincent
- Centre Hospitalier Universitaire de Lille, Institut Cœur Poumon, Cardiology, Department of Interventional Cardiology for Coronary, Valves and Structural Heart Diseases (F.V., T.D., C.D., N.D., B.V., B.S., T.P., H.S., G.S., E.VB.).,Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1011- European Genomic Institute for Diabetes, F-59000 Lille, France (F.V., E.VB.).,Clinical Trials Center, Cardiovascular Research Foundation, New York (F.V., B.R., M. Simonato).,Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval/Québec Heart and Lung Institute, Laval University, Canada (F.V., J.T., M. Shen, P.P.)
| | - Julien Ternacle
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval/Québec Heart and Lung Institute, Laval University, Canada (F.V., J.T., M. Shen, P.P.).,Hôpital Cardiologique Haut-Lévêque, Centre Hospitalier Universitaire de Bordeaux, Pessac, France (J.T.)
| | - Tom Denimal
- Centre Hospitalier Universitaire de Lille, Institut Cœur Poumon, Cardiology, Department of Interventional Cardiology for Coronary, Valves and Structural Heart Diseases (F.V., T.D., C.D., N.D., B.V., B.S., T.P., H.S., G.S., E.VB.)
| | - Mylène Shen
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval/Québec Heart and Lung Institute, Laval University, Canada (F.V., J.T., M. Shen, P.P.)
| | - Bjorn Redfors
- Clinical Trials Center, Cardiovascular Research Foundation, New York (F.V., B.R., M. Simonato)
| | - Cédric Delhaye
- Centre Hospitalier Universitaire de Lille, Institut Cœur Poumon, Cardiology, Department of Interventional Cardiology for Coronary, Valves and Structural Heart Diseases (F.V., T.D., C.D., N.D., B.V., B.S., T.P., H.S., G.S., E.VB.)
| | - Matheus Simonato
- Clinical Trials Center, Cardiovascular Research Foundation, New York (F.V., B.R., M. Simonato)
| | - Nicolas Debry
- Centre Hospitalier Universitaire de Lille, Institut Cœur Poumon, Cardiology, Department of Interventional Cardiology for Coronary, Valves and Structural Heart Diseases (F.V., T.D., C.D., N.D., B.V., B.S., T.P., H.S., G.S., E.VB.)
| | - Basile Verdier
- Centre Hospitalier Universitaire de Lille, Institut Cœur Poumon, Cardiology, Department of Interventional Cardiology for Coronary, Valves and Structural Heart Diseases (F.V., T.D., C.D., N.D., B.V., B.S., T.P., H.S., G.S., E.VB.)
| | - Bahira Shahim
- Centre Hospitalier Universitaire de Lille, Institut Cœur Poumon, Cardiology, Department of Interventional Cardiology for Coronary, Valves and Structural Heart Diseases (F.V., T.D., C.D., N.D., B.V., B.S., T.P., H.S., G.S., E.VB.)
| | - Thibault Pamart
- Centre Hospitalier Universitaire de Lille, Institut Cœur Poumon, Cardiology, Department of Interventional Cardiology for Coronary, Valves and Structural Heart Diseases (F.V., T.D., C.D., N.D., B.V., B.S., T.P., H.S., G.S., E.VB.)
| | - Hugues Spillemaeker
- Centre Hospitalier Universitaire de Lille, Institut Cœur Poumon, Cardiology, Department of Interventional Cardiology for Coronary, Valves and Structural Heart Diseases (F.V., T.D., C.D., N.D., B.V., B.S., T.P., H.S., G.S., E.VB.)
| | - Guillaume Schurtz
- Centre Hospitalier Universitaire de Lille, Institut Cœur Poumon, Cardiology, Department of Interventional Cardiology for Coronary, Valves and Structural Heart Diseases (F.V., T.D., C.D., N.D., B.V., B.S., T.P., H.S., G.S., E.VB.)
| | | | - Vinod H Thourani
- Department of Cardiovascular Surgery, Marcus Valve Center, Piedmont Heart Institute, Atlanta, GA (V.H.T.)
| | - Philippe Pibarot
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval/Québec Heart and Lung Institute, Laval University, Canada (F.V., J.T., M. Shen, P.P.)
| | - Eric Van Belle
- Centre Hospitalier Universitaire de Lille, Institut Cœur Poumon, Cardiology, Department of Interventional Cardiology for Coronary, Valves and Structural Heart Diseases (F.V., T.D., C.D., N.D., B.V., B.S., T.P., H.S., G.S., E.VB.).,Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1011- European Genomic Institute for Diabetes, F-59000 Lille, France (F.V., E.VB.)
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40
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Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2021; 143:e72-e227. [PMID: 33332150 DOI: 10.1161/cir.0000000000000923] [Citation(s) in RCA: 568] [Impact Index Per Article: 189.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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41
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Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2021; 143:e35-e71. [PMID: 33332149 DOI: 10.1161/cir.0000000000000932] [Citation(s) in RCA: 353] [Impact Index Per Article: 117.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
AIM This executive summary of the valvular heart disease guideline provides recommendations for clinicians to diagnose and manage valvular heart disease as well as supporting documentation to encourage their use. METHODS A comprehensive literature search was conducted from January 1, 2010, to March 1, 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, Cochrane, Agency for Healthcare Research and Quality Reports, and other selected database relevant to this guideline. Structure: Many recommendations from the earlier valvular heart disease guidelines have been updated with new evidence and provides newer options for diagnosis and treatment of valvular heart disease. This summary includes only the recommendations from the full guideline which focus on diagnostic work-up, the timing and choice of surgical and catheter interventions, and recommendations for medical therapy. The reader is referred to the full guideline for graphical flow charts, text, and tables with additional details about the rationale for and implementation of each recommendation, and the evidence tables detailing the data considered in developing these guidelines.
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Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2021; 77:e25-e197. [PMID: 33342586 DOI: 10.1016/j.jacc.2020.11.018] [Citation(s) in RCA: 846] [Impact Index Per Article: 282.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O’Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary. J Am Coll Cardiol 2021; 77:450-500. [DOI: 10.1016/j.jacc.2020.11.035] [Citation(s) in RCA: 272] [Impact Index Per Article: 90.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Tastet L, Généreux P, Bernard J, Pibarot P. The Role of Extravalvular Cardiac Damage Staging in Aortic Valve Disease Management. Can J Cardiol 2021; 37:1004-1015. [PMID: 33539990 DOI: 10.1016/j.cjca.2021.01.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 01/19/2021] [Accepted: 01/22/2021] [Indexed: 10/22/2022] Open
Abstract
Current management of patients with aortic valve disease, including aortic valve stenosis (AS), aortic valve regurgitation (AR), and mixed aortic valve disease (MAVD), remains challenging. American and European guideline recommendations regarding the timing of intervention are mainly based on the assessment of disease severity (ie, grading), presence of symptoms related to aortic valve disease, left ventricular systolic dysfunction, or LV enlargement. Furthermore, the decision regarding the type of intervention (ie, surgical vs transcatheter) is primarily based on risk assessment from surgical risk scores. There is, however, less emphasis on the importance of the assessment of anatomic and functional cardiac repercussions of aortic valve disease to guide the clinical management of these patients. Recently, a novel approach has been proposed to improve the management of aortic valve disease with 2 main components for risk stratification of the disease: 1) grading the severity of aortic valve disease, and 2) staging the extent of extravalvular cardiac damage associated with aortic valve disease with the use of echocardiography. To date, this novel approach of extravalvular cardiac damage staging was proposed and validated only in the context of AS but could be extended to other valvular heart diseases, including AR and MAVD. Further studies are also needed to test the incremental value of additional imaging parameters (eg, myocardial fibrosis by magnetic resonance) as well as blood biomarkers (eg, natriuretic peptide, cardiac troponin, and others) to the existing cardiac damage staging schemes.
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Affiliation(s)
- Lionel Tastet
- Institut universitaire de cardiologie et de pneumologie de Québec-Université Laval, Québec City, Québec, Canada
| | - Philippe Généreux
- Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, New Jersey, USA; Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA; Hôpital du Sacré-Cœur de Montréal, Montréal, Québec, Canada
| | - Jérémy Bernard
- Institut universitaire de cardiologie et de pneumologie de Québec-Université Laval, Québec City, Québec, Canada
| | - Philippe Pibarot
- Institut universitaire de cardiologie et de pneumologie de Québec-Université Laval, Québec City, Québec, Canada.
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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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Izumi C, Eishi K, Ashihara K, Arita T, Otsuji Y, Kunihara T, Komiya T, Shibata T, Seo Y, Daimon M, Takanashi S, Tanaka H, Nakatani S, Ninami H, Nishi H, Hayashida K, Yaku H, Yamaguchi J, Yamamoto K, Watanabe H, Abe Y, Amaki M, Amano M, Obase K, Tabata M, Miura T, Miyake M, Murata M, Watanabe N, Akasaka T, Okita Y, Kimura T, Sawa Y, Yoshida K. JCS/JSCS/JATS/JSVS 2020 Guidelines on the Management of Valvular Heart Disease. Circ J 2020; 84:2037-2119. [DOI: 10.1253/circj.cj-20-0135] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Chisato Izumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Kiyoyuki Eishi
- Division of Cardiovascular Surgery, Nagasaki University Graduate School of Biomedical Sciences
| | - Kyomi Ashihara
- Department of Cardiology, Tokyo Women’s Medical University Hospital
| | - Takeshi Arita
- Division of Cardiovascular Medicine Heart & Neuro-Vascular Center, Fukuoka Wajiro
| | - Yutaka Otsuji
- Department of Cardiology, Hospital of University of Occupational and Environmental Health
| | - Takashi Kunihara
- Department of Cardiac Surgery, The Jikei University School of Medicine
| | - Tatsuhiko Komiya
- Department of Cardiovascular Surgery, Kurashiki Central Hospital
| | - Toshihiko Shibata
- Department of Cardiovascular Surgery, Osaka City University Postgraduate of Medicine
| | - Yoshihiro Seo
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences
| | - Masao Daimon
- Department of Clinical Laboratory/Cardiology, The University of Tokyo Hospital
| | | | | | - Satoshi Nakatani
- Division of Health Sciences, Osaka University Graduate School of Medicine
| | - Hiroshi Ninami
- Department of Cardiac Surgery, Tokyo Women’s Medical University
| | - Hiroyuki Nishi
- Department of Cardiovascular Surgery, Osaka General Medical Center
| | | | - Hitoshi Yaku
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine
| | | | - Kazuhiro Yamamoto
- Division of Cardiovascular Medicine, Endocrinology and Metabolism, Faculty of Medicine, Tottori University
| | | | - Yukio Abe
- Department of Cardiology, Osaka City General Hospital
| | - Makoto Amaki
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Masashi Amano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Kikuko Obase
- Division of Cardiovascular Surgery, Nagasaki University Graduate School of Biomedical Sciences
| | - Minoru Tabata
- Department of Cardiovascular Surgery, Tokyo Bay Urayasu Ichikawa Medical Center
| | - Takashi Miura
- Division of Cardiovascular Surgery, Nagasaki University Graduate School of Biomedical Sciences
| | | | - Mitsushige Murata
- Department of Laboratory Medicine, Tokai University Hachioji Hospital
| | - Nozomi Watanabe
- Department of Cardiology, Miyazaki Medical Association Hospital
| | - Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Yutaka Okita
- Department of Cardiovascular Surgery, Takatsuki Hospital
| | - Takeshi Kimura
- Department of Cardiology, Kyoto University Graduate School of Medicine
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Kiyoshi Yoshida
- Department of Cardiology, Sakakibara Heart Institute of Okayama
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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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Early Valve Replacement for Severe Aortic Valve Disease: Effect on Mortality and Clinical Ramifications. J Clin Med 2020; 9:jcm9092694. [PMID: 32825345 PMCID: PMC7563468 DOI: 10.3390/jcm9092694] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 08/17/2020] [Accepted: 08/18/2020] [Indexed: 12/23/2022] Open
Abstract
Timing of aortic valve intervention for chronic aortic regurgitation (AR) and/or aortic stenosis (AS) potentially affects long-term survival. The 2014 American Heart Association/American College of Cardiology (AHA/ACC) guidelines provide recommendations for the timing of intervention. Subsequent to the guidelines' release, several studies have been published that suggest a survival benefit from earlier timing of surgery for severe AR and/or AS. The aim of this review was to determine whether patients who have chronic aortic regurgitation (AR) and/or aortic stenosis (AS) have a survival benefit from earlier timing of aortic valve surgery. Medical databases were systematically searched from January 2015 to April 2020 for randomized controlled trials (RCTs) and observational studies that examined the timing of aortic valve replacement surgery for chronic AR and/or AS. For chronic AR, four observational studies and no RCTs were identified. For chronic AS, five observational studies, one RCT and one meta-analysis were identified. One observational study examining mixed aortic valve disease (MAVD) was identified. All of these studies, for AR, AS, and MAVD, found long-term survival benefit from timing of aortic valve surgery earlier than the current guidelines. Larger prospective RCTs are required to evaluate the benefit of earlier surgical intervention.
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Khan F, Okuno T, Malebranche D, Lanz J, Praz F, Stortecky S, Windecker S, Pilgrim T. Transcatheter Aortic Valve Replacement in Patients With Multivalvular Heart Disease. JACC Cardiovasc Interv 2020; 13:1503-1514. [DOI: 10.1016/j.jcin.2020.03.052] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 02/07/2020] [Accepted: 03/13/2020] [Indexed: 12/21/2022]
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50
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Isaza N, Desai MY, Kapadia SR, Krishnaswamy A, Rodriguez LL, Grimm RA, Conic JZ, Saijo Y, Roselli EE, Gillinov AM, Johnston DR, Svensson LG, Griffin BP, Popović ZB. Long-Term Outcomes in Patients With Mixed Aortic Valve Disease and Preserved Left Ventricular Ejection Fraction. J Am Heart Assoc 2020; 9:e014591. [PMID: 32204665 PMCID: PMC7428636 DOI: 10.1161/jaha.119.014591] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Background Concurrent presence of aortic stenosis and aortic regurgitation is termed mixed aortic valve disease (MAVD). Although multiple articles have addressed patients with “isolated” aortic stenosis or aortic regurgitation, the natural history, impact, and outcomes of MAVD are not well defined. Here, we evaluate long‐term outcomes in patients with MAVD and cardiovascular adaptations to chronic MAVD. Methods and Results This observational cohort study evaluated 862 adult patients (56.8% male) with preserved left ventricular ejection fraction and at least moderate aortic regurgitation and moderate aortic stenosis. Primary outcome was all‐cause mortality. Subgroup analysis was based on treatment modality (aortic valve replacement [AVR] versus medical management). A regression analysis of longitudinal echocardiographic parameters was performed to assess the natural history of MAVD. Mean age was 68±15 years, and mean left ventricular ejection fraction was 58±5%. At 4.6 years (25th–75th percentile range, 1.0–8.7), 58.6% of patients underwent an AVR and 48.8% patients died. In both unadjusted and adjusted Cox survival analysis, AVR was associated with improved survival (hazard ratio, 0.41; 95% CI, 0.34–0.51, P<0.001). Impact of AVR persisted when stratifying the cohort by symptom status and baseline aortic valve area (log rank, P<0.001 for both) and after propensity‐score matching (hazard ratio, 0.40; 95% CI, 0.32–0.50; P<0.001). In the longitudinal analysis, there were statistically significant changes over time in aortic valve peak gradient (P<0.001) and aortic valve area (P<0.001) and only mild increases in left ventricular end‐diastolic (P<0.007) and ‐systolic (P<0.001) volumes. Conclusions MAVD confers a high risk of all‐cause mortality. However, AVR significantly reduces this risk independent of aortic valve area, symptom status, and after controlling for confounding variables.
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Affiliation(s)
- Nicolas Isaza
- Department of Cardiovascular Medicine Sydell and Arnold Miller Family Heart & Vascular Institute Cleveland Clinic Foundation Cleveland OH.,Department of Thoracic and Cardiovascular Surgery Sydell and Arnold Miller Family Heart & Vascular Institute Cleveland Clinic Foundation Cleveland OH
| | - Milind Y Desai
- Department of Cardiovascular Medicine Sydell and Arnold Miller Family Heart & Vascular Institute Cleveland Clinic Foundation Cleveland OH.,Department of Thoracic and Cardiovascular Surgery Sydell and Arnold Miller Family Heart & Vascular Institute Cleveland Clinic Foundation Cleveland OH
| | - Samir R Kapadia
- Department of Cardiovascular Medicine Sydell and Arnold Miller Family Heart & Vascular Institute Cleveland Clinic Foundation Cleveland OH.,Department of Thoracic and Cardiovascular Surgery Sydell and Arnold Miller Family Heart & Vascular Institute Cleveland Clinic Foundation Cleveland OH
| | - Amar Krishnaswamy
- Department of Cardiovascular Medicine Sydell and Arnold Miller Family Heart & Vascular Institute Cleveland Clinic Foundation Cleveland OH.,Department of Thoracic and Cardiovascular Surgery Sydell and Arnold Miller Family Heart & Vascular Institute Cleveland Clinic Foundation Cleveland OH
| | - L Leonardo Rodriguez
- Department of Cardiovascular Medicine Sydell and Arnold Miller Family Heart & Vascular Institute Cleveland Clinic Foundation Cleveland OH.,Department of Thoracic and Cardiovascular Surgery Sydell and Arnold Miller Family Heart & Vascular Institute Cleveland Clinic Foundation Cleveland OH
| | - Richard A Grimm
- Department of Cardiovascular Medicine Sydell and Arnold Miller Family Heart & Vascular Institute Cleveland Clinic Foundation Cleveland OH.,Department of Thoracic and Cardiovascular Surgery Sydell and Arnold Miller Family Heart & Vascular Institute Cleveland Clinic Foundation Cleveland OH
| | - Julijana Z Conic
- Department of Cardiovascular Medicine Sydell and Arnold Miller Family Heart & Vascular Institute Cleveland Clinic Foundation Cleveland OH.,Department of Thoracic and Cardiovascular Surgery Sydell and Arnold Miller Family Heart & Vascular Institute Cleveland Clinic Foundation Cleveland OH
| | - Yoshihito Saijo
- Department of Cardiovascular Medicine Sydell and Arnold Miller Family Heart & Vascular Institute Cleveland Clinic Foundation Cleveland OH.,Department of Thoracic and Cardiovascular Surgery Sydell and Arnold Miller Family Heart & Vascular Institute Cleveland Clinic Foundation Cleveland OH
| | - Eric E Roselli
- Department of Cardiovascular Medicine Sydell and Arnold Miller Family Heart & Vascular Institute Cleveland Clinic Foundation Cleveland OH.,Department of Thoracic and Cardiovascular Surgery Sydell and Arnold Miller Family Heart & Vascular Institute Cleveland Clinic Foundation Cleveland OH
| | - A Marc Gillinov
- Department of Cardiovascular Medicine Sydell and Arnold Miller Family Heart & Vascular Institute Cleveland Clinic Foundation Cleveland OH.,Department of Thoracic and Cardiovascular Surgery Sydell and Arnold Miller Family Heart & Vascular Institute Cleveland Clinic Foundation Cleveland OH
| | - Douglas R Johnston
- Department of Cardiovascular Medicine Sydell and Arnold Miller Family Heart & Vascular Institute Cleveland Clinic Foundation Cleveland OH.,Department of Thoracic and Cardiovascular Surgery Sydell and Arnold Miller Family Heart & Vascular Institute Cleveland Clinic Foundation Cleveland OH
| | - Lars G Svensson
- Department of Cardiovascular Medicine Sydell and Arnold Miller Family Heart & Vascular Institute Cleveland Clinic Foundation Cleveland OH.,Department of Thoracic and Cardiovascular Surgery Sydell and Arnold Miller Family Heart & Vascular Institute Cleveland Clinic Foundation Cleveland OH
| | - Brian P Griffin
- Department of Cardiovascular Medicine Sydell and Arnold Miller Family Heart & Vascular Institute Cleveland Clinic Foundation Cleveland OH.,Department of Thoracic and Cardiovascular Surgery Sydell and Arnold Miller Family Heart & Vascular Institute Cleveland Clinic Foundation Cleveland OH
| | - Zoran B Popović
- Department of Cardiovascular Medicine Sydell and Arnold Miller Family Heart & Vascular Institute Cleveland Clinic Foundation Cleveland OH.,Department of Thoracic and Cardiovascular Surgery Sydell and Arnold Miller Family Heart & Vascular Institute Cleveland Clinic Foundation Cleveland OH
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