1
|
Shechter A, Patel V, Kaewkes D, Lee M, Hong GJ, Koren O, Chakravarty T, Koseki K, Nagasaka T, Skaf S, Makar M, Makkar RR, Siegel RJ. Preprocedural transthoracic echocardiography for predicting outcomes of transcatheter edge-to-edge repair for chronic primary mitral regurgitation. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2024; 77:621-631. [PMID: 38142937 DOI: 10.1016/j.rec.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 12/04/2023] [Indexed: 12/26/2023]
Abstract
INTRODUCTION AND OBJECTIVES Limited data exist on the prognostic usefulness of transthoracic echocardiography preceding MitraClip for chronic primary mitral regurgitation (MR). We evaluated the predictive ability of transthoracic echocardiography in this setting. METHODS A total of 410 patients (median age, 83 years, 60.7% males) were included in the study. The primary outcome was the 1-year composite of all-cause mortality or heart failure hospitalization. Secondary endpoints encompassed individual elements of the primary outcome, the persistence of significant functional impairment or above-moderate MR at 1 year, and above-mild MR at 1-month. RESULTS The only parameter associated with the risk of the primary outcome was a ventricular end systolic diameter index of ≥2.1 cm/m2, corresponding to the cohort's 4th quartile (HR, 2.44; 95%CI, 1.09-4.68; P=.022). Concurrently, higher left atrial volume index (LAVi) and a mid-diastolic medial-lateral mitral annular diameter (MAD) equal to or above the cohort's median of 32.2mm were linked to a higher probability of death and heart failure hospitalization, respectively. LAVi of ≥ 60mL/m2, above-mild mitral annular calcification, and above-moderate tricuspid regurgitation conferred higher odds of functional class III-IV or above-moderate MR persistence. All variables except LAVi and MAD, as well as indexed mid-diastolic medial-lateral MAD of ≥ 20.2mm/m2 and mitral effective regurgitant orifice area of ≥ 0.40 cm2, were associated with greater-than-mild MR at 1 month. CONCLUSIONS Preprocedural increased indexed left heart dimensions, mainly left ventricular end-systolic diameter index, MAD, mitral annular calcification, mitral effective regurgitant orifice area, and tricuspid regurgitation mark a less favorable course post-MitraClip for chronic primary MR.
Collapse
Affiliation(s)
- Alon Shechter
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, United States; Department of Cardiology, Rabin Medical Center, Petach Tikva, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Vivek Patel
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, United States
| | - Danon Kaewkes
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, United States; Department of Medicine, Faculty of Medicine, Khon Kaen University, Thailand
| | - Mirae Lee
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, United States; Division of Cardiology, Department of Medicine, Samsung Changwon Hospital, Changwon, Republic of Korea
| | - Gloria J Hong
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, United States
| | - Ofir Koren
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, United States; Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - Tarun Chakravarty
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, United States
| | - Keita Koseki
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, United States; Department of Cardiovascular Medicine, The University of Tokyo, Tokyo, Japan
| | - Takashi Nagasaka
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, United States; Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Sabah Skaf
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, United States
| | - Moody Makar
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, United States
| | - Raj R Makkar
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, United States
| | - Robert J Siegel
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, United States; David Geffen School of Medicine, University of California Los Angeles, Los Angeles, United States.
| |
Collapse
|
2
|
Lee SH, Yoon SJ, Sun BJ, Kim HM, Kim HY, Lee S, Shim CY, Kim EK, Cho DH, Park JB, Seo JS, Son JW, Kim IC, Lee SH, Heo R, Lee HJ, Park JH, Song JM, Lee SC, Kim H, Kang DH, Ha JW, Kim KH. 2023 Korean Society of Echocardiography position paper for diagnosis and management of valvular heart disease, part I: aortic valve disease. J Cardiovasc Imaging 2024; 32:11. [PMID: 39061115 PMCID: PMC11282617 DOI: 10.1186/s44348-024-00019-0] [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: 09/06/2023] [Accepted: 11/24/2023] [Indexed: 07/28/2024] Open
Abstract
This manuscript represents the official position of the Korean Society of Echocardiography on valvular heart diseases. This position paper focuses on the clinical management of valvular heart diseases with reference to the guidelines recently published by the American College of Cardiology/American Heart Association and the European Society of Cardiology. The committee tried to reflect the recently published results on the topic of valvular heart diseases and Korean data by a systematic literature search based on validity and relevance. In part I of this article, we will review and discuss the current position of aortic valve disease in Korea.
Collapse
Affiliation(s)
- Sun Hwa Lee
- Division of Cardiology, Department of Internal Medicine, Jeonbuk National University Medical School, Jeonbuk National University Hospital, Jeonju, Republic of Korea
| | - Se-Jung Yoon
- Division of Cardiology, National Health Insurance Service Ilsan Hospital, Goyang, Republic of Korea
| | - Byung Joo Sun
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hyue Mee Kim
- Division of Cardiology, Department of Internal Medicine, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Republic of Korea
| | - Hyung Yoon Kim
- Department of Cardiovascular Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Sahmin Lee
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Chi Young Shim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Eun Kyoung Kim
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Heart Vascular Stroke Institute, Samsung Medical Center, Seoul, Republic of Korea
| | - Dong-Hyuk Cho
- Division of Cardiology, Department of Internal Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Jun-Bean Park
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jeong-Sook Seo
- Division of Cardiology, Department of Internal Medicine, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Jung-Woo Son
- Division of Cardiology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - In-Cheol Kim
- Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
| | - Sang-Hyun Lee
- Division of Cardiology, Pusan National Yangsan Hospital, Pusan National University School of Medicine, Busan, Republic of Korea
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National Yangsan Hospital, Busan, Republic of Korea
| | - Ran Heo
- Division of Cardiology, Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Hyun-Jung Lee
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jae-Hyeong Park
- Division of Cardiology, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Republic of Korea
- Regional Cardiocerebrovascular Center, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Jong-Min Song
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang-Chol Lee
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Heart Vascular Stroke Institute, Samsung Medical Center, Seoul, Republic of Korea
| | - Hyungseop Kim
- Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
| | - Duk-Hyun Kang
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jong-Won Ha
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kye Hun Kim
- Department of Cardiovascular Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea.
| |
Collapse
|
3
|
Amoroso NS, Sharma RP, Généreux P, Pinto DS, Dobbles M, Kwon M, Thourani VH, Gillam LD. Clinical journey for patients with aortic regurgitation: A retrospective observational study from a multicenter database. Catheter Cardiovasc Interv 2024; 104:145-154. [PMID: 38764317 DOI: 10.1002/ccd.31085] [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: 10/26/2023] [Revised: 02/20/2024] [Accepted: 05/08/2024] [Indexed: 05/21/2024]
Abstract
BACKGROUND Data using real-world assessments of aortic regurgitation (AR) severity to identify rates of Heart Valve Team evaluation and aortic valve replacement (AVR), as well as mortality among untreated patients, are lacking. The present study assessed these trends in care and outcomes for real-world patients with documented AR. METHODS Using a deidentified data set (January 2018-March 2023) representing 1,002,853 patients >18 years of age from 25 US institutions participating in the egnite Database (egnite, Inc.) with appropriate permissions, patients were classified by AR severity in echocardiographic reports. Rates of evaluation by the Heart Valve Team, AVR, and all-cause mortality without AVR were examined using Kaplan-Meier estimates and compared using the log-rank test. RESULTS Within the data set, 845,113 patients had AR severity documented. For moderate-to-severe or severe AR, respectively, 2-year rates (95% confidence interval) of evaluation by the Heart Valve Team (43.5% [41.7%-45.3%] and 65.4% [63.3%-67.4%]) and AVR (19.4% [17.6%-21.1%] and 46.5% [44.2%-48.8%]) were low. Mortality at 2 years without AVR increased with greater AR severity, up to 20.7% for severe AR (p < 0.001). In exploratory analyses, 2-year mortality for untreated patients with left ventricular end-systolic dimension index > 25 mm/m2 was similar for moderate (34.3% [29.2%-39.1%]) and severe (37.2% [24.9%-47.5%]) AR. CONCLUSIONS Moderate or greater AR is associated with poor clinical outcomes among untreated patients at 2 years. Rates of Heart Valve Team evaluation and AVR were low for those with moderate or greater AR, suggesting that earlier referral to the Heart Valve Team could be beneficial.
Collapse
Affiliation(s)
- Nicholas S Amoroso
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Rahul P Sharma
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Philippe Généreux
- Department of Cardiovascular Medicine, Morristown Medical Center, Morristown, New Jersey, USA
| | - Duane S Pinto
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
- JenaValve Technology, Inc., Irvine, California, USA
| | | | | | - Vinod H Thourani
- Department of Cardiovascular Surgery, Marcus Valve Center, Piedmont Heart Institute, Atlanta, Georgia, USA
| | - Linda D Gillam
- Department of Cardiovascular Medicine, Morristown Medical Center, Morristown, New Jersey, USA
| |
Collapse
|
4
|
Xiao W, Yuan JL, Chen Y, Ma G, Zhang C, Sun L, Hong C, Ye T. Development and validation of a prediction model for heart failure in patients with heart valvular regurgitation. ESC Heart Fail 2024. [PMID: 38923827 DOI: 10.1002/ehf2.14899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 05/06/2024] [Accepted: 05/24/2024] [Indexed: 06/28/2024] Open
Abstract
AIMS Patients with heart valvular regurgitation is increasing; early screening of potential patients developing heart failure (HF) is crucial. METHODS From 1 November 2019 to 31 October 2023, a total of 509 patients with heart valvular regurgitation hospitalized in the Department of Cardiovascular Disease of the First Affiliated Hospital of Guangzhou University of Traditional Medicine were enrolled. Three hundred fifty-six cases were selected as the training set for modelling, and 153 cases were selected as the validation set for the internal validation of the model. RESULTS A predictive model of heart failure with the following nine risk factors was developed: atrial fibrillation (AF), pulmonary infection (PI), coronary artery disease (CAD), creatinine (CREA), low-density lipoprotein cholesterol (LDL-C), d-dimer (DDi), left ventricular end-diastolic diameter (LVEDd), mitral regurgitation (MR) and aortic regurgitation (AR). The model was evaluated by the C-index [the training set: area under curve (AUC) 0.937, 95% confidence interval (CI) 0.911-0.963; the validation set: AUC 0.928, 95% CI 0.890-0.967]. Hosmer-Lemeshow test (the training set: χ2 10.908, P = 0.207; the validation set: χ2 4.896, P = 0.769) revealed that both the training and validation sets performed well in terms of model differentiation and calibration. Decision curve analysis showed that both the training and validation sets have higher net benefits, indicating that the model has good utility. Ten-fold cross-validation showed that the training set has high similarities with the validation set, which means that the model has good stability. CONCLUSIONS The occurrence of heart failure in patients with valvular regurgitation has a significant correlation with AF, PI, CAD, CREA, LDL-C, DDi, LVEDd, MR and AR. Based on these risk factors, a prediction model for heart failure was developed and validated, which showed good differentiation and utility, high accuracy and stability, providing a method for predicting heart failure.
Collapse
Affiliation(s)
- WenKang Xiao
- Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Jia-Lin Yuan
- Guangzhou University of Chinese Medicine, Guangzhou, China
| | - YunYi Chen
- Guangzhou University of Chinese Medicine, Guangzhou, China
| | - GuiPing Ma
- Department of Cardiovascular Disease, Beijing University of Chinese Medicine Shenzhen Hospital, Shenzhen, China
| | | | - Le Sun
- Department of Rheumatology, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China
| | - ChuangXiong Hong
- The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Taochun Ye
- The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
- Guangdong Clinical Research Academy of Chinese Medicine, Guangzhou, China
| |
Collapse
|
5
|
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.
Collapse
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
| |
Collapse
|
6
|
Hisatomi K, Miura T. The Importance of Left Ventricular End-Systolic Diameter for Aortic Valve Replacement in Japanese Asymptomatic Patients With Chronic Severe Aortic Regurgitation. Circ J 2024:CJ-24-0342. [PMID: 38825488 DOI: 10.1253/circj.cj-24-0342] [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: 06/04/2024]
Affiliation(s)
- Kazuki Hisatomi
- Department of Cardiovascular Surgery, Nagasaki University Hospital
| | - Takashi Miura
- Department of Cardiovascular Surgery, Nagasaki University Hospital
| |
Collapse
|
7
|
Marigliano AN, Ortiz JT, Casas J, Evangelista A. Aortic Regurgitation: From Valvular to Myocardial Dysfunction. J Clin Med 2024; 13:2929. [PMID: 38792470 PMCID: PMC11122337 DOI: 10.3390/jcm13102929] [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: 04/03/2024] [Revised: 04/30/2024] [Accepted: 05/02/2024] [Indexed: 05/26/2024] Open
Abstract
Chronic aortic regurgitation (AR) leads to volume overload in the left ventricle (LV), which is well tolerated for years. In this condition, the LV usually dilates with minimal reduction in the ejection fraction (EF), even in the absence of symptoms. Echocardiography is the primary imaging test used to quantify AR. However, no single assessment of Doppler measures is accurate and precise in individual patients; therefore, the integration of multiple parameters is necessary. Recent guidelines recommend surgical treatment for severe AR in patients who are symptomatic or have an LVEF < 55% and an end-systolic diameter > 50 mm. Nevertheless, advances in imaging technology have improved the quantification of AR and the assessment of LV subclinical dysfunction. It is widely recognized that patients who undergo aortic valve replacement/repair (AVR) due to symptoms or a low LVEF experience worse outcomes than those undergoing AVR for non-Class I indications. In fact, subclinical irreversible myocardial damage may occur in clinically well-compensated and closely monitored patients while awaiting formal surgical indications. This condition could be prevented by the use of multimodal imaging parameters, in particular longitudinal LV strain and magnetic resonance imaging. In addition, better cut-off values for mortality predictors should be established. This review aims to identify simple models that integrate several echocardiographic and cardiac magnetic resonance-derived parameters to predict the optimal timing of surgical treatment in asymptomatic patients with chronic severe AR.
Collapse
Affiliation(s)
- Alba-Nidia Marigliano
- Heart Institute, Teknon Medical Center, 08022 Barcelona, Spain; (A.-N.M.); (J.-T.O.)
| | - José-Tomas Ortiz
- Heart Institute, Teknon Medical Center, 08022 Barcelona, Spain; (A.-N.M.); (J.-T.O.)
| | - Jorge Casas
- Instituto Cedic, Bahía Blanca B8000, Argentina;
| | - Arturo Evangelista
- Heart Institute, Teknon Medical Center, 08022 Barcelona, Spain; (A.-N.M.); (J.-T.O.)
| |
Collapse
|
8
|
Saeed M, Bersali A, Darwish A, Qamar F, Maragiannis D, El-Tallawi KC, Malahfji M, Shah DJ. Assessing Regurgitation Severity, Adverse Remodeling, and Fibrosis with CMR in Aortic Regurgitation. Curr Cardiol Rep 2024; 26:413-421. [PMID: 38517604 DOI: 10.1007/s11886-024-02044-3] [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] [Accepted: 03/15/2024] [Indexed: 03/24/2024]
Abstract
PURPOSE OF REVIEW Cardiac magnetic resonance (CMR) is emerging as a valuable imaging modality for the assessment of aortic regurgitation (AR). In this review, we discuss the assessment of AR severity, left ventricular (LV) remodeling, and tissue characterization by CMR while highlighting the latest studies and addressing future research needs. RECENT FINDINGS Recent studies have further established CMR-based thresholds of AR severity and LV remodeling that are associated with adverse clinical outcomes, and lower than current guideline criteria. In addition, tissue profiling with late gadolinium enhancement (LGE) and extracellular volume (ECV) quantification can reliably assess adverse myocardial tissue remodeling which is also associated with adverse outcomes. The strengths and reproducibility of CMR in evaluating ventricular volumes, tissue characteristics, and regurgitation severity position it as an excellent modality in evaluating and following AR patients. Advanced CMR techniques for the detection of tissue remodeling have shown significant potential and merit further investigation.
Collapse
Affiliation(s)
- Mujtaba Saeed
- Cardiovascular MRI Laboratory, Division of Cardiovascular Imaging, Houston Methodist DeBakey Heart & Vascular Center, Weill Cornell Medical College, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA
| | - Akila Bersali
- Cardiovascular MRI Laboratory, Division of Cardiovascular Imaging, Houston Methodist DeBakey Heart & Vascular Center, Weill Cornell Medical College, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA
| | - Amr Darwish
- Cardiovascular MRI Laboratory, Division of Cardiovascular Imaging, Houston Methodist DeBakey Heart & Vascular Center, Weill Cornell Medical College, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA
| | - Fatima Qamar
- Cardiovascular MRI Laboratory, Division of Cardiovascular Imaging, Houston Methodist DeBakey Heart & Vascular Center, Weill Cornell Medical College, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA
| | - Dimitrios Maragiannis
- Cardiovascular MRI Laboratory, Division of Cardiovascular Imaging, Houston Methodist DeBakey Heart & Vascular Center, Weill Cornell Medical College, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA
| | - Kinan Carlos El-Tallawi
- Cardiovascular MRI Laboratory, Division of Cardiovascular Imaging, Houston Methodist DeBakey Heart & Vascular Center, Weill Cornell Medical College, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA
| | - Maan Malahfji
- Cardiovascular MRI Laboratory, Division of Cardiovascular Imaging, Houston Methodist DeBakey Heart & Vascular Center, Weill Cornell Medical College, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA
| | - Dipan J Shah
- Cardiovascular MRI Laboratory, Division of Cardiovascular Imaging, Houston Methodist DeBakey Heart & Vascular Center, Weill Cornell Medical College, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA.
| |
Collapse
|
9
|
Jasinski MJ, Nienaber CA. Paradigm shift to earlier surgery for aortic regurgitation: What should be done? J Thorac Cardiovasc Surg 2024; 167:e159-e160. [PMID: 37921734 DOI: 10.1016/j.jtcvs.2023.09.075] [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: 09/22/2023] [Accepted: 09/30/2023] [Indexed: 11/04/2023]
Affiliation(s)
- Marek J Jasinski
- Department of Cardiac Surgery, Wroclaw Medical University, Wroclaw, Poland; Royal Brompton Hospital, London, United Kingdom
| | | |
Collapse
|
10
|
Kočková R, Vojáček J, Bedáňová H, Fila P, Skalský I, Žáková D, Klán M, Míková B, Mědílek K, Tuna M, Fialová M, Dvořáková R, Hlubocká Z, Panovský R, Slabý K, Kelen de Oliveira E, Casselman F, Pěnička M. Rationale and design of the ELEANOR trial early aortic valve surgery versus watchful waiting strategy in severe asymptomatic aortic regurgitation, ACRONYM: ELEANOR. Heliyon 2024; 10:e29470. [PMID: 38638969 PMCID: PMC11024602 DOI: 10.1016/j.heliyon.2024.e29470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 03/17/2024] [Accepted: 04/08/2024] [Indexed: 04/20/2024] Open
Abstract
Background The optimal treatment of patients with severe symptomatic aortic regurgitation (AR) is state-of-the-art surgery. Asymptomatic patients with advanced left ventricular (LV) dilatation and/or impaired ejection fraction should undergo surgical treatment, but there is no guidelines consensus on cut-off values for this recommendation. Multimodality imaging has brought new tools for the accurate selection of asymptomatic patients at risk of early clinical deterioration, however, prospective and randomized data are pending. Cardiac magnetic resonance (CMR)-derived AR quantification along with LV remodeling assessment appears to be the most accurate tool for a selection of such patients at risk. Trial design The objective of our prospective and multicenter study is to determine whether patients at risk of early clinical deterioration as per CMR assessment will benefit from early surgical treatment. The study is designed as a superiority trial to demonstrate that early surgical treatment is safe and more effective than the standard treatment. A total of 217 asymptomatic patients with severe AR, but without current guidelines-based surgical indication, will be enrolled across all centers. We expect 24 % of patients identified as high clinical risk and therefore eligible for 1:1 randomization to early surgical treatment within 3 months or a watchful waiting strategy. Follow-up will be annual. We expect a complete restoration of LV size and function along with improved quality of life and physical performance in a short-term follow-up of 12 months. The primary endpoint will be a composite safety and efficacy with all criteria mandatory: 15 % or larger reduction of baseline CMR-derived LV end-diastolic volume index, LV ejection fraction >50 %, and no major adverse cardiovascular events. The annual follow-up will continue for a minimum of 4 years until the required number of endpoints is achieved to show a statistically significant difference in cardiovascular morbidity and mortality in early surgically treated patients. Conclusion The ELEANOR trial is the first multicenter randomized controlled study to compare early surgical treatment with a watchful waiting strategy in asymptomatic patients with chronic severe AR at high risk of early clinical deterioration as per CMR assessment but without guidelines-based indications for surgical treatment.
Collapse
Affiliation(s)
- Radka Kočková
- Na Homolce Hospital, Prague, Czech Republic
- Charles University, Faculty of Medicine in Hradec Králové, Hradec Králové, Czech Republic
| | - Jan Vojáček
- Charles University, Faculty of Medicine in Hradec Králové, Hradec Králové, Czech Republic
- University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Helena Bedáňová
- Centre of Cardiovascular Surgery and Transplantation, Brno, Czech Republic
| | - Petr Fila
- Centre of Cardiovascular Surgery and Transplantation, Brno, Czech Republic
- Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | | | - Daniela Žáková
- Centre of Cardiovascular Surgery and Transplantation, Brno, Czech Republic
| | | | | | - Karel Mědílek
- Charles University, Faculty of Medicine in Hradec Králové, Hradec Králové, Czech Republic
- University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Martin Tuna
- Charles University, Faculty of Medicine in Hradec Králové, Hradec Králové, Czech Republic
- University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Monika Fialová
- University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Radka Dvořáková
- University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Zuzana Hlubocká
- 2nd Department of Internal Cardiovascular Medicine, General University Hospital in Prague, First Faculty of Medicine, Charles University, Czech Republic
| | - Roman Panovský
- International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czech Republic
- 1st Department of Internal, Brno, Czech Republic Medicine/Cardioangiology at St. Anne's University Hospital, Brno, Czech Republic
| | - Kryštof Slabý
- Department of Rehabilitation and Sports Medicine, Second Faculty of Medicine, Charles University in Prague, Czech Republic
| | - Elayne Kelen de Oliveira
- CardioPaTh PhD Program, Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
- Cardiovascular Center OLV Clinic Aalst, Belgium
| | | | | |
Collapse
|
11
|
Hahn RT, Muraru D, Lindman BR, Delgado V, Dweck MR. Heart valve disease: at the threshold of a new era in patient management. Lancet 2024; 403:1519-1522. [PMID: 38554723 DOI: 10.1016/s0140-6736(24)00423-9] [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: 02/28/2024] [Accepted: 02/28/2024] [Indexed: 04/02/2024]
Affiliation(s)
- Rebecca T Hahn
- Department of Cardiology, Columbia University Irving Medical Center, New York, NY 10032, USA.
| | - Denisa Muraru
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy; Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Brian R Lindman
- Structural Heart and Valve Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Marc R Dweck
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| |
Collapse
|
12
|
Tsampasian V, Victor K, Bhattacharyya S, Oxborough D, Ring L. Echocardiographic assessment of aortic regurgitation: a narrative review. Echo Res Pract 2024; 11:1. [PMID: 38167345 PMCID: PMC10762934 DOI: 10.1186/s44156-023-00036-7] [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: 10/09/2023] [Accepted: 11/08/2023] [Indexed: 01/05/2024] Open
Abstract
Aortic regurgitation (AR) is the third most frequently encountered valve lesion and may be caused by abnormalities of the valve cusps or the aorta. Echocardiography is instrumental in the assessment of AR as it enables the delineation of valvular morphology, the mechanism of the lesion and the grading of severity. Severe AR has a major impact on the myocardium and carries a significant risk of morbidity and mortality if left untreated. Established and novel echocardiographic methods, such as global longitudinal strain and three-dimensional echocardiography, allow an estimation of this risk and provide invaluable information for patient management and prognosis. This narrative review summarises the epidemiology of AR, reviews current practices and recommendations with regards to the echocardiographic assessment of AR and outlines novel echocardiographic tools that may prove beneficial in patient assessment and management.
Collapse
Affiliation(s)
| | | | | | - David Oxborough
- Research Institute of Sports and Exercise Science and Liverpool Centre for Cardiovascular Science, Liverpool John Moores University, Liverpool, UK
| | - Liam Ring
- West Suffolk Hospital NHS Foundation Trust, Bury St Edmunds, UK
| |
Collapse
|
13
|
Ranard LS, Bonow RO, Nishimura R, Mack MJ, Thourani VH, Bavaria J, O'Gara PT, Bax JJ, Blanke P, Delgado V, Leipsic J, Lang RM, Michelena HI, Cavalcante JL, Vahl TP, Leon MB, Rigolin VH. Imaging Methods for Evaluation of Chronic Aortic Regurgitation in Adults: JACC State-of-the-Art Review. J Am Coll Cardiol 2023; 82:1953-1966. [PMID: 37940233 DOI: 10.1016/j.jacc.2023.08.051] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 08/21/2023] [Indexed: 11/10/2023]
Abstract
A global multidisciplinary workshop was convened to discuss the multimodality diagnostic evaluation of aortic regurgitation (AR). Specifically, the focus was on assessment tools for AR severity and analyzing evolving data on the optimal timing of aortic valve intervention. The key concepts from this expert panel are summarized as: 1) echocardiography is the primary imaging modality for assessment of AR severity; however, when data is incongruent or incomplete, cardiac magnetic resonance may be helpful; 2) assessment of left ventricular size and function is crucial in determining the timing of intervention; 3) recent evidence suggests current cutpoints for intervention in asymptomatic severe AR patients requires further scrutiny; 4) left ventricular end-systolic volume index has emerged as an additional parameter that has promise in guiding timing of intervention; and 5) the role of additional factors (including global longitudinal strain, regurgitant fraction, and myocardial extracellular volume) is worthy of future investigation.
Collapse
Affiliation(s)
- Lauren S Ranard
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Robert O Bonow
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Northwestern Memorial Hospital, Chicago, Illinois, USA
| | - Rick Nishimura
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael J Mack
- Division of Cardiothoracic Surgery, Heart Hospital Baylor Plano, Baylor Healthcare System, Plano, Texas, USA
| | - Vinod H Thourani
- Department of Cardiovascular Surgery, Marcus Valve Center, Piedmont Heart Institute, Atlanta, Georgia, USA
| | - Joseph Bavaria
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Patrick T O'Gara
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Philipp Blanke
- Department of Radiology, St Paul's Hospital & University of British Columbia, Vancouver, British Columbia, Canada
| | - Victoria Delgado
- Department of Cardiology, Hospital University Germans Trias i Pujol, Badalona, Spain
| | - Jonathon Leipsic
- Department of Radiology, St Paul's Hospital & University of British Columbia, Vancouver, British Columbia, Canada
| | - Roberto M Lang
- Section of Cardiology, Heart and Vascular Center, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Hector I Michelena
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - João L Cavalcante
- Division of Cardiology, Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Torsten P Vahl
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Martin B Leon
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Vera H Rigolin
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Northwestern Memorial Hospital, Chicago, Illinois, USA.
| |
Collapse
|
14
|
Moya A, Buytaert D, Penicka M, Bartunek J, Vanderheyden M. State-of-the-Art: Noninvasive Assessment of Left Ventricular Function Through Myocardial Work. J Am Soc Echocardiogr 2023; 36:1027-1042. [PMID: 37437670 DOI: 10.1016/j.echo.2023.07.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 07/04/2023] [Accepted: 07/04/2023] [Indexed: 07/14/2023]
Abstract
The assessment of myocardial work (MW) using noninvasive pressure-strain loop analysis is a novel echocardiographic method that provides a more precise assessment of cardiac performance by considering the left ventricular loading condition. By integrating various MW components such as index, efficiency, and constructive and wasted work, an extensive analysis of left ventricular mechanics and energetics can be achieved. This approach offers a more comprehensive assessment of global cardiac function and performance, surpassing conventional surrogate indices. In this review, we aim to summarize the existing knowledge on MW and its distinctive characteristics in various cardiac pathologies.
Collapse
Affiliation(s)
- Ana Moya
- Cardiovascular Center and Cardiovascular Research Centre, OLV Hospital, Aalst, Belgium; CardioPath PhD Program, Department of Advanced Biomedical Sciences, Cardiovascular Pathophysiology and Therapeutics, University of Naples Federico II, Naples, Italy.
| | - Dimitri Buytaert
- Cardiovascular Center and Cardiovascular Research Centre, OLV Hospital, Aalst, Belgium
| | - Martin Penicka
- Cardiovascular Center and Cardiovascular Research Centre, OLV Hospital, Aalst, Belgium
| | - Jozef Bartunek
- Cardiovascular Center and Cardiovascular Research Centre, OLV Hospital, Aalst, Belgium
| | - Marc Vanderheyden
- Cardiovascular Center and Cardiovascular Research Centre, OLV Hospital, Aalst, Belgium
| |
Collapse
|
15
|
Malahfji M, Saeed M, Zoghbi WA. Aortic Regurgitation: Review of the Diagnostic Criteria and the Management Guidelines. Curr Cardiol Rep 2023; 25:1373-1380. [PMID: 37715804 DOI: 10.1007/s11886-023-01955-x] [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] [Accepted: 08/28/2023] [Indexed: 09/18/2023]
Abstract
PURPOSE OF REVIEW The evaluation of aortic regurgitation (AR) has advanced from physical examination and angiography towards evidence based non-invasive quantitative methods, primarily with echocardiography and more recently with cardiac magnetic resonance (CMR). This review highlights the guidelines and recent evidence in the diagnosis and management of AR; and outlines future areas of research. RECENT FINDINGS Contemporary large cohorts of AR patients studied with echocardiography and CMR suggest that the left ventricular remodeling and systolic function triggers for intervention may be lower than previously recommended in the guidelines and emphasize the importance of LV volumes in risk stratification. Important gaps of knowledge in the quantitation of AR severity and patient risk stratification were fulfilled recently. Potential thresholds for intervention using ventricular volumes and CMR quantitative findings were recently described. The criteria for what constitutes hemodynamically significant AR and the optimal timing of intervention AR deserve further study.
Collapse
Affiliation(s)
- Maan Malahfji
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA.
| | - Mujtaba Saeed
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA
| | - William A Zoghbi
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA
| |
Collapse
|
16
|
Barradas‐Pires A, Merás P, Constantine A, Costola G, de la Cal TS, Rafiq I, Kempny A, Li W, Babu‐Narayan SV, Hoschtitzky JA, Gatzoulis MA, Rubio AM, Dimopoulos K. Repair of Aortic Regurgitation in Young Adults: Sooner Rather Than Later. J Am Heart Assoc 2023; 12:e029251. [PMID: 37721152 PMCID: PMC10547301 DOI: 10.1161/jaha.122.029251] [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: 12/19/2022] [Accepted: 07/31/2023] [Indexed: 09/19/2023]
Abstract
Background Establishing surgical criteria for aortic valve replacement (AVR) in severe aortic regurgitation in young adults is challenging due to the lack of evidence-based recommendations. We studied indications for AVR in young adults with severe aortic regurgitation and their outcomes, as well as the relationship between presurgical echocardiographic parameters and postoperative left ventricular (LV) size, function, clinical events, and valve-related complications. Methods and Results Data were collected retrospectively on 172 consecutive adult patients who underwent AVR or repair for severe aortic regurgitation between 2005 and 2019 in a tertiary cardiac center (age at surgery 29 [22-41] years, 81% male). One-third underwent surgery before meeting guideline indications. Postsurgery, 65% achieved LV size and function normalization. LV ejection fraction showed no significant change from baseline. A higher presurgical LV end-systolic diameter correlated with a lack of LV normalization (odds ratio per 1-cm increase 2.81, P<0.01). The baseline LV end-systolic diameter cut-off for predicting lack of LV normalization was 43 mm. Pre- and postoperative LV dimensions and postoperative LV ejection fraction predicted clinical events during follow-up. Prosthetic valve-related complications occurred in 20.3% during an average 5.6-year follow-up. Freedom from aortic reintervention was 98%, 96.5%, and 85.4% at 1, 5, and 10 years, respectively. Conclusions Young adult patients with increased baseline LV end-systolic diameter or prior cardiac surgery are less likely to achieve LV normalization after AVR. Clinicians should carefully balance the long-term benefits of AVR against procedural risks and future interventions, especially in younger patients. Evidence-based criteria for AVR in severe aortic regurgitation in young adults are crucial to improve outcomes.
Collapse
Affiliation(s)
- Ana Barradas‐Pires
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Cardiology Department, Royal Brompton HospitalGuy’s and St Thomas’ NHS Foundation TrustLondonUnited Kingdom
- Department of MedicineAutonomous University of BarcelonaBarcelonaSpain
| | - Pablo Merás
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Cardiology Department, Royal Brompton HospitalGuy’s and St Thomas’ NHS Foundation TrustLondonUnited Kingdom
- Cardiology DepartmentUniversity Hospital La PazMadridSpain
| | - Andrew Constantine
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Cardiology Department, Royal Brompton HospitalGuy’s and St Thomas’ NHS Foundation TrustLondonUnited Kingdom
- National Heart and Lung InstituteImperial College LondonLondonUnited Kingdom
| | - Giulia Costola
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Cardiology Department, Royal Brompton HospitalGuy’s and St Thomas’ NHS Foundation TrustLondonUnited Kingdom
| | - Teresa Segura de la Cal
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Cardiology Department, Royal Brompton HospitalGuy’s and St Thomas’ NHS Foundation TrustLondonUnited Kingdom
- Cardiology DepartmentUniversity Hospital 12 de OctubreMadridSpain
| | - Isma Rafiq
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Cardiology Department, Royal Brompton HospitalGuy’s and St Thomas’ NHS Foundation TrustLondonUnited Kingdom
| | - Aleksander Kempny
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Cardiology Department, Royal Brompton HospitalGuy’s and St Thomas’ NHS Foundation TrustLondonUnited Kingdom
- National Heart and Lung InstituteImperial College LondonLondonUnited Kingdom
| | - Wei Li
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Cardiology Department, Royal Brompton HospitalGuy’s and St Thomas’ NHS Foundation TrustLondonUnited Kingdom
- National Heart and Lung InstituteImperial College LondonLondonUnited Kingdom
| | - Sonya V. Babu‐Narayan
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Cardiology Department, Royal Brompton HospitalGuy’s and St Thomas’ NHS Foundation TrustLondonUnited Kingdom
- National Heart and Lung InstituteImperial College LondonLondonUnited Kingdom
| | - J. Andreas Hoschtitzky
- National Heart and Lung InstituteImperial College LondonLondonUnited Kingdom
- Cardiothoracic and Congenital Heart Surgery, The Royal Brompton HospitalGuy’s and St Thomas’ NHS Foundation TrustLondonUnited Kingdom
| | - Michael A. Gatzoulis
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Cardiology Department, Royal Brompton HospitalGuy’s and St Thomas’ NHS Foundation TrustLondonUnited Kingdom
- National Heart and Lung InstituteImperial College LondonLondonUnited Kingdom
| | - Antonio Martinez Rubio
- Department of MedicineAutonomous University of BarcelonaBarcelonaSpain
- Cardiology DepartmentUniversity Hospital Parc TauliSabadellSpain
| | - Konstantinos Dimopoulos
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Cardiology Department, Royal Brompton HospitalGuy’s and St Thomas’ NHS Foundation TrustLondonUnited Kingdom
- National Heart and Lung InstituteImperial College LondonLondonUnited Kingdom
| |
Collapse
|
17
|
Poletti E, De Backer O, Scotti A, Costa G, Bruno F, Fiorina C, Buzzatti N, Latini A, Rudolph TK, van den Dorpel MMP, Brinkmann C, Patel KP, Panoulas V, Schofer J, Giordano A, Barbanti M, Regazzoli D, Taramasso M, Saia F, Baumbach A, Maisano F, Van Mieghem NM, Søndergaard L, Latib A, Amat Santos IJ, Bedogni F, Testa L. Transcatheter Aortic Valve Replacement for Pure Native Aortic Valve Regurgitation: The PANTHEON International Project. JACC Cardiovasc Interv 2023; 16:1974-1985. [PMID: 37648345 DOI: 10.1016/j.jcin.2023.07.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 07/03/2023] [Accepted: 07/11/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND Transcatheter aortic valve replacement (TAVR) in patients with pure severe native aortic valve regurgitation (NAVR) has been associated with suboptimal results. The available evidence concerns mostly outdated transcatheter heart valves (THVs). OBJECTIVES The aim of this study was to investigate the performance of new-generation THVs in patients treated for pure severe NAVR. METHODS The PANTHEON (Performance of Currently Available Transcatheter Aortic Valve Platforms in Inoperable Patients With Pure Aortic Regurgitation of a Native Valve) study retrospectively included patients who underwent TAVR with currently available devices (both self-expanding [SE] and balloon expandable [BE]) for severe NAVR. Technical and device success rates as well as a composite of all-cause mortality and heart failure rehospitalization at 1 year were evaluated. The rate and clinical consequences of acute transcatheter valve embolization or migration (TVEM) were also considered. RESULTS A total of 201 patients were included. Overall technical and device success rates were 83.6% and 76.1%, respectively, and did not differ between SE and BE devices. These figures were due mostly to TVEM occurrence (14.6% vs 16.1%; P = 0.47) and residual moderate or greater aortic regurgitation (9.2% vs 10.1%; P = 0.87). Patients who experienced TVEM compared with those without TVEM had a significantly higher incidence of the composite endpoint at 1 year (25.7% vs 15.8%; P = 0.05). CONCLUSIONS Despite improved THV platforms and techniques, TAVR for pure severe NAVR remains a challenging procedure, with significant risk for TVEM. SE and BE platforms demonstrated comparable performance in this setting. (Performance of Currently Available Transcatheter Aortic Valve Platforms in Inoperable Patients With Pure Aortic Regurgitation of a Native Valve [PANTHEON]; NCT05319171).
Collapse
Affiliation(s)
- Enrico Poletti
- Clinical and Interventional Cardiology Department, IRCCS Policlinico San Donato, Milan, Italy
| | - Ole De Backer
- Department of Cardiology, The Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Andrea Scotti
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Giuliano Costa
- Division of Cardiology, CAST, Azienda Ospedaliero - Universitaria Policlinico G. Rodolico - San Marco, University of Catania, Catania, Italy
| | - Francesco Bruno
- Department of Cardiology, Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, Harefield Hospital, Harefield, United Kingdom
| | | | | | - Alessia Latini
- Cardio Center, IRCCS Humanitas Research Hospital, Rozzano-Milan, Italy
| | - Tanja K Rudolph
- Department for General and Interventional Cardiology/Angiology, Heart and Diabetes Center North Rhine-Westphalia Bochum, University Hospital of the Ruhr University, Bad Oeynhausen, Germany
| | - Mark M P van den Dorpel
- Department of Interventional Cardiology, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | | | - Kush P Patel
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London United Kingdom
| | - Vasileios Panoulas
- Department of Cardiology, Royal Brompton and Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, Harefield Hospital, Harefield, United Kingdom
| | - Joachim Schofer
- MVZ Department of Structural Heart Disease at St. Georg, Hamburg, Germany
| | - Arturo Giordano
- Cardiovascular Interventional Operative Unit, Presidio Ospedaliero Pineta Grande, Castel Volturno, Caserta, Italy; Operative Unit of Hemodynamics, Casa di Salute Santa Lucia, Naples, Italy
| | | | - Damiano Regazzoli
- Cardio Center, IRCCS Humanitas Research Hospital, Rozzano-Milan, Italy
| | - Maurizio Taramasso
- HerzZentrum Hirslanden Zurich Clinic of Cardiac Surgery, Zurich, Switzerland
| | - Francesco Saia
- Cardiology Unit, Cardio-Thoracic-Vascular Department, IRCCS University Hospital of Bologna, Bologna, Italy
| | - Andreas Baumbach
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London United Kingdom
| | | | - Nicolas M Van Mieghem
- Department of Interventional Cardiology, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Lars Søndergaard
- Department of Cardiology, The Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Azeem Latib
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Ignacio J Amat Santos
- Instituto de Ciencias del Corazón, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Francesco Bedogni
- Clinical and Interventional Cardiology Department, IRCCS Policlinico San Donato, Milan, Italy
| | - Luca Testa
- Clinical and Interventional Cardiology Department, IRCCS Policlinico San Donato, Milan, Italy.
| |
Collapse
|
18
|
Lebehn M, Vahl T, Kampaktsis P, Hahn RT. Contemporary Evaluation and Clinical Treatment Options for Aortic Regurgitation. J Cardiovasc Dev Dis 2023; 10:364. [PMID: 37754793 PMCID: PMC10532324 DOI: 10.3390/jcdd10090364] [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: 07/28/2023] [Revised: 08/21/2023] [Accepted: 08/22/2023] [Indexed: 09/28/2023] Open
Abstract
Aortic regurgitation (AR) is the third most frequent form of valvular disease and has increasing prevalence with age. This will be of increasing clinical importance with the advancing age of populations around the globe. An understanding of the various etiologies and mechanisms leading to AR requires a detailed understanding of the structure of the aortic valve and aortic root. While acute and chronic AR may share a similar etiology, their hemodynamic impact on the left ventricle (LV) and management are very different. Recent studies suggest current guideline recommendations for chronic disease may result in late intervention and suboptimal outcomes. Accurate quantitation of ventricular size and function, as well as grading of the severity of regurgitation, requires a multiparametric and multimodality imaging approach with an understanding of the strengths and weaknesses of each metric. Echocardiography remains the primary imaging modality for diagnosis with supplemental information provided by computed tomography (CT) and cardiac magnetic resonance imaging (CMR). Emerging transcatheter therapies may allow the treatment of patients at high risk for surgery, although novel methods to assess AR severity and its impact on LV size and function may improve the timing and outcomes of surgical intervention.
Collapse
Affiliation(s)
- Mark Lebehn
- Department of Medicine, Columbia University Irving Medical Center, New York, NY 10032, USA
| | - Torsten Vahl
- Department of Medicine, Columbia University Irving Medical Center, New York, NY 10032, USA
- Cardiovascular Research Foundation, New York, NY 10019, USA
| | - Polydoros Kampaktsis
- Department of Medicine, Columbia University Irving Medical Center, New York, NY 10032, USA
| | - Rebecca T. Hahn
- Department of Medicine, Columbia University Irving Medical Center, New York, NY 10032, USA
- Cardiovascular Research Foundation, New York, NY 10019, USA
| |
Collapse
|
19
|
Malahfji M, Senapati A, Debs D, Saeed M, Tayal B, Nguyen DT, Graviss EA, Shah DJ. Sex differences in myocardial remodeling and extracellular volume in aortic regurgitation. Sci Rep 2023; 13:11334. [PMID: 37443191 PMCID: PMC10344872 DOI: 10.1038/s41598-023-37444-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 06/21/2023] [Indexed: 07/15/2023] Open
Abstract
Whether sex differences exist in the cardiac remodeling related to aortic regurgitation (AR) is unclear. Cardiac magnetic resonance (CMR) is the current non-invasive reference standard for cardiac remodeling assessment and can evaluate tissue characteristics. This prospective cohort included patients with AR undergoing CMR between 2011 and 2020. We excluded patients with confounding causes of remodeling. We quantified left ventricular (LV) volume, mass, AR severity, replacement fibrosis by late Gadolinium enhancement (LGE), and extracellular expansion by extracellular volume fraction (ECV). We studied 280 patients (109 women), median age 59.5 (47.2, 68.6) years (P for age = 0.25 between sexes). Women had smaller absolute LV volume and mass than men across the spectrum of regurgitation volume (RVol) (P ≤ 0.01). In patients with ≥ moderate AR and with adjustment for body surface area, indexed LV end-diastolic volume and mass were not significantly different between sexes (all P > 0.5) but men had larger indexed LV end systolic volume and lower LV ejection fraction (P ≥ 0.01). Women were more likely to have NYHA class II or greater symptoms than men but underwent surgery at a similar rate. Prevalence and extent of LGE was not significantly different between sexes or across RVol. Increasing RVol was independently associated with increasing ECV in women, but not in men (adjusted P for interaction = 0.03). In conclusion, women had lower LV volumes and mass than men across AR severity but their ECV increased with higher regurgitant volume, while ECV did not change in men. Indexing to body surface area did not fully correct for the cardiac remodeling differences between men and women. Women were more likely to have symptoms but underwent surgery at a similar rate to men. Further research is needed to determine if differences in ECV would translate to differences in the course of AR and outcomes.
Collapse
Affiliation(s)
- Maan Malahfji
- Cardiovascular MRI Laboratory, Division of Cardiovascular Imaging, Houston Methodist DeBakey Heart & Vascular Center, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA
| | - Alpana Senapati
- Cardiovascular MRI Laboratory, Division of Cardiovascular Imaging, Houston Methodist DeBakey Heart & Vascular Center, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA
| | - Dany Debs
- Cardiovascular MRI Laboratory, Division of Cardiovascular Imaging, Houston Methodist DeBakey Heart & Vascular Center, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA
| | - Mujtaba Saeed
- Cardiovascular MRI Laboratory, Division of Cardiovascular Imaging, Houston Methodist DeBakey Heart & Vascular Center, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA
| | - Bhupendar Tayal
- Cardiovascular MRI Laboratory, Division of Cardiovascular Imaging, Houston Methodist DeBakey Heart & Vascular Center, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA
| | - Duc T Nguyen
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital Research Institute, Houston, TX, USA
| | - Edward A Graviss
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital Research Institute, Houston, TX, USA
| | - Dipan J Shah
- Cardiovascular MRI Laboratory, Division of Cardiovascular Imaging, Houston Methodist DeBakey Heart & Vascular Center, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA.
| |
Collapse
|
20
|
Hanet V, Schäfers HJ, Lansac E, de Kerchove L, El Hamansy I, Vojácek J, Contino M, Pouleur AC, Beauloye C, Pasquet A, Vanoverschelde JL, Vancraeynest D, Gerber BL. Impact of early versus class I-triggered surgery on postoperative survival in severe aortic regurgitation: An observational study from the Aortic Valve Insufficiency and Ascending Aorta Aneurysm International Registry. J Thorac Cardiovasc Surg 2023:S0022-5223(23)00545-7. [PMID: 37422134 DOI: 10.1016/j.jtcvs.2023.06.018] [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: 02/27/2023] [Revised: 06/07/2023] [Accepted: 06/25/2023] [Indexed: 07/10/2023]
Abstract
OBJECTIVES Class I triggers for severe and chronic aortic regurgitation surgery mainly rely on symptoms or systolic dysfunction, resulting in a negative outcome despite surgical correction. Therefore, US and European guidelines now advocate for earlier surgery. We sought to determine whether earlier surgery leads to improved postoperative survival. METHODS We evaluated the postoperative survival of patients who underwent surgery for severe aortic regurgitation in the international multicenter registry for aortic valve surgery, Aortic Valve Insufficiency and Ascending Aorta Aneurysm International Registry, over a median follow-up of 37 months. RESULTS Among 1899 patients (aged 49 ± 15 years, 85% were male), 83% and 84% had class I indication according to the American Heart Association and European Society of Cardiology, respectively, and most were offered repair surgery (92%). Twelve patients (0.6%) died after surgery, and 68 patients died within 10 years after the procedure. Heart failure symptoms (hazard ratio, 2.60 [1.20-5.66], P = .016) and either left ventricular end-systolic diameter greater than 50 mm or left ventricular end-systolic diameter index greater than 25 mm/m2 (hazard ratio, 1.64 [1.05-2.55], P = .030) predicted survival independently over and above age, gender, and bicuspid phenotype. Therefore, patients who underwent surgery based on any class I trigger had worse adjusted survival. However, patients who underwent surgery while meeting early imaging triggers (left ventricular end-systolic diameter index 20-25 mm/m2 or left ventricular ejection fraction 50% to 55%) had no significant outcome penalty. CONCLUSIONS In this international registry of severe aortic regurgitation, surgery when meeting class I triggers led to postoperative outcome penalty compared with earlier triggers (left ventricular end-systolic diameter index 20-25 mm/m2 or ventricular ejection fraction 50%-55%). This observation, which applies to expert centers where aortic valve repair is feasible, should encourage the global use of repair techniques and the conduction of randomized trials.
Collapse
Affiliation(s)
- Vincent Hanet
- Department of Cardiovascular Diseases, Cliniques Universitaires St Luc, Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique IREC UCLouvain, Brussels, Belgium
| | | | - Emmanuel Lansac
- Surgery Department, Institut Mutualiste Montsouris, Paris, France
| | - Laurent de Kerchove
- Department of Cardiovascular Diseases, Cliniques Universitaires St Luc, Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique IREC UCLouvain, Brussels, Belgium
| | | | - Jan Vojácek
- Surgery Department, Charles University Hospital, Hradec Kralove, Czech Republic
| | - Monica Contino
- Surgery Department, Socio Sanitaria Territoriale Università degli Studi di Milano, Milano, Italy
| | - Anne-Catherine Pouleur
- Department of Cardiovascular Diseases, Cliniques Universitaires St Luc, Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique IREC UCLouvain, Brussels, Belgium
| | - Christophe Beauloye
- Department of Cardiovascular Diseases, Cliniques Universitaires St Luc, Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique IREC UCLouvain, Brussels, Belgium
| | - Agnès Pasquet
- Department of Cardiovascular Diseases, Cliniques Universitaires St Luc, Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique IREC UCLouvain, Brussels, Belgium
| | - Jean-Louis Vanoverschelde
- Department of Cardiovascular Diseases, Cliniques Universitaires St Luc, Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique IREC UCLouvain, Brussels, Belgium
| | - David Vancraeynest
- Department of Cardiovascular Diseases, Cliniques Universitaires St Luc, Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique IREC UCLouvain, Brussels, Belgium
| | - Bernhard L Gerber
- Department of Cardiovascular Diseases, Cliniques Universitaires St Luc, Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique IREC UCLouvain, Brussels, Belgium.
| |
Collapse
|
21
|
Peigh G, Puthumana JJ, Bonow RO. Aortic Regurgitation and Heart Failure: Advances in Diagnosis, Management, and Interventions. Heart Fail Clin 2023; 19:285-296. [PMID: 37230644 DOI: 10.1016/j.hfc.2023.02.007] [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] [Indexed: 05/27/2023]
Abstract
This review discusses the contemporary clinical evaluation and management of patients with comorbid aortic regurgitation (AR) and heart failure (HF) (AR-HF). Importantly, as clinical HF exists along the spectrum of AR severity, the present review also details novel strategies to detect early signs of HF before the clinical syndrome ensues. Indeed, there may be a vulnerable cohort of AR patients who benefit from early detection and management of HF. Additionally, while the mainstay of operative management for AR has historically been surgical aortic valve replacement, this review discusses alternate procedures that may be beneficial in high-risk cohorts.
Collapse
Affiliation(s)
- Graham Peigh
- Division of Cardiology, Northwestern University, Feinberg School of Medicine, 676 North St. Clair Suite 600, Chicago, IL 60611, USA.
| | - Jyothy J Puthumana
- Division of Cardiology, Northwestern University, Feinberg School of Medicine, 676 North St. Clair Suite 600, Chicago, IL 60611, USA
| | - Robert O Bonow
- Division of Cardiology, Northwestern University, Feinberg School of Medicine, 676 North St. Clair Suite 600, Chicago, IL 60611, USA
| |
Collapse
|
22
|
Sannino A, Meucci MC. Advances in Risk Stratification of Chronic Aortic Regurgitation: Time for a Change in Guidelines? J Am Coll Cardiol 2023; 81:1899-1901. [PMID: 37164522 DOI: 10.1016/j.jacc.2023.03.411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 03/29/2023] [Accepted: 03/30/2023] [Indexed: 05/12/2023]
Affiliation(s)
- Anna Sannino
- Division of Cardiology, Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy; Division of Cardiology, Baylor Research Institute, Plano, Texas, USA.
| | - Maria Chiara Meucci
- Department of Cardiovascular Science, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy. https://twitter.com/meucci_chiara
| |
Collapse
|
23
|
Malahfji M, Crudo V, Kaolawanich Y, Nguyen DT, Telmesani A, Saeed M, Reardon MJ, Zoghbi WA, Polsani V, Elliott M, Bonow RO, Graviss EA, Kim R, Shah DJ. Influence of Cardiac Remodeling on Clinical Outcomes in Patients With Aortic Regurgitation. J Am Coll Cardiol 2023; 81:1885-1898. [PMID: 36882135 DOI: 10.1016/j.jacc.2023.03.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 03/02/2023] [Indexed: 03/07/2023]
Abstract
BACKGROUND Quantitative cardiac magnetic resonance (CMR) outcome studies in aortic regurgitation (AR) are few. It is unclear if volume measurements are beneficial over diameters. OBJECTIVES This study sought to evaluate the association of CMR quantitative thresholds and outcomes in AR patients. METHODS In a multicenter study, asymptomatic patients with moderate or severe AR on CMR with preserved left ventricular ejection fraction (LVEF) were evaluated. Primary outcome was development of symptoms or decrease in LVEF to <50%, development of guideline indications for surgery based on LV dimensions, or death under medical management. Secondary outcome was the same as the primary outcome, excluding surgery for remodeling indications. We excluded patients who underwent surgery within 30 days of CMR. Receiver-operating characteristic analyses for the association with outcomes were performed. RESULTS We studied 458 patients (median age: 60 years; IQR: 46-70 years). During a median follow-up of 2.4 years (IQR: 0.9-5.3 years), 133 events occurred. Optimal thresholds were regurgitant volume of 47 mL and regurgitant fraction of 43%, indexed LV end-systolic (iLVES) volume of 43 mL/m2, indexed LV end-diastolic volume of 109 mL/m2, and iLVES diameter of 2 cm/m2. In multivariable regression analysis, iLVES volume of ≥43 mL/m2 (HR: 2.53; 95% CI: 1.75-3.66; P < 0.001) and indexed LV end-diastolic volume of ≥109 mL/m2 were independently associated with the outcomes and provided additional discrimination improvement over iLVES diameter, whereas iLVES diameter was independently associated with the primary outcome but not the secondary outcome. CONCLUSIONS In asymptomatic AR patients with preserved LVEF, CMR findings can be used to guide management. CMR-based LVES volume assessment performed favorably compared to LV diameters.
Collapse
Affiliation(s)
- Maan Malahfji
- Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas, USA
| | - Valentina Crudo
- Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas, USA
| | - Yodying Kaolawanich
- Division of Cardiology, Department of Internal Medicine, Duke University, Durham, North Carolina, USA
| | - Duc T Nguyen
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital Research Institute, Houston, Texas, USA
| | - Amr Telmesani
- Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas, USA
| | - Mujtaba Saeed
- Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas, USA
| | - Michael J Reardon
- Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas, USA
| | - William A Zoghbi
- Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas, USA
| | | | - Michael Elliott
- Sanger Heart & Vascular Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Robert O Bonow
- Division of Cardiology, Department of Internal Medicine, Northwestern University, Chicago, Illinois, USA
| | - Edward A Graviss
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital Research Institute, Houston, Texas, USA
| | - Raymond Kim
- Division of Cardiology, Department of Internal Medicine, Duke University, Durham, North Carolina, USA
| | - Dipan J Shah
- Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas, USA.
| |
Collapse
|
24
|
Anand V, Hu H, Weston AD, Scott CG, Michelena HI, Pislaru SV, Carter RE, Pellikka PA. Machine learning-based risk stratification for mortality in patients with severe aortic regurgitation. EUROPEAN HEART JOURNAL. DIGITAL HEALTH 2023; 4:188-195. [PMID: 37265866 PMCID: PMC10232267 DOI: 10.1093/ehjdh/ztad006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 12/06/2022] [Indexed: 06/03/2023]
Abstract
Aims The current guidelines recommend aortic valve intervention in patients with severe aortic regurgitation (AR) with the onset of symptoms, left ventricular enlargement, or systolic dysfunction. Recent studies have suggested that we might be missing the window of early intervention in a significant number of patients by following the guidelines. Methods and results The overarching goal was to determine if machine learning (ML)-based algorithms could be trained to identify patients at risk for death from AR independent of aortic valve replacement (AVR). Models were trained with five-fold cross-validation on a dataset of 1035 patients, and performance was reported on an independent dataset of 207 patients. Optimal predictive performance was observed with a conditional random survival forest model. A subset of 19/41 variables was selected for inclusion in the final model. Variable selection was performed with 10-fold cross-validation using random survival forest model. The top variables included were age, body surface area, body mass index, diastolic blood pressure, New York Heart Association class, AVR, comorbidities, ejection fraction, end-diastolic volume, and end-systolic dimension, and the relative variable importance averaged across five splits of cross-validation in each repeat were evaluated. The concordance index for predicting survival of the best-performing model was 0.84 at 1 year, 0.86 at 2 years, and 0.87 overall, respectively. Conclusion Using common echocardiographic parameters and patient characteristics, we successfully trained multiple ML models to predict survival in patients with severe AR. This technique could be applied to identify high-risk patients who would benefit from early intervention, thereby improving patient outcomes.
Collapse
Affiliation(s)
- Vidhu Anand
- Corresponding author. Tel: +507 284 4441, Fax: +507 266 0228,
| | - Hanwen Hu
- Department of Quantitative Health Sciences Research, Mayo Clinic, Jacksonville, FL 32202, USA
| | - Alexander D Weston
- Department of Quantitative Health Sciences Research, Mayo Clinic, Jacksonville, FL 32202, USA
| | - Christopher G Scott
- Department of Quantitative Health Science, Mayo Clinic, Rochester, MN 55905, USA
| | - Hector I Michelena
- Department of Cardiovascular Medicine, Mayo Clinic Rochester Minnesota, 200 First Street SW, Rochester, MN 55905, USA
| | - Sorin V Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic Rochester Minnesota, 200 First Street SW, Rochester, MN 55905, USA
| | - Rickey E Carter
- Department of Quantitative Health Sciences Research, Mayo Clinic, Jacksonville, FL 32202, USA
| | | |
Collapse
|
25
|
Akintoye E, Saijo Y, Braghieri L, Badwan O, Patel H, Dabbagh MM, El Dahdah J, Jellis CL, Desai MY, Rodriguez LL, Grimm RA, Griffin BP, Popović ZB. Impact of Age and Sex on Left Ventricular Remodeling in Patients With Aortic Regurgitation. J Am Coll Cardiol 2023; 81:1474-1487. [PMID: 37045517 PMCID: PMC9982944 DOI: 10.1016/j.jacc.2023.02.037] [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: 11/15/2022] [Revised: 01/17/2023] [Accepted: 02/09/2023] [Indexed: 04/14/2023]
Abstract
BACKGROUND Current guidelines for aortic regurgitation (AR) recommend the same linear left ventricular (LV) dimension for intervention regardless of age and sex. OBJECTIVES The purpose of this study was to evaluate the impact of age and sex on the degree of LV remodeling and outcomes. METHODS We included consecutive patients with severe AR who were serially monitored by echocardiogram between 2010 and 2016. The 2 main endpoints were as follows: 1) LV end-systolic volume indexed to body surface area (LVESVi) and LV end-diastolic volume indexed to body surface area; and 2) adverse events (AE). We evaluated the longitudinal rate of LV remodeling and determined the association between LV volume and AE by age and sex. RESULTS A total of 525 adult patients (26% women) with a median echocardiogram follow-up of 2.0 years (IQR: 1.0-3.6 years) were included. At baseline, older patients (age ≥60 years) had smaller LV volumes compared with younger patients (age <60 years), eg, the mean LVESVi was 27.3 mL/m2 vs 32.3 mL/m2, respectively. Similarly, women had smaller LV volumes compared with men (mean LVESVi was 23.3 mL/m2 vs 32.4 mL/m2). On serial evaluation, older patients and women maintained smaller LV volumes compared with younger patients and men, respectively. There were 210 (40%) AE during follow-up. The optimal discriminatory threshold for AE varies by age and sex, eg, the LVESVi threshold was highest for young men (50 mL/m2), intermediate for older men (35 mL/m2), and lowest for women (27 mL/m2). CONCLUSIONS On serial evaluation, older patients and women with chronic AR maintained smaller LV volumes than younger patients and men, respectively, and develop AE at lower LV volumes.
Collapse
Affiliation(s)
- Emmanuel Akintoye
- Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA. https://twitter.com/eakintoyeMD
| | - Yoshihito Saijo
- Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Lorenzo Braghieri
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Osamah Badwan
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Hardik Patel
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - M Marwan Dabbagh
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Joseph El Dahdah
- Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Christine L Jellis
- Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA. https://twitter.com/ChrisJellisMD
| | - Milind Y Desai
- Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA. https://twitter.com/DesaiMilindY
| | - L Leonardo Rodriguez
- Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Richard A Grimm
- Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Brian P Griffin
- Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA. https://twitter.com/BrianGriffinMD
| | - Zoran B Popović
- Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA.
| |
Collapse
|
26
|
Long-term outcomes after aortic valve surgery in patients with aortic regurgitation with preserved ejection fraction and left ventricular dilation. Gen Thorac Cardiovasc Surg 2023; 71:51-58. [PMID: 35852755 DOI: 10.1007/s11748-022-01849-9] [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: 04/17/2022] [Accepted: 06/22/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVES This study aims to assess the long-term outcomes and prognostic predictors of asymptomatic patients with severe aortic regurgitation (AR) accompanied by left ventricular ejection fraction (LVEF) ≥ 55% and left ventricular end-diastolic diameter (LVEDD) > 65 mm undergoing aortic valve replacement (AVR). METHODS We retrospectively studied 291 consecutive asymptomatic patients with severe AR accompanied by LVEF ≥ 55% and LVEDD > 65 mm undergoing AVR from January 2000 to December 2013. The long-term outcomes and prognostic predictors were evaluated. RESULTS There were 2 (0.7%) in-hospital deaths caused by multiple organ failure. The overall survival rate was 95.2% at 5 years, 89.9% at 10 years, 85.9% at 15 years, and 85.9% at 20 years. The left ventricular end-systolic volume index (LVESVi) was an independent predictor of overall mortality, with 59 ml/m2 being the best cut-off value. The left ventricular (LV) dimension decreased within 1 year after surgery and sustained thereafter. There were 15.5% of patients had incomplete LV reverse remodeling. LVESVi was an independent predictor of incomplete LV reverse remodeling, with 56 ml/m2 being the best cut-off value. CONCLUSIONS AVR can be performed with an acceptable outcome in patients with severe AR accompanied by LVEF ≥ 55% and LVEDD > 65 mm. The LVESVi has the best predictive value for prognosis and the cut-off value is 59 ml/m2, and has the best predictive value for incomplete LV reverse remodeling and the cut-off value is 56 ml/m2.
Collapse
|
27
|
Ajmone Marsan N, Delgado V, Shah DJ, Pellikka P, Bax JJ, Treibel T, Cavalcante JL. Valvular heart disease: shifting the focus to the myocardium. Eur Heart J 2023; 44:28-40. [PMID: 36167923 PMCID: PMC9805407 DOI: 10.1093/eurheartj/ehac504] [Citation(s) in RCA: 28] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 07/12/2022] [Accepted: 08/26/2022] [Indexed: 01/05/2023] Open
Abstract
Adverse cardiac remodelling is the main determinant of patient prognosis in degenerative valvular heart disease (VHD). However, to give an indication for valvular intervention, current guidelines include parameters of cardiac chamber dilatation or function which are subject to variability, do not directly reflect myocardial structural changes, and, more importantly, seem to be not sensitive enough in depicting early signs of myocardial dysfunction before irreversible myocardial damage has occurred. To avoid irreversible myocardial dysfunction, novel biomarkers are advocated to help refining indications for intervention and risk stratification. Advanced echocardiographic modalities, including strain analysis, and magnetic resonance imaging have shown to be promising in providing new tools to depict the important switch from adaptive to maladaptive myocardial changes in response to severe VHD. This review, therefore, summarizes the current available evidence on the role of these new imaging biomarkers in degenerative VHD, aiming at shifting the clinical perspective from a valve-centred to a myocardium-focused approach for patient management and therapeutic decision-making.
Collapse
Affiliation(s)
- Nina Ajmone Marsan
- Department of Cardiology, Leiden Univesity Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - Victoria Delgado
- Department of Cardiology, Leiden Univesity Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
- Department of Cardiology, Germans Trias i Pujol Hospital, Carretera de Canyet s/n. 08916 Badalona, Barcelona, Spain
| | - Dipan J Shah
- Division of Cardiovascular Imaging, Weill Cornell Medical College, Houston Methodist DeBakey Heart & Vascular Center, 6565 Fannin St, Houston, TX 77030, USA
| | - Patricia Pellikka
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA
| | - Jeroen J Bax
- Department of Cardiology, Leiden Univesity Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - Thomas Treibel
- Department of Cardiology, Barts Heart Centre and University College London, West Smithfield, London EC1A 7BE, UK
| | - João L Cavalcante
- Department of Cardiology, Minneapolis Heart Institute at Abbott Northwestern Hospital, 800 E 28th St, Minneapolis, MN 55407, USA
| |
Collapse
|
28
|
Kočková R, Línková H, Hlubocká Z, Mědílek K, Tuna M, Vojáček J, Skalský I, Černý Š, Malý J, Hlubocký J, Mizukami T, De Colle C, Pěnička M. Multiparametric Strategy to Predict Early Disease Decompensation in Asymptomatic Severe Aortic Regurgitation. Circ Cardiovasc Imaging 2022; 15:e014901. [PMID: 36538596 DOI: 10.1161/circimaging.122.014901] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Use of the current echocardiography-based indications for aortic regurgitation (AR) surgery might result in late valve replacement at the stage of irreversible myocardial damage. Therefore, we aimed to identify simple models combining multiple echocardiography or magnetic resonance imaging (MRI)-derived indices and natriuretic peptides (BNP [brain natriuretic peptide] or NT-proBNP [N-terminnal pro-B type natriuretic peptide]) to predict early disease decompensation in asymptomatic severe AR. METHODS This prospective and multicenter study included asymptomatic patients with severe AR, preserved left ventricular ejection fraction (>50%), and sinus rhythm. The echocardiography and MRI images were analyzed centrally in the CoreLab. The study end point was the onset of indication for aortic valve surgery as per current guidelines. RESULTS The derivative cohort consisted of 127 asymptomatic patients (age 45±14 years, 84% males) with 41 (32%) end points during a median follow-up of 1375 (interquartile range, 1041-1783) days. In multivariable Cox regression analysis, age, BNP, 3-dimensional vena contracta area, MRI left ventricular end-diastolic volume index, regurgitant volume, and a fraction were identified as independent predictors of end point (all P<0.05). However, a combined model including one parameter of AR assessment (MRI regurgitant volume or regurgitant fraction or 3-dimensional vena contracta area), 1 parameter of left ventricular remodeling (MRI left ventricular end-diastolic volume index or echocardiography 2-dimensional global longitudinal strain or E wave), and BNP showed significantly higher predictive accuracy (area under the curve, 0.74-0.81) than any parameter alone (area under the curve, 0.61-0.72). These findings were confirmed in the validation cohort (n=100 patients, 38 end points). CONCLUSIONS In asymptomatic severe AR, multimodality and multiparametric model combining 2 imaging indices with natriuretic peptides, showed high accuracy to identify early disease decompensation. Further prospective studies are warranted to explore the clinical benefit of implementing these models to guide patient management. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT02910349.
Collapse
Affiliation(s)
- Radka Kočková
- Cardiothoracic Surgery Department, Na Homolce Hospital, Czech Republic (R.K., I.S., S.C.)
| | - Hana Línková
- Department of Cardiology, Royal Vinohrady University Hospital, Czech Republic (H.L.)
| | - Zuzana Hlubocká
- Department of Cardiology (Z.H.), General University Hospital, Prague, Czech Republic
| | - Karel Mědílek
- 1st Department Medicine - Cardioangiology, University Hospital Hradec Králové, Sokolská Czech Republic (K.M.)
| | - Martin Tuna
- Department of Cardiac Surgery, University Hospital Hradec Králové, Hradec Králové, Czech Republic (M.T., J.V.)
| | - Jan Vojáček
- Department of Cardiac Surgery, University Hospital Hradec Králové, Hradec Králové, Czech Republic (M.T., J.V.)
| | - Ivo Skalský
- Cardiothoracic Surgery Department, Na Homolce Hospital, Czech Republic (R.K., I.S., S.C.)
| | - Štěpán Černý
- Cardiothoracic Surgery Department, Na Homolce Hospital, Czech Republic (R.K., I.S., S.C.)
| | - Jiří Malý
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.M.)
| | - Jaroslav Hlubocký
- Department of Cardiovascular Surgery (J.H.), General University Hospital, Prague, Czech Republic
| | - Takuya Mizukami
- Cardiovascular Center Aalst, Belgium (T.M., C.D.C., M.P.).,Division of Clinical Pharmacology, Department of Pharmacology, Showa University, Tokyo, Japan (T.M.)
| | - Cristina De Colle
- Cardiovascular Center Aalst, Belgium (T.M., C.D.C., M.P.).,Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy (C.D.C.)
| | - Martin Pěnička
- Cardiovascular Center Aalst, Belgium (T.M., C.D.C., M.P.)
| |
Collapse
|
29
|
Xu Z, Lu D, Yuan J, Wang L, Wang J, Lei Z, Liu S, Wu J, Wang J, Huang L. Storax Attenuates Cardiac Fibrosis following Acute Myocardial Infarction in Rats via Suppression of AT1R-Ankrd1-P53 Signaling Pathway. Int J Mol Sci 2022; 23:13161. [PMID: 36361958 PMCID: PMC9657855 DOI: 10.3390/ijms232113161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 10/17/2022] [Accepted: 10/26/2022] [Indexed: 02/05/2023] Open
Abstract
Myocardial fibrosis following acute myocardial infarction (AMI) seriously affects the prognosis and survival rate of patients. This study explores the role and regulation mechanism of storax, a commonly used traditional Chinese medicine for treatment of cardiovascular diseases, on myocardial fibrosis and cardiac function. The AMI rat model was established by subcutaneous injection of Isoproterenol hydrochloride (ISO). Storax (0.1, 0.2, 0.4 g/kg) was administered by gavage once/d for 7 days. Electrocardiogram, echocardiography, hemodynamic and cardiac enzyme in AMI rats were measured. HE, Masson, immunofluorescence and TUNEL staining were used to observe the degree of pathological damage, fibrosis and cardiomyocyte apoptosis in myocardial tissue, respectively. Expression of AT1R, CARP and their downstream related apoptotic proteins were detected by WB. The results demonstrated that storax could significantly improve cardiac electrophysiology and function, decrease serum cardiac enzyme activity, reduce type I and III collagen contents to improve fibrosis and alleviate myocardial pathological damage and cardiomyocyte apoptosis. It also found that storax can significantly down-regulate expression of AT1R, Ankrd1, P53, P-p53 (ser 15), Bax and cleaved Caspase-3 and up-regulate expression of Mdm2 and Bcl-2. Taken together, these findings indicated that storax effectively protected cardiomyocytes against myocardial fibrosis and cardiac dysfunction by inhibiting the AT1R-Ankrd1-P53 signaling pathway.
Collapse
Affiliation(s)
- Zhuo Xu
- State Key Laboratory of Southwestern Chinese Medicine Resources, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China
- School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China
| | - Danni Lu
- State Key Laboratory of Southwestern Chinese Medicine Resources, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China
- School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China
| | - Jianmei Yuan
- State Key Laboratory of Southwestern Chinese Medicine Resources, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China
- School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China
| | - Liying Wang
- State Key Laboratory of Southwestern Chinese Medicine Resources, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China
- School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China
| | - Jiajun Wang
- State Key Laboratory of Southwestern Chinese Medicine Resources, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China
- School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China
| | - Ziqin Lei
- State Key Laboratory of Southwestern Chinese Medicine Resources, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China
- School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China
| | - Si Liu
- State Key Laboratory of Southwestern Chinese Medicine Resources, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China
- School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China
| | - Junjie Wu
- State Key Laboratory of Southwestern Chinese Medicine Resources, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China
- School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China
| | - Jian Wang
- State Key Laboratory of Southwestern Chinese Medicine Resources, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China
- School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China
| | - Lihua Huang
- State Key Laboratory of Southwestern Chinese Medicine Resources, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China
- School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China
| |
Collapse
|
30
|
Dumpies O, Pausch J, Reichenspurner H, Thiele H. Frühe Herzklappentherapie bei asymptomatischen Patienten – was gilt schon jetzt? AKTUELLE KARDIOLOGIE 2022. [DOI: 10.1055/a-1842-4283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
ZusammenfassungBei einer asymptomatischen hochgradigen Aortenklappenstenose (AS) mit normaler linksventrikulärer Funktion sollte eine „Watchful-Waiting“-Strategie verfolgt werden. Asymptomatische
Patienten mit Risikofaktoren, wie sehr schwere AS, schwere kalzifizierter AS oder 3-fach erhöhtem proBNP-Level, können bei niedrigem operativem Risiko eine Intervention erhalten. Erste
randomisierte Studien weisen auf einen Vorteil des frühzeitigen Aortenklappenersatzes bei niedrigem OP-Risiko hin.Für Patienten mit einer asymptomatischen hochgradigen Aortenklappeninsuffizienz sollte bei niedrigem operativem Risiko bereits frühzeitig eine OP erwogen werden, wenn sich Zeichen der
linksventrikulären Schädigung zeigen.Bei asymptomatischer primärer Mitralklappeninsuffizienz (MI) kann die chirurgische Mitralklappenrekonstruktion bereits vor dem Auftreten einer linksventrikulären Dilatation oder
anderweitigen Folgeschäden erwogen werden, falls mit einer hohen Rekonstruktionswahrscheinlichkeit zu rechnen ist.
Collapse
Affiliation(s)
- Oliver Dumpies
- Klinik für Innere Medizin/Kardiologie, Herzzentrum Leipzig – Universität Leipzig, Leipzig, Deutschland
| | - Jonas Pausch
- Klinik für Herz- und Gefäßchirurgie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Hermann Reichenspurner
- Klinik für Herz- und Gefäßchirurgie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Holger Thiele
- Klinik für Innere Medizin/Kardiologie, Herzzentrum Leipzig – Universität Leipzig, Leipzig, Deutschland
| |
Collapse
|
31
|
Elias P, Poterucha TJ, Rajaram V, Moller LM, Rodriguez V, Bhave S, Hahn RT, Tison G, Abreau SA, Barrios J, Torres JN, Hughes JW, Perez MV, Finer J, Kodali S, Khalique O, Hamid N, Schwartz A, Homma S, Kumaraiah D, Cohen DJ, Maurer MS, Einstein AJ, Nazif T, Leon MB, Perotte AJ. Deep Learning Electrocardiographic Analysis for Detection of Left-Sided Valvular Heart Disease. J Am Coll Cardiol 2022; 80:613-626. [PMID: 35926935 DOI: 10.1016/j.jacc.2022.05.029] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 05/05/2022] [Accepted: 05/09/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Valvular heart disease is an important contributor to cardiovascular morbidity and mortality and remains underdiagnosed. Deep learning analysis of electrocardiography (ECG) may be useful in detecting aortic stenosis (AS), aortic regurgitation (AR), and mitral regurgitation (MR). OBJECTIVES This study aimed to develop ECG deep learning algorithms to identify moderate or severe AS, AR, and MR alone and in combination. METHODS A total of 77,163 patients undergoing ECG within 1 year before echocardiography from 2005-2021 were identified and split into train (n = 43,165), validation (n = 12,950), and test sets (n = 21,048; 7.8% with any of AS, AR, or MR). Model performance was assessed using area under the receiver-operating characteristic (AU-ROC) and precision-recall curves. Outside validation was conducted on an independent data set. Test accuracy was modeled using different disease prevalence levels to simulate screening efficacy using the deep learning model. RESULTS The deep learning algorithm model accuracy was as follows: AS (AU-ROC: 0.88), AR (AU-ROC: 0.77), MR (AU-ROC: 0.83), and any of AS, AR, or MR (AU-ROC: 0.84; sensitivity 78%, specificity 73%) with similar accuracy in external validation. In screening program modeling, test characteristics were dependent on underlying prevalence and selected sensitivity levels. At a prevalence of 7.8%, the positive and negative predictive values were 20% and 97.6%, respectively. CONCLUSIONS Deep learning analysis of the ECG can accurately detect AS, AR, and MR in this multicenter cohort and may serve as the basis for the development of a valvular heart disease screening program.
Collapse
Affiliation(s)
- Pierre Elias
- Seymour, Paul, and Gloria Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center and NewYork-Presbyterian Hospital, New York, New York, USA
| | - Timothy J Poterucha
- Seymour, Paul, and Gloria Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center and NewYork-Presbyterian Hospital, New York, New York, USA
| | - Vijay Rajaram
- Seymour, Paul, and Gloria Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center and NewYork-Presbyterian Hospital, New York, New York, USA
| | - Luca Matos Moller
- Seymour, Paul, and Gloria Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center and NewYork-Presbyterian Hospital, New York, New York, USA
| | - Victor Rodriguez
- Department of Biomedical Informatics, Columbia University, New York, New York, USA
| | - Shreyas Bhave
- Department of Biomedical Informatics, Columbia University, New York, New York, USA
| | - Rebecca T Hahn
- Seymour, Paul, and Gloria Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center and NewYork-Presbyterian Hospital, New York, New York, USA
| | - Geoffrey Tison
- Division of Cardiology, University of California-San Francisco, San Francisco, California, USA
| | - Sean A Abreau
- Division of Cardiology, University of California-San Francisco, San Francisco, California, USA
| | - Joshua Barrios
- Division of Cardiology, University of California-San Francisco, San Francisco, California, USA
| | | | - J Weston Hughes
- Division of Cardiology, Stanford University, Palo Alto, California, USA
| | - Marco V Perez
- Division of Cardiology, Stanford University, Palo Alto, California, USA
| | - Joshua Finer
- NewYork-Presbyterian Hospital, New York, New York, USA
| | - Susheel Kodali
- Seymour, Paul, and Gloria Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center and NewYork-Presbyterian Hospital, New York, New York, USA
| | - Omar Khalique
- Seymour, Paul, and Gloria Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center and NewYork-Presbyterian Hospital, New York, New York, USA
| | - Nadira Hamid
- Seymour, Paul, and Gloria Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center and NewYork-Presbyterian Hospital, New York, New York, USA
| | - Allan Schwartz
- Seymour, Paul, and Gloria Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center and NewYork-Presbyterian Hospital, New York, New York, USA
| | - Shunichi Homma
- Seymour, Paul, and Gloria Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center and NewYork-Presbyterian Hospital, New York, New York, USA
| | - Deepa Kumaraiah
- Seymour, Paul, and Gloria Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center and NewYork-Presbyterian Hospital, New York, New York, USA
| | - David J Cohen
- Cardiovascular Research Foundation, New York, New York, USA; Department of Cardiology, St. Francis Hospital, Roslyn, New York, USA
| | - Mathew S Maurer
- Seymour, Paul, and Gloria Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center and NewYork-Presbyterian Hospital, New York, New York, USA
| | - Andrew J Einstein
- Seymour, Paul, and Gloria Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center and NewYork-Presbyterian Hospital, New York, New York, USA
| | - Tamim Nazif
- Seymour, Paul, and Gloria Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center and NewYork-Presbyterian Hospital, New York, New York, USA
| | - Martin B Leon
- Seymour, Paul, and Gloria Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center and NewYork-Presbyterian Hospital, New York, New York, USA; Cardiovascular Research Foundation, New York, New York, USA
| | - Adler J Perotte
- Department of Biomedical Informatics, Columbia University, New York, New York, USA.
| |
Collapse
|
32
|
Kassier A. Guidelines for Aortic Regurgitation and Thoracic Aortic Aneurysms in Asian Population. JACC: ASIA 2022; 2:487-489. [PMID: 36339360 PMCID: PMC9627914 DOI: 10.1016/j.jacasi.2022.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
33
|
Patrick WL, Rosen JL, Bavaria JE, Ahmed S, Freas A, Yarlagadda S, Cannon B, Iyengar A, Kelly JJ, Zhao Y, Grimm JC, Szeto WY, Desai ND. Valve-sparing Root Reimplantation In Patients With Left Ventricular Dilation. Eur J Cardiothorac Surg 2022; 62:6647842. [PMID: 35861386 DOI: 10.1093/ejcts/ezac393] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 06/29/2022] [Accepted: 07/19/2022] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The purpose of this study was to evaluate the association between left ventricular (LV) dilation and outcomes following valve-sparing root reimplantation. METHODS Patients with an indexed left ventricular internal diameter during systole (iLVIDS) of ≥ 2.0 cm/m2 were categorized as having LV dilation. Outcomes were post-operative aortic insufficiency (AI), re-intervention, and all-cause mortality. The cumulative incidence of each outcome was computed using the Kaplan-Meier estimator. Adjusted comparisons between strata were performed for each outcome using a Cox proportional-hazards model. Where possible, the competing risk of death was accounted for. Multilevel mixed-effects ordered logistic regression was performed for AI grade at follow-up. RESULTS There were 295 patients of whom 52 had LV dilation. Operative outcomes were excellent; there were no significant differences between groups. Patients with LV dilation demonstrated significant improvement in iLVIDS overtime. There was no association between LV dilation and post-operative AI grade >2 (HR 0.88, 95% CI 0.21 to 3.67, p = 0.89) or odds of increased AI grade overtime (OR = 0.76, 95% CI 0.30 to 1.93, p = 0.57). There were no re-interventions among those with LV dilation. Adjusted mortality was significantly higher among those with LV dilation (HR 5.56, 95% CI 1.56 to 19.9), however, deaths were unrelated to aortic valve dilation. CONCLUSIONS Left ventricular dilation is not associated with poorer operative outcomes, post-operative AI, or re-intervention. It is associated with increased risk of mortality, though not from valvular dysfunction. LV dilation should not deter VSRR when otherwise indicated.
Collapse
Affiliation(s)
- William L Patrick
- Division of Cardiovascular Surgery, University of Pennsylvania.,Leonard Davis Institute, University of Pennsylvania, Philadelphia, Pennsylvania.,Penn Cardiovascular Outcomes, Quality, & Evaluative Research Center, Philadelphia, Pennsylvania
| | - Jake L Rosen
- Division of Cardiovascular Surgery, University of Pennsylvania
| | | | - Sania Ahmed
- Division of Cardiovascular Surgery, University of Pennsylvania
| | - Andrew Freas
- Division of Cardiovascular Surgery, University of Pennsylvania
| | | | - Brittany Cannon
- Division of Cardiovascular Surgery, University of Pennsylvania
| | - Amit Iyengar
- Division of Cardiovascular Surgery, University of Pennsylvania
| | - John J Kelly
- Division of Cardiovascular Surgery, University of Pennsylvania
| | - Yu Zhao
- Division of Cardiovascular Surgery, University of Pennsylvania.,Leonard Davis Institute, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joshua C Grimm
- Division of Cardiovascular Surgery, University of Pennsylvania
| | - Wilson Y Szeto
- Division of Cardiovascular Surgery, University of Pennsylvania
| | - Nimesh D Desai
- Division of Cardiovascular Surgery, University of Pennsylvania.,Leonard Davis Institute, University of Pennsylvania, Philadelphia, Pennsylvania.,Penn Cardiovascular Outcomes, Quality, & Evaluative Research Center, Philadelphia, Pennsylvania
| |
Collapse
|
34
|
Anand V, Nishimura RA, Rigolin VH. Earlier Intervention in Asymptomatic Chronic Aortic Regurgitation-Novel Indicators of Myocardial Overload. JAMA Cardiol 2022; 7:883-884. [PMID: 35857301 DOI: 10.1001/jamacardio.2022.2115] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Vidhu Anand
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Rick A Nishimura
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Vera H Rigolin
- Division of Cardiovascular Diseases, Northwestern University, Chicago, Illinois
| |
Collapse
|
35
|
Hashimoto G, Enriquez-Sarano M, Stanberry LI, Oh F, Wang M, Acosta K, Sato H, Lopes BBC, Fukui M, Garcia S, Goessl M, Sorajja P, Bapat VN, Lesser J, Cavalcante JL. Association of Left Ventricular Remodeling Assessment by Cardiac Magnetic Resonance With Outcomes in Patients With Chronic Aortic Regurgitation. JAMA Cardiol 2022; 7:924-933. [PMID: 35857306 DOI: 10.1001/jamacardio.2022.2108] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Importance Chronic aortic regurgitation (AR) causes left ventricular (LV) volume overload, which results in progressive LV remodeling negatively affecting outcomes. Whether cardiac magnetic resonance (CMR) volumetric quantification can provide incremental risk stratification over standard clinical and echocardiographic evaluation in patients with chronic moderate or severe AR is unknown. Objective To compare LV remodeling measurements by CMR and echocardiography between patients with and without heart failure symptoms and to verify the association of remodeling measurements of patients with chronic moderate or severe AR but no or minimal symptoms with clinical outcomes receiving medical management. Design, Setting, and Participants This multicenter retrospective cohort study included consecutive patients with at least moderate chronic native AR evaluated by 2-dimensional transthoracic echocardiography and CMR examination within 90 days from each other between January 2012 and February 2020 at Allina Health System. Data were analyzed from June 2021 to January 2022. Exposures Clinical evaluation and risk stratification by CMR. Main Outcomes and Measures The end point was a composite of death, heart failure hospitalization, or progression of New York Heart Association functional class while receiving medical management, censoring patients at the time of aortic valve replacement (when performed) or at the end of follow-up. Results Of the 178 included patients, 119 (66.9%) were male, 158 (88.8%) presented with no or minimal symptoms (New York Heart Association class I or II), and the median (IQR) age was 58 (44-69) years. Compared with patients with no or minimal symptoms, symptomatic patients had greater LV end-systolic volume index (LVESVi) by CMR (median [IQR], 66 [46-85] mL/m2 vs 42 [30-58] mL/m2; P < .001), while there were no significant differences by echocardiography (LVESVi: median [IQR], 38 [30-58] mL/m2 vs 27 [20-42] mL/m2; P = .07; LV end-systolic diameter index: median [IQR], 21 [17-25] mm/m2 vs 18 [15-22] mm/m2; P = .17). During the median (IQR) follow-up of 3.3 (1.6-5.8) years, 50 patients with no or minimal symptoms receiving medical management developed the composite end point, which, in multivariate analysis adjusted for age and EuroSCORE II, was independently associated with LVESVi of 45 mL/m2 or greater and aortic regurgitant fraction of 32% or greater, the latter adding incremental prognostic value to CMR volumetric assessment. Conclusions and Relevance In patients with chronic moderate or severe AR, patients presenting with heart failure symptoms have greater LVESVi by CMR than those with no or minimal symptoms. In patients with no or minimal symptoms, CMR quantification of LVESVi and AR severity may identify those at risk of death or incident heart failure and therefore should be considered in the clinical evaluation and decision-making of these patients.
Collapse
Affiliation(s)
- Go Hashimoto
- Cardiovascular Imaging Research Center and Core Lab, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Maurice Enriquez-Sarano
- Valve Science Center, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota.,Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Larissa I Stanberry
- Cardiovascular Imaging Research Center and Core Lab, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Felix Oh
- Cardiovascular Imaging Research Center and Core Lab, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Matthew Wang
- Cardiovascular Imaging Research Center and Core Lab, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Keith Acosta
- Cardiovascular Imaging Research Center and Core Lab, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Hirotomo Sato
- Cardiovascular Imaging Research Center and Core Lab, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Bernardo B C Lopes
- Cardiovascular Imaging Research Center and Core Lab, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Miho Fukui
- Cardiovascular Imaging Research Center and Core Lab, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Santiago Garcia
- Valve Science Center, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota.,Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Mario Goessl
- Valve Science Center, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota.,Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Paul Sorajja
- Valve Science Center, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota.,Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Vinayak N Bapat
- Valve Science Center, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota.,Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - John Lesser
- Valve Science Center, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota.,Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - João L Cavalcante
- Cardiovascular Imaging Research Center and Core Lab, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota.,Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| |
Collapse
|
36
|
Bonow RO, O'Gara PT. Left Ventricular Volume and Outcomes in Patients With Chronic Aortic Regurgitation. JAMA Cardiol 2022; 7:885-886. [PMID: 35857309 DOI: 10.1001/jamacardio.2022.2152] [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: 11/14/2022]
Affiliation(s)
- Robert O Bonow
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois.,Editor, JAMA Cardiology
| | - Patrick T O'Gara
- Division of Cardiovascular Disease, Brigham and Women's Hospital, Boston, Massachusetts.,Deputy Editor, JAMA Cardiology
| |
Collapse
|
37
|
Vejpongsa P, Xu J, Quinones MA, Shah DJ, Zoghbi WA. Differences in Cardiac Remodeling in Left-Sided Valvular Regurgitation: Implications for Optimal Definition of Significant Aortic Regurgitation. JACC. CARDIOVASCULAR IMAGING 2022; 15:1730-1741. [PMID: 35842362 DOI: 10.1016/j.jcmg.2022.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 04/20/2022] [Accepted: 05/19/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND Grading of aortic regurgitation (AR) and mitral regurgitation (MR) is similar in the cardiology guidelines despite distinct differences in left ventricular (LV) adaptive pathophysiology. OBJECTIVES This study compared differences in LV remodeling in patients with similar degrees of AR and MR severity and evaluated optimal cutoffs for significant AR in relation to the outcome of aortic valve replacement or repair (AVR) during follow-up. METHODS From 2008 to 2018, consecutive patients with isolated AR or MR who had cardiovascular magnetic resonance (CMR) were identified and CMR parameters were compared. Patients with left ventricular ejection fraction (LVEF) <50%, ischemic scar >5%, valve stenosis, or concomitant regurgitation were excluded. Patients were followed longitudinally for AVR. RESULTS Baseline characteristics of isolated AR (n = 418) and isolated MR (n = 1,073) were comparable except for higher male proportion and hypertension in AR, while heart failure was more prevalent in MR. Indexed LV end-diastolic and end-systolic volumes and mass were higher in AR compared with MR at the same level of regurgitant fraction. During follow-up (mean 2.1 years), 18.7% of AR patients underwent AVR based on symptoms or LV remodeling. Interestingly, 38.0% of patients that underwent AVR within 3 months after CMR did not meet severe AVR by current guidelines of AR severity. AR regurgitant fraction>35% had high sensitivity (86%) and specificity (88%) for identifying patients who underwent AVR. CONCLUSIONS For similar regurgitation severity, LV remodeling is different in AR compared with MR. Cardiac symptoms and significant LV remodeling in AR requiring AVR occur frequently in patients with less severity than currently proposed. The study findings suggest that the optimal threshold for severe AR with CMR is different than MR and is lower than currently stated in the guidelines.
Collapse
Affiliation(s)
- Pimprapa Vejpongsa
- Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
| | - Jiaqiong Xu
- Center for Outcomes Research, Houston Methodist Research Institute, Houston, Texas, USA
| | - Miguel A Quinones
- Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
| | - Dipan J Shah
- Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
| | - William A Zoghbi
- Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA.
| |
Collapse
|
38
|
Staging cardiac damage in patients with aortic regurgitation. Int J Cardiovasc Imaging 2022; 38:2645-2653. [DOI: 10.1007/s10554-022-02673-1] [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: 04/15/2022] [Accepted: 06/07/2022] [Indexed: 11/26/2022]
|
39
|
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]
|
40
|
Sex-Related Factors in Valvular Heart Disease. J Am Coll Cardiol 2022; 79:1506-1518. [DOI: 10.1016/j.jacc.2021.08.081] [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: 05/26/2021] [Revised: 08/02/2021] [Accepted: 08/03/2021] [Indexed: 11/17/2022]
|
41
|
Yang LT, Takeuchi M, Scott CG, Thapa P, Wang TD, Villarraga HR, Padang R, Enriquez-Sarano M, Michelena HI. Automated Global Longitudinal Strain Exhibits a Robust Association with Death in Asymptomatic Chronic Aortic Regurgitation. J Am Soc Echocardiogr 2022; 35:692-702.e8. [PMID: 35341954 DOI: 10.1016/j.echo.2021.10.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 09/13/2021] [Accepted: 10/31/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Whether automated left ventricular global longitudinal strain (LVGLS) is associated with outcomes in asymptomatic aortic regurgitation (AR) is unknown. OBJECTIVE To explore the impact of automated LVGLS on survival and compare it with conventional LV parameters in chronic asymptomatic AR. METHODS LVGLS (presented as absolute value) was measured using fully-automated two-dimensional strain software in consecutive patients with isolated chronic ≥moderate-severe AR between 2004 and 2020; incremental value of LVGLS was assessed. Limited correction of endocardial border tracking was performed if needed. RESULTS Of 550 asymptomatic patients (age 60±17 years; 86% men), average LVGLS was 17±3% (1st and 2nd tertile, 15.8% and 18.5%). In 16% cases, tracking border was partially corrected; average time for analysis was 25±5 seconds. At a median (interquartile range) of 4.8(1.5-9.9) years, 87 patients had died (19 died after aortic-valve surgery [AVS]). Separate multivariable models adjusted for age, sex, Charlson index, AR severity and time-dependent AVS demonstrated that LVEF(hazard ratio[HR] per 10%: 0.9), LV end-systolic volume index(LVESVi; HR per 5ml/m2: 1.08) and LVGLS(HR per unit: 0.87) were independently associated with death(all p≤0.018); however, LVGLS remained statistically significant (HR: 0.86-0.9; P≤0.007) as compared head-to-head to LVEF, LVESVi and LV end-systolic dimension index(LVESDi). The association of LVGLS and mortality was consistent across all subgroups (P for interaction all≥0.08). Spline curves showed that continuous risk of death rose at LVGLS <15%. Those with LVGLS <15% had 2.6-fold risk of death [95% CI 1.54-4.23] while those with LVGLS <15% plus LVESVi≥45ml/m2 had 3.96-fold risk[95% CI 1.94-8.03]. CONCLUSION In this large cohort of asymptomatic patients with ≥moderate-severe AR, automated LVGLS was feasible, efficient, and independently associated with death on head-to-head comparison with conventional LVEF, LVESDi, and LVESVi. The automated-LVGLS threshold of <15% alone or combined with LVESVi≥45ml/m2, was significantly associated with increased mortality risk and may be considered in early surgery decision-making.
Collapse
Affiliation(s)
- Li-Tan Yang
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester Minnesota; Cardiovascular Center and Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.
| | - Masaaki Takeuchi
- Department of Laboratory and Transfusion Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Christopher G Scott
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester Minnesota
| | - Prabin Thapa
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester Minnesota
| | - Tzung-Dau Wang
- Cardiovascular Center and Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | | | - Ratnasari Padang
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester Minnesota
| | | | - Hector I Michelena
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester Minnesota.
| |
Collapse
|
42
|
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.
Collapse
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
| |
Collapse
|
43
|
Tower-Rader A, Mathias IS, Obuchowski NA, Kocyigit D, Kumar Y, Donnellan E, Bolen M, Phelan D, Flamm S, Griffin B, Cho L, Svensson LG, Pettersson G, Popovic Z, Kwon D. Sex-based differences in left ventricular remodeling in patients with chronic aortic regurgitation: a multi-modality study. J Cardiovasc Magn Reson 2022; 24:12. [PMID: 35193584 PMCID: PMC8862390 DOI: 10.1186/s12968-022-00845-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 01/16/2022] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Significant aortic regurgitation (AR) leads to left ventricular (LV) remodeling; however, little data exist regarding sex-based differences in LV remodeling in this setting. We sought to compare LV remodeling and AR severity, assessed by echocardiography and cardiovascular magnetic resonance (CMR), to discern sex-based differences. METHODS Patients with ≥ moderate chronic AR by echocardiography who underwent CMR within 90 days between December 2005 and October 2015 were included. Nonlinear regression models were built to assess the effect of AR regurgitant fraction (RF) on LV remodeling. A generalized linear model and Bland Altman analyses were constructed to evaluate differences between CMR and echocardiography. Referral for surgical intervention based on symptoms and LV remodeling was evaluated. RESULTS Of the 243 patients (48.3 ± 16.6 years, 58 (24%) female), 119 (49%) underwent surgical intervention with a primary indication of severe AR, 97 (82%) men, 22 (18%) women. Significant sex differences in LV remodeling emerged on CMR. Women demonstrated significantly smaller LV end-diastolic volume index (LVEDVI) (96.8 ml/m2 vs 125.6 ml/m2, p < 0.001), LV end-systolic volume index (LVESVI) (41.1 vs 54.5 ml/m2, p < 0.001), blunted LV dilation in the setting of increasing AR severity (LVEDVI p value < 0.001, LVESVI p value 0.011), and LV length indexed (8.32 vs 9.69 cm, p < 0.001). On Bland Altman analysis, a significant interaction with sex and LV diameters was evident, demonstrating a significant increase in the difference between CMR and echocardiography measurements as the LV enlarged in women: LVEDVI (p = 0.006), LVESVI (p < 0.001), such that echocardiographic measurements increasingly underestimated LV diameters in women as the LV enlarged. LV length was higher for males with a linear effect from RF (p < 0.001), with LV length increasing at a higher rate with increasing RF for males compared to females (two-way interaction with sex p = 0.005). Sphericity volume index was higher for men after adjusting for a relative wall thickness (p = 0.033). CONCLUSIONS CMR assessment of chronic AR revealed significant sex differences in LV remodeling and significant echocardiographic underestimation of LV dilation, particularly in women. Defining optimal sex-based CMR thresholds for surgical referral should be further developed. TRIAL REGISTRATION NA.
Collapse
Affiliation(s)
- Albree Tower-Rader
- Department of Cardiology, Harvard Medical School, Massachusetts General Hospital, 55 Fruit St, Yawkey 5B, Boston, MA, 02114, USA
| | - Isadora Sande Mathias
- Department of Cardiology, Houston Methodist Hospital, Weill Cornell Medical College, 6565 Fannin St., Houston, TX, 77030, USA
| | - Nancy A Obuchowski
- Quantitative Health Sciences, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
| | - Duygu Kocyigit
- Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
| | - Yash Kumar
- Case Western University, 10900 Euclid Ave, Cleveland, OH, 44106-7017, USA
| | - Eoin Donnellan
- Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
| | - Michael Bolen
- Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
| | - Dermot Phelan
- Sanger Heart & Vascular Institute, Atrium Health, 1237 Harding Place, MOB1 Suite 5000, Charlotte, NC, 28204, USA
| | - Scott Flamm
- Imaging Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
| | - Brian Griffin
- Imaging Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
| | - Leslie Cho
- Imaging Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
| | - Lars G Svensson
- Imaging Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
| | - Gosta Pettersson
- Imaging Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
| | - Zoran Popovic
- Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
- Imaging Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
| | - Deborah Kwon
- Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA.
| |
Collapse
|
44
|
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: 106] [Impact Index Per Article: 53.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
|
45
|
Baker JN, Klokocovnik T, Miceli A, Glauber M, Wei LM, Badhwar V, Gerdisch MW, Rankin JS, Fischlein TJM. Minimally invasive aortic valve repair using geometric ring annuloplasty. J Card Surg 2022; 37:70-75. [PMID: 34669217 DOI: 10.1111/jocs.16084] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 09/24/2021] [Accepted: 10/10/2021] [Indexed: 01/06/2023]
Abstract
OBJECTIVES As aortic valve repair (AVr) for aortic insufficiency (AI) expands, minimally invasive (Mi) approaches are increasingly being applied. Cardiac surgical techniques can be more difficult through small incisions, and this report analyzes medium-term outcomes for MiAVr facilitated by geometric ring annuloplasty. METHODS Since 2013, 58 patients were selected for AVr through upper sternotomy third-interspace incisions. The average age was 58.9 ± 15.4 (mean ± SD) years, 71% were male, and preoperative AI grade was 3.6 ± 0.8. Sixty-two percent (36/58) had a proximal aortic replacement for ascending aortic aneurysms (n = 26) and/or remodeling grafts for aortic root aneurysms (n = 10). Annuloplasty rings were placed subannularly (69% trileaflet; 31% bicuspid), and leaflet procedures were performed in 70%. The average ring diameter was 21.6 ± 1.4 mm, and the average aortic clamp time was 113 ± 35 min. RESULTS After repair, AI grade fell to an average of 0.5 ± 0.6 (p < .0001), with a mean valve gradient of 12.5 ± 7.1 mmHg. No operative mortalities or major complications occurred. Three patients required reoperations for bleeding, and two had pacemakers. At an average follow-up of 38 months (maximal 88 months), three late deaths and no valve-related complications were observed. Four patients required reoperative aortic valve replacement over follow-up, and Kaplan-Meier survival and freedom from reoperation both exceeded 80% at 88 months. At the last follow-up, the average AI grade was 0.7 ± 0.7, and the mean valve gradient was 12.7 ± 6.3 mmHg. CONCLUSIONS Geometric ring annuloplasty was safe and seemed to facilitate performing AVr ± proximal aortic replacement through Mi incisions. Hemodynamic improvements were significant, medium-term clinical outcomes were acceptable, and results could improve further with experience.
Collapse
Affiliation(s)
- Joshua N Baker
- Department of Cardiac Surgery, Heart Center at Missouri Baptist Medical Center, St. Louis, Missouri, USA
| | | | - Antonio Miceli
- Department of Cardiac Surgery, Istituto Clinico Sant'Ambrogio, Milano, Italy
| | - Mattia Glauber
- Department of Cardiac Surgery, Istituto Clinico Sant'Ambrogio, Milano, Italy
| | - Lawrence M Wei
- Department of Cardiovascular and Thoracic Surgery, West Virginia University Heart and Vascular Institute, Morgantown, West Virginia, USA
| | - Vinay Badhwar
- Department of Cardiovascular and Thoracic Surgery, West Virginia University Heart and Vascular Institute, Morgantown, West Virginia, USA
| | - Marc W Gerdisch
- Department of Cardiac Surgery, Franciscan St. Francis Heart Center, Indianapolis, Indiana, USA
| | - James Scott Rankin
- Department of Cardiovascular and Thoracic Surgery, West Virginia University Heart and Vascular Institute, Morgantown, West Virginia, USA
| | - Theodor J M Fischlein
- Department of Cardiac Surgery, Klinikum Nürnberg Cardiovascular Center, Paracelsus Medical University, Nuremberg, Germany
| |
Collapse
|
46
|
Non-invasive left ventricular myocardial work in patients with chronic aortic regurgitation and preserved left ventricular ejection fraction. J Am Soc Echocardiogr 2022; 35:703-711.e3. [DOI: 10.1016/j.echo.2022.01.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 01/08/2022] [Accepted: 01/12/2022] [Indexed: 11/17/2022]
|
47
|
Latifi AN, Ortiz J, Cunningham JW, McGregor PC, Aragam J. Early Identification of Decompensated Aortic Regurgitation With Stress Echocardiography. CASE (PHILADELPHIA, PA.) 2021; 5:403-407. [PMID: 34993372 PMCID: PMC8712953 DOI: 10.1016/j.case.2021.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
•Chronic severe AR progresses slowly with a long asymptomatic compensated phase.•Stress echocardiography (SE) has the ability to uncover subclinical LV dysfunction.•SE can identify patients with severe AR who may benefit from earlier intervention.
Collapse
Affiliation(s)
- Ahmad N. Latifi
- Cardiovascular Division, Boston Medical Center, Boston, Massachusetts
- Department of Cardiology, Boston Veterans Affairs Healthcare System, West Roxbury, Massachusetts
| | - Jake Ortiz
- Department of Cardiology, Boston Veterans Affairs Healthcare System, West Roxbury, Massachusetts
| | - Jonathan W. Cunningham
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Pei-Chun McGregor
- Department of Cardiology, Boston Veterans Affairs Healthcare System, West Roxbury, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Jayashri Aragam
- Department of Cardiology, Boston Veterans Affairs Healthcare System, West Roxbury, Massachusetts
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
48
|
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: 304] [Impact Index Per Article: 101.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
|
49
|
[ESC/EACTS guidelines 2021 on the management of valvular heart diseases : What are the most important innovations?]. Herz 2021; 47:19-30. [PMID: 34609559 DOI: 10.1007/s00059-021-05068-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/09/2021] [Indexed: 10/20/2022]
Abstract
In August 2021 the European Society for Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) updated their guidelines on the management of valvular heart disease. Since the publication of the previous version in 2017 new evidence regarding epidemiology, diagnosis and treatment of valvular heart diseases has been accumulating, which led to reassessment of several recommendations. Most importantly, the critical role of the heart team in treatment decision-making was reemphasized, the criteria for choosing the mode of aortic valve interventions were clarified, the definition of severe secondary mitral regurgitation was revised and the recommendation for transcatheter edge-to-edge mitral valve repair in patients with this condition was upgraded. Additionally, antithrombotic therapeutic regimens in patients with native valvular heart diseases and bioprostheses were reappraised, the indications for early surgery in selected asymptomatic patient groups were expanded and the potential of transcatheter tricuspid valve interventions in inoperable and high-risk patients was acknowledged, although the latter needs to be further evaluated. This review article summarizes the most important recommendations of the new guidelines.
Collapse
|
50
|
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: 2144] [Impact Index Per Article: 714.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
|