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Ilonze OJ, Ebong IA, Guglin M, Nair A, Rich J, McLaughlin V, Tedford RJ, Mazimba S. Considerations in the Diagnosis and Management of Pulmonary Hypertension Associated With Left Heart Disease. JACC. HEART FAILURE 2024:S2213-1779(24)00436-0. [PMID: 38970588 DOI: 10.1016/j.jchf.2024.04.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 03/04/2024] [Accepted: 04/08/2024] [Indexed: 07/08/2024]
Abstract
Pulmonary hypertension associated with left heart disease (PH-LHD) remains the most common cause of pulmonary hypertension globally. Etiologies include heart failure with reduced and preserved ejection fraction and left-sided valvular heart diseases. Despite the increasing prevalence of PH-LHD, there remains a paucity of knowledge about the hemodynamic definition, diagnosis, treatment modalities, and prognosis among clinicians. Moreover, clinical trials have produced mixed results on the usefulness of pulmonary vasodilator therapies for PH-LHD. In this expert review, we have outlined the critical role of meticulous hemodynamic evaluation and provocative testing for cases of diagnostic uncertainty. Therapeutic strategies-pharmacologic, device-based, and surgical therapies used for managing PH-LHD-are also outlined. PH-LHD in advanced heart failure, and the role of mechanical circulatory support in PH-LHD is briefly explored. An in-depth understanding of PH-LHD by all clinicians is needed for improved recognition and outcomes among patients with PH-LHD.
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Affiliation(s)
- Onyedika J Ilonze
- Division of Cardiovascular Medicine, Krannert Cardiovascular Research Center, Indiana University, Indianapolis, Indiana, USA.
| | - Imo A Ebong
- Division of Cardiology, University of California Davis, Sacramento, California, USA
| | - Maya Guglin
- Division of Cardiovascular Medicine, Krannert Cardiovascular Research Center, Indiana University, Indianapolis, Indiana, USA
| | - Ajith Nair
- Winters Center for Heart Failure Research, Michael E. DeBakey VA Medical Center, Texas Heart Institute, Baylor College of Medicine, Houston, Texas, USA
| | - Jonathan Rich
- Division of Cardiology, Bluhm Cardiovascular Institute Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Vallerie McLaughlin
- University of Michigan Hospital and Health Systems, Ann Arbor, Michigan, USA
| | - Ryan J Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Sula Mazimba
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, Virginia, USA; AdventHealth, Orlando, Florida, USA
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Nies RJ, Nettersheim FS, Braumann S, Ney S, Ochs L, Dohr J, Nies JF, Wienemann H, Adam M, Mauri V, Baldus S, Rosenkranz S. Right ventricular dysfunction and impaired right ventricular-pulmonary arterial coupling in paradoxical low-flow, low-gradient aortic stenosis. Eur J Heart Fail 2024. [PMID: 38887164 DOI: 10.1002/ejhf.3329] [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: 10/23/2023] [Revised: 05/03/2024] [Accepted: 05/27/2024] [Indexed: 06/20/2024] Open
Abstract
AIMS Paradoxical low-flow, low-gradient aortic stenosis (pLFLG AS) may represent a diagnostic challenge, and its pathophysiology is complex. While left ventricular (LV) systolic function is preserved, right ventricular dysfunction (RVD) and consecutive LV underfilling may contribute to low-flow and reduced stroke volume index, and to adverse outcomes following transcatheter aortic valve implantation (TAVI). The aim of this study was to evaluate the potential role of RVD in pLFLG AS, and to assess the impact of pre-procedural RVD on clinical outcomes after TAVI in patients with pLFLG AS. METHODS AND RESULTS Out of 2739 native AS patients, who received TAVI at the University of Cologne Heart Center between March 2013 and June 2021, 114 patients displayed pLFLG AS and were included in this study. Right ventricular (RV) function was assessed by transthoracic echocardiography, and a fractional area change (FAC) ≤35% and/or a tricuspid annular plane systolic excursion (TAPSE) <18 mm determined RVD. In addition, the TAPSE/systolic pulmonary artery pressure ratio (TAPSE/sPAP) was monitored as a measure of RV-pulmonary arterial (PA) coupling. An impaired FAC and TAPSE was present in 21.9% and 45.6% of patients, respectively, identifying RVD in 50.0%. RVD (p = 0.016), reduced FAC (p = 0.049), reduced TAPSE (p = 0.035) and impaired RV-PA coupling (TAPSE/sPAP ratio <0.31 mm/mmHg; p = 0.009) were associated with significantly higher all-cause mortality compared to patients with normal RV function. After adjustment for sex, age, body mass index, EuroSCORE II, previous myocardial infarction and mitral regurgitation, independent predictors for all-cause mortality were FAC, sPAP, TAPSE/sPAP ratio, right atrial area, RV diameter and tricuspid regurgitation. CONCLUSIONS Adverse RV remodelling, RVD and impaired RV-PA coupling provide an explanation for low-flow and reduced stroke volume index in a subset of patients with pLFLG AS, and are associated with excess mortality after TAVI.
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Affiliation(s)
- Richard J Nies
- Department of Cardiology, Heart Center, University of Cologne, Cologne, Germany
| | - Felix S Nettersheim
- Department of Cardiology, Heart Center, University of Cologne, Cologne, Germany
| | - Simon Braumann
- Department of Cardiology, Heart Center, University of Cologne, Cologne, Germany
| | - Svenja Ney
- Department of Cardiology, Heart Center, University of Cologne, Cologne, Germany
| | - Laurin Ochs
- Department of Cardiology, Heart Center, University of Cologne, Cologne, Germany
| | - Johannes Dohr
- Department of Cardiology, Heart Center, University of Cologne, Cologne, Germany
| | - Jasper F Nies
- Department of Nephrology, University of Cologne, Cologne, Germany
| | - Hendrik Wienemann
- Department of Cardiology, Heart Center, University of Cologne, Cologne, Germany
| | - Matti Adam
- Department of Cardiology, Heart Center, University of Cologne, Cologne, Germany
| | - Victor Mauri
- Department of Cardiology, Heart Center, University of Cologne, Cologne, Germany
| | - Stephan Baldus
- Department of Cardiology, Heart Center, University of Cologne, Cologne, Germany
- Cologne Cardiovascular Research Center (CCRC), Heart Center, Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Stephan Rosenkranz
- Department of Cardiology, Heart Center, University of Cologne, Cologne, Germany
- Cologne Cardiovascular Research Center (CCRC), Heart Center, Faculty of Medicine, University of Cologne, Cologne, Germany
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3
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Lachmann M, Hesse A, Trenkwalder T, Xhepa E, Rheude T, von Scheidt M, Covarrubias HAA, Rippen E, Hramiak O, Pellegrini C, Schuster T, Yuasa S, Schunkert H, Kastrati A, Kupatt C, Laugwitz KL, Joner M. Invasive Assessment of Right Ventricular to Pulmonary Artery Coupling Improves 1-year Mortality Prediction After Transcatheter Aortic Valve Replacement and Anticipates the Persistence of Extra-Aortic Valve Cardiac Damage. STRUCTURAL HEART : THE JOURNAL OF THE HEART TEAM 2024; 8:100282. [PMID: 38799808 PMCID: PMC11121747 DOI: 10.1016/j.shj.2024.100282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 12/04/2023] [Accepted: 01/03/2024] [Indexed: 05/29/2024]
Abstract
Background The interplay between the right ventricle and the pulmonary artery, known as right ventricular to pulmonary artery (RV-PA) coupling, is crucial for assessing right ventricular systolic function against the afterload from the pulmonary circulation. Pulmonary artery pressure levels are ideally measured by right heart catheterization. Yet, echocardiography represents the most utilized method for evaluating pulmonary artery pressure levels, albeit with limitations in accuracy. This study therefore aims to evaluate the prognostic significance of right ventricular to pulmonary artery (RV-PA) coupling expressed as tricuspid annular plane systolic excursion (TAPSE) related to systolic pulmonary artery pressure (sPAP) levels measured by right heart catheterization (TAPSE/sPAPinvasive) or estimated by transthoracic echocardiography (TAPSE/sPAPechocardiography) in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement (TAVR). Methods Using data from a bicentric registry, this study compares TAPSE/sPAPinvasive vs. TAPSE/sPAPechocardiography in predicting 1-year all-cause mortality after TAVR. Results Among 333 patients with complete echocardiography and right heart catheterization data obtained before TAVR, their mean age was 79.8 ± 6.74 years, 39.6% were female, and general 1-year survival was 89.8%. sPAPinvasive and sPAPechocardiography showed only moderate correlation (Pearson correlation coefficient R: 0.53, p value: <0.0001). TAPSE/sPAPinvasive was superior to TAPSE/sPAPechocardiography in predicting 1-year all-cause mortality after TAVR (area under the curve: 0.662 vs. 0.569, p value: 0.025). Patients with reduced TAPSE/sPAPinvasive levels (< 0.365 mm/mmHg) evidenced significantly lower 1-year survival rates than patients with preserved TAPSE/sPAPinvasive levels (81.8 vs. 93.6%, p value: 0.001; hazard ratio for 1-year mortality: 3.09 [95% confidence interval: 1.55-6.17]). Echocardiographic follow-up data revealed that patients with reduced RV-PA coupling suffer from persistent right ventricular dysfunction (TAPSE: 16.6 ± 4.05 mm vs. 21.6 ± 4.81 mm in patients with preserved RV-PA coupling) and severe tricuspid regurgitation (diagnosed in 19.7 vs. 6.58% in patients with preserved RV-PA coupling). Conclusions RV-PA coupling expressed as TAPSE/sPAPinvasive can refine stratification of severe aortic stenosis patients into low-risk and high-risk cohorts for mortality after TAVR. Moreover, it can help to anticipate persistent extra-aortic valve cardiac damage, which will demand further treatment.
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Affiliation(s)
- Mark Lachmann
- First Department of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Amelie Hesse
- First Department of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Teresa Trenkwalder
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
- Department of Cardiology, Deutsches Herzzentrum München, Technical University of Munich, Munich, Germany
| | - Erion Xhepa
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
- Department of Cardiology, Deutsches Herzzentrum München, Technical University of Munich, Munich, Germany
| | - Tobias Rheude
- Department of Cardiology, Deutsches Herzzentrum München, Technical University of Munich, Munich, Germany
| | - Moritz von Scheidt
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
- Department of Cardiology, Deutsches Herzzentrum München, Technical University of Munich, Munich, Germany
| | | | - Elena Rippen
- First Department of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Oksana Hramiak
- First Department of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- Specialized Department of Cardiology, Ternopil City Communal Hospital №2, Ternopil National Medical University, Ternopil, Ukraine
| | - Costanza Pellegrini
- Department of Cardiology, Deutsches Herzzentrum München, Technical University of Munich, Munich, Germany
| | - Tibor Schuster
- Department of Family Medicine, McGill University, Montreal, Canada
| | - Shinsuke Yuasa
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Heribert Schunkert
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
- Department of Cardiology, Deutsches Herzzentrum München, Technical University of Munich, Munich, Germany
| | - Adnan Kastrati
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
- Department of Cardiology, Deutsches Herzzentrum München, Technical University of Munich, Munich, Germany
| | - Christian Kupatt
- First Department of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Karl-Ludwig Laugwitz
- First Department of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Michael Joner
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
- Department of Cardiology, Deutsches Herzzentrum München, Technical University of Munich, Munich, Germany
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Khalil S, Tabowei G, Kaur M, Dadzie SK, Kansakar S, Moqattash M, Komminni PK, Palleti SK. Effect of Pulmonary Hypertension on Survival Outcomes in Patients With Transcatheter Aortic Valve Replacement: A Systematic Review and Meta-Analysis. Cureus 2024; 16:e58540. [PMID: 38957831 PMCID: PMC11218420 DOI: 10.7759/cureus.58540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/18/2024] [Indexed: 07/04/2024] Open
Abstract
The aim of this meta-analysis was to determine the effect of pulmonary hypertension (PH) on survival in patients undergoing transcatheter aortic valve replacement (TAVR). The present study was conducted according to the guidelines of Preferred Reporting of Systematic Review and Meta-Analysis (PRISMA). We conducted a comprehensive search of electronic databases including PubMed/MEDLINE, Embase, Cochrane Library, and Web of Science from January 1, 2015, to March 10, 2024. Outcomes assessed in this meta-analysis included early and late all-cause mortality and cardiovascular mortality. Total 15 studies were integrated into the pooled analysis to assess the impact of PH on outcomes among patients undergoing TAVR, comprising a total sample size of 35,732 individuals. The pooled prevalence of PH stood at 52.57% (n=18,767). Predominantly, the studies were conducted in the United States (n=6), followed by Germany (n=3), with one study each from Japan, Italy, Switzerland, Brazil, Poland, and Australia. Pooled analysis showed that risk of short-term mortality was greater in patients with PH compared to patients without PH (risk ratio (RR): 1.46, 95% CI: 1.19 to 1.80). Risk of long-term mortality was greater in patients with PH (RR: 1.42, 95% CI: 1.29 to 1.55). Risk of cardiovascular mortality was also greater in patients with PH compared to patients without PH (RR: 1.66, 95% CI: 1.36 to 2.02). We advocate for further research to address gaps in understanding different types of PH and their impacts on mortality and cardiovascular outcomes.
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Affiliation(s)
| | - Godfrey Tabowei
- Internal Medicine, Texas Tech University Health Sciences Center, Odessa, USA
| | - Mandeep Kaur
- Internal Medicine, HCA Capital Hospital, Tallahassee, USA
| | - Samuel K Dadzie
- Internal Medicine, Piedmont Athens Regional Medical Center, Athens, USA
| | - Sajog Kansakar
- Internal Medicine, Maimonides Medical Center, Brooklyn, USA
| | | | | | - Sujith K Palleti
- Nephrology, Louisiana State University Health Sciences Center, Shreveport, USA
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Emami Meybodi M, Bamarinejad A, Bamarinejad F, Abhari AP, Fakhrolmobasheri M, Khosravi Larijani F, Nasiri S, Shafie D. Prognostic Implication of Preprocedural Pulmonary Hypertension in Patients with Severe Aortic Valve Stenosis Undergoing Transcatheter Aortic Valve Implantation: A Systematic Review and Meta-analysis. Cardiol Rev 2024:00045415-990000000-00200. [PMID: 38285645 DOI: 10.1097/crd.0000000000000583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2024]
Abstract
Pulmonary hypertension (PH) is a common comorbidity in patients with aortic stenosis (AS) who are candidates for transcatheter aortic valve implantation (TAVI). Herein, we sought to elucidate the prognostic value of preprocedural PH on the early and late mortality after TAVI. The Cochrane Library, Scopus, PubMed, Web of Science, Embase, and ProQuest were screened using a predefined search query. We considered odds ratios (ORs) as the measure of effect. Meta-regression analysis was applied to investigate the potential impact of baseline characteristics on the outcomes. Egger's and Begg's tests were used to assess the publication bias. Thirty-three studies comprising 34 datasets representing 68,435 patients were included in the analysis. Regardless of the definition and severity of PH, pooled data analysis indicated that preprocedural PH was associated with higher cardiac and overall 30-day [OR, 1.45 (1.15-1.82) and OR, 1.75 (1.42-2.17), respectively], and 1-year mortality [OR, 1.63 (1.35-1.96) and OR, 1.59 (1.38-1.82), respectively]. Meta-regression analysis demonstrated that older age, higher New York Heart Association function class, history of hypertension, diabetes, and lower left ventricular ejection fraction were predictors of higher mortality rate following TAVI. Moreover, we found that preprocedural PH is significantly associated with higher in-hospital mortality and 30-day acute kidney injury. Our results demonstrated that preprocedural PH is associated with higher early and late cardiac and overall mortality following TAVI; however, this finding is limited regarding the considerable inconsistency in the definition of PH and PH severity among studies.
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Affiliation(s)
- Mahmood Emami Meybodi
- From the Department of Cardiology, Afshar Hospital, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Atefe Bamarinejad
- Heart Failure Research Center, Isfahan Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Fateme Bamarinejad
- Heart Failure Research Center, Isfahan Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Amir Parsa Abhari
- Heart Failure Research Center, Isfahan Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohammad Fakhrolmobasheri
- Heart Failure Research Center, Isfahan Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | | | - Shidrokh Nasiri
- Heart Failure Research Center, Isfahan Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Davood Shafie
- Heart Failure Research Center, Isfahan Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
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Cardaioli F, Nai Fovino L, Fabris T, Masiero G, Arturi F, Trevisanello A, Zuccarelli V, Napodano M, Fraccaro C, Continisio S, Tarantini G. Updated definition of pulmonary hypertension and outcome after transcatheter aortic valve implantation. Heart 2023; 110:27-34. [PMID: 37414524 DOI: 10.1136/heartjnl-2023-322881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 06/22/2023] [Indexed: 07/08/2023] Open
Abstract
OBJECTIVE The European Society of Cardiology guidelines have recently defined new cut-offs for pulmonary hypertension (PH) and pulmonary vasculature resistance (PVR; median pulmonary artery pressure (mPAP) >20 instead of 25 mm Hg and PVR >2 instead of 3 Wood unit). The prognostic value of this updated classification after transcatheter aortic valve implantation (TAVI) is unknown. METHODS 579 consecutive patients treated by TAVI with preprocedural right heart catheterisation evaluation were included. Patients were grouped as: (1) no PH, (2) isolated precapillary/combined (I-PreC/Co) PH and (3) isolated postcapillary PH (I-PoC). All-cause death, cardiovascular death and hospitalisations for heart failure (HF) were evaluated at follow-up. We also analysed the prognostic role of residual postprocedural PH. RESULTS Out of 579 patients, 299 (52%) had PH according to the new criteria compared with 185 (32%) according to the previous ones. Overall median age was 82 years, while 55.3% patients were male. Patients with PH were more frequently diagnosed with chronic obstructive pulmonary disease and atrial fibrillation and were characterised by higher surgical risk as compared with patients without PH.At a median follow-up of 2.9 years, the presence of PH according to previous definition was associated with worse survival (p<0.001) and HF hospitalisation (p=0.002) rates, irrespective of PVR values. With newer cut-offs, PH was associated with worse outcomes only in patients with increased PVR, while no differences were found between patients with PH and normal PVR values and those without PH. Postprocedural mPAP normalisation was observed in 45% of the cases, but it was associated with improved long-term survival only in the I-PoC PH group. CONCLUSIONS New ESC PH cut-offs increased the number of PH diagnoses. The presence of PH, particularly in the setting of increased PVR, identify patients at higher risk for postprocedural mortality and rehospitalisation. Normalisation of PH was associated with better survival only in I-PoC group.
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Affiliation(s)
- Francesco Cardaioli
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Università degli Studi di Padova, Padova, Italy
| | - Luca Nai Fovino
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Università degli Studi di Padova, Padova, Italy
| | - Tommaso Fabris
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Università degli Studi di Padova, Padova, Italy
| | - Giulia Masiero
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Università degli Studi di Padova, Padova, Italy
| | - Federico Arturi
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Università degli Studi di Padova, Padova, Italy
| | - Aurora Trevisanello
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Università degli Studi di Padova, Padova, Italy
| | - Vittorio Zuccarelli
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Università degli Studi di Padova, Padova, Italy
| | - Massimo Napodano
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Università degli Studi di Padova, Padova, Italy
| | - Chiara Fraccaro
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Università degli Studi di Padova, Padova, Italy
| | - Saverio Continisio
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Università degli Studi di Padova, Padova, Italy
| | - Giuseppe Tarantini
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Università degli Studi di Padova, Padova, Italy
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7
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Turner V, Maret E, Kim JB, Codari M, Hinostroza V, Mastrodicasa D, Watkins AC, Fearon WF, Fischbein MP, Haddad F, Willemink MJ, Fleischmann D. Reduced Pulmonary Artery Distensibility Predicts Persistent Pulmonary Hypertension and 2-Year Mortality in Patients with Severe Aortic Stenosis Undergoing TAVR. Acad Radiol 2023; 30:2825-2833. [PMID: 37147161 DOI: 10.1016/j.acra.2023.03.014] [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: 01/04/2023] [Revised: 03/10/2023] [Accepted: 03/13/2023] [Indexed: 05/07/2023]
Abstract
RATIONALE AND OBJECTIVES Post-TAVR persistent pulmonary hypertension (PH) is a better predictor of poor outcome than pre-TAVR PH. In this longitudinal study we sought to evaluate whether pulmonary artery (distensibility (DPA) measured on preprocedural ECG-gated CTA is associated with persistent-PH and 2-year mortality after TAVR. MATERIALS AND METHODS Three hundred and thirty-six patients undergoing TAVR between July 2012 and March 2016 were retrospectively included and followed for all-cause mortality until November 2017. All patients underwent retrospectively ECG-gated CTA prior to TAVR. Main pulmonary artery (MPA) area was measured in systole and in diastole. DPA was calculated as: [(area-MPAmax-area-MPAmin)/area-MPAmax]%. ROC analysis was performed to assess the AUC for persistent-PH. Youden Index was used to determine the optimal threshold of DPA for persistent-PH. Two groups were compared based on a DPA threshold of 8% (specificity of 70% for persistent-PH). Kaplan-Meier, Cox proportional-hazard, and logistic regression analyses were performed. The primary clinical endpoint was defined as persistent-PH post-TAVR. The secondary endpoint was defined as all-cause mortality 2 years after TAVR. RESULTS Median follow-up time was 413 (interquartiles 339-757) days. A total of 183 (54%) had persistent-PH and 68 (20%) patients died within 2-years after TAVR. Patients with DPA<8% had significantly more persistent-PH (67% vs 47%, p<0.001) and 2-year deaths (28% vs 15%, p=0.006), compared to patients with DPA>8%. Adjusted multivariable regression analyses showed that DPA<8% was independently associated with persistent-PH (OR 2.10 [95%-CI 1.3-4.5], p=0.007) and 2-year mortality (HR 2.91 [95%-CI 1.5-5.8], p=0.002). Kaplan-Meier analysis showed that 2-year mortality of patients with DPA<8% was significantly higher compared to patients with DPA≥8% (mortality 28% vs 15%; log-rank p=0.003). CONCLUSION DPA on preprocedural CTA is independently associated with persistent-PH and two-year mortality in patients who undergo TAVR.
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Affiliation(s)
- Valery Turner
- Department of Radiology, Stanford University School of Medicine, MC:5659, 453 Quarry Road, Stanford, CA, 94304.
| | - Eva Maret
- Department of Radiology, Stanford University School of Medicine, MC:5659, 453 Quarry Road, Stanford, CA, 94304; Department of Clinical Physiology, Karolinska University Hospital, and Karolinska Institutet, Stockholm, Sweden
| | - Juyong B Kim
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California; Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
| | - Marina Codari
- Department of Radiology, Stanford University School of Medicine, MC:5659, 453 Quarry Road, Stanford, CA, 94304
| | - Virginia Hinostroza
- Department of Radiology, Stanford University School of Medicine, MC:5659, 453 Quarry Road, Stanford, CA, 94304
| | - Domenico Mastrodicasa
- Department of Radiology, Stanford University School of Medicine, MC:5659, 453 Quarry Road, Stanford, CA, 94304; Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
| | - A Claire Watkins
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - William F Fearon
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California; Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Michael P Fischbein
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California; Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Francois Haddad
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California; Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
| | - Martin J Willemink
- Department of Radiology, Stanford University School of Medicine, MC:5659, 453 Quarry Road, Stanford, CA, 94304
| | - Dominik Fleischmann
- Department of Radiology, Stanford University School of Medicine, MC:5659, 453 Quarry Road, Stanford, CA, 94304; Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California
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8
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Alwan L, Tomii D, Heg D, Okuno T, Lanz J, Praz F, Chong-Nguyen C, Stortecky S, Reineke D, Windecker S, Pilgrim T. Impact of right ventricular-pulmonary arterial coupling on clinical outcomes in patients undergoing transcatheter aortic valve implantation. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 56:27-34. [PMID: 37210220 DOI: 10.1016/j.carrev.2023.05.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 05/02/2023] [Accepted: 05/11/2023] [Indexed: 05/22/2023]
Abstract
AIMS The interplay between pulmonary hypertension (PH) and right ventricular (RV) function is reflected in an index of RV function to pulmonary artery (PA) systolic pressure (PASP). The present study aimed to assess the importance of RV-PA coupling on clinical outcomes after transcatheter aortic valve implantation (TAVI). METHODS AND RESULTS In a prospective TAVI registry, clinical outcomes of TAVI patients with RV dysfunction or PH were stratified according to coupling or uncoupling of tricuspid annular plane systolic excursion (TAPSE) to PASP, and compared to those of patients with normal RV function and absence of PH. The median TAPSE/PASP ratio was used to differentiate uncoupling (>0.39) from coupling (<0.39). Among 404 TAVI patients, 201 patients (49.8 %) had RVD or PH at baseline: 174 patients had RV-PA uncoupling, and 27 had coupling at baseline. RV-PA hemodynamics normalized in 55.6 % of patients with RV-PA coupling and in 28.2 % of patients with RV-PA uncoupling, and deteriorated in 33.3 % of patients with RV-PA coupling and in 17.8 % of patients with no RVD, respectively, at discharge. Patients with RV-PA uncoupling after TAVI showed a trend towards an increased risk of cardiovascular death at 1 year as compared to patients with normal RV-function (HRadjusted 2.06, 95 % CI 0.97-4.37). CONCLUSION After TAVI, RV-PA coupling changed in a significant proportion of patients and is a potentially important metric for risk stratification of TAVI patients with RVD or PH. TWEET: "Patients with right ventricular dysfunction and pulmonary hypertension are at increased risk of death after TAVI. Integrated right ventricular to pulmonary artery hemodynamics change after TAVI in a significant proportion of patients and is instrumental to refine risk stratification." CLINICAL TRIAL REGISTRATION https://www. CLINICALTRIALS gov: NCT01368250.
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Affiliation(s)
- Louhai Alwan
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Daijiro Tomii
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland. https://twitter.com/DaijiroTomii
| | - Dik Heg
- CTU Bern, University of Bern, Bern, Switzerland
| | - Taishi Okuno
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Jonas Lanz
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Fabien Praz
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | | | - Stefan Stortecky
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - David Reineke
- Department of Cardiovascular Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Stephan Windecker
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Thomas Pilgrim
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland.
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9
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Viva T, Postolache A, Nguyen Trung ML, Danthine P, Petitjean H, Bruno VD, Martinez C, Lempereur M, Guazzi M, Aghezzaf S, Coisne A, Oury C, Dulgheru R, Lancellotti P. A new integrative approach combining right heart catheterization and echocardiography to stage aortic stenosis-related cardiac damage. Front Cardiovasc Med 2023; 10:1184308. [PMID: 37600042 PMCID: PMC10436206 DOI: 10.3389/fcvm.2023.1184308] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 07/13/2023] [Indexed: 08/22/2023] Open
Abstract
Introduction Although staging of the extent of aortic stenosis (AS)-related cardiac damages is usually performed via echocardiography, this technique has considerable limitations in assessing pulmonary artery and right chamber pressures. The present hypothesis-generating study sought to explore the efficacy of a staging system of cardiac damage based on echocardiographic and invasive [right heart catheterization (RHC)] hemodynamic parameters in patients undergoing transcatheter aortic valve implantation (TAVI). Methods We studied 90 symptomatic patients with severe AS in whom echocardiographic and invasive evaluation by RHC was obtained prior to TAVI. Cardiac damage stages were defined as follows: no cardiac damage (stage 0), left ventricular (LV) damage (stage 1), left atrial or mitral valve damage (stage 2), pulmonary vasculature or tricuspid valve damage (stage 3), and right ventricular (RV) dysfunction or low-flow state (stage 4). With the integrative approach using RHC, pulmonary hypertension (PH) was defined as an mPAP ≥25 mmHg and the low-flow state corresponded to a cardiac index of <1.8 L/min/m2 and a right atrial pressure of >10 mmHg. Results During follow-up (median: 2.9 years), 43 patients (47.8%) died. The integrative cardiac damage staging was associated with a significant increase in all-cause and cardiovascular mortality per each increase of cardiac damage stage, whereas the outcome was similar according to the echocardiographic staging. Conclusions A staging system of cardiac lesion based on echocardiographic and invasive hemodynamic parameters in patients with severe AS undergoing TAVI predicts mortality. Patients with pre-existing PH, ≥ moderate tricuspid regurgitation and/or RV dysfunction, and a low-flow state had a markedly increased risk of death. Further larger studies are needed to validate our findings.
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Affiliation(s)
- Tommaso Viva
- GIGA Cardiovascular Sciences, CHU Sart Tilman, Cardiology Department, University of Liège Hospital, Liège, Belgium
- Department of Biomedical Sciences for Health, University of Milano, Milan, Italy
- Department of Minimally Invasive Cardiac Surgery, IRCCS Galeazzi—Sant’Ambrogio Hospital, Milan, Italy
| | - Adriana Postolache
- GIGA Cardiovascular Sciences, CHU Sart Tilman, Cardiology Department, University of Liège Hospital, Liège, Belgium
| | - Mai-Linh Nguyen Trung
- GIGA Cardiovascular Sciences, CHU Sart Tilman, Cardiology Department, University of Liège Hospital, Liège, Belgium
| | - Pauline Danthine
- GIGA Cardiovascular Sciences, CHU Sart Tilman, Cardiology Department, University of Liège Hospital, Liège, Belgium
| | - Hélène Petitjean
- GIGA Cardiovascular Sciences, CHU Sart Tilman, Cardiology Department, University of Liège Hospital, Liège, Belgium
| | - Vito Domenico Bruno
- Department of Minimally Invasive Cardiac Surgery, IRCCS Galeazzi—Sant’Ambrogio Hospital, Milan, Italy
| | - Christophe Martinez
- GIGA Cardiovascular Sciences, CHU Sart Tilman, Cardiology Department, University of Liège Hospital, Liège, Belgium
| | - Mathieu Lempereur
- GIGA Cardiovascular Sciences, CHU Sart Tilman, Cardiology Department, University of Liège Hospital, Liège, Belgium
| | - Marco Guazzi
- School of Medicine, Department of Biological Sciences, University of Milano, Milan, Italy
- CardiologyDivision, San Paolo Hospital, Milan, Italy
| | - Samy Aghezzaf
- CHU Lille, Institut Pasteur de Lille, University Lille, Inserm, Lille, France
| | - Augustin Coisne
- CHU Lille, Institut Pasteur de Lille, University Lille, Inserm, Lille, France
- Cardiovascular Research Foundation, New York, NY, United States
| | - Cécile Oury
- GIGA Cardiovascular Sciences, CHU Sart Tilman, Cardiology Department, University of Liège Hospital, Liège, Belgium
| | - Raluca Dulgheru
- GIGA Cardiovascular Sciences, CHU Sart Tilman, Cardiology Department, University of Liège Hospital, Liège, Belgium
| | - Patrizio Lancellotti
- GIGA Cardiovascular Sciences, CHU Sart Tilman, Cardiology Department, University of Liège Hospital, Liège, Belgium
- Gruppo Villa Maria Care and Research, Maria Cecilia Hospital, Cotignola, and Anthea Hospital, Bari, Italy
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10
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Liu TX, Tanenbaum MT, Seo CH, Park D, Lystash JC, Joseph M, Arnold WS. Left Ventricular Diastolic Dysfunction and Pulmonary Hypertension: Outcomes in SAVR. Thorac Cardiovasc Surg 2023; 71:398-406. [PMID: 33862634 DOI: 10.1055/s-0041-1727138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Severe pulmonary hypertension (PH) and left ventricular diastolic dysfunction (LVDD) are independently associated with poor outcomes in cardiac surgery. We evaluated the relationship of several measures of LVDD, PH, and hemodynamic subtypes of PH including precapillary pulmonary hypertension(pcPH) and isolated post-capillary pulmonary hypertension(ipcPH) and combined pre and post capillary pulmonary hypertension(cpcPH) capillary PH to postoperative outcomes in a cohort of patients who underwent elective isolated-AVR. METHODS We evaluated (n = 206) patients in our local STS database who underwent elective isolated-AVR between 2014 and 2018, with transthoracic echocardiogram (n = 177) or right heart catheterization (n = 183) within 1 year of operation (or both, n = 161). The primary outcome was a composite end point of death, prolonged ventilation, ICU readmission, and hospital stay >14 days. RESULTS Severe PH was associated with worse outcomes (moderate: OR, 1.1, p = 0.09; severe: OR, 1.28, p = 0.01), but degree of LVDD was not associated with worse outcomes. Across hemodynamic subtypes of PH, odds of composite outcome were similar (p = 0.89), however, patients with cpcPH had more postoperative complications (67 vs. 36%, p = 0.06) and patients with ipcPH had greater all-cause mortality at 1 (8 vs. 1%, p = 0.03) and 3 years (27 vs. 4%, p = 0.008). CONCLUSION Severe PH conferred modestly greater risk of adverse events, and both LVDD grade and the combination of severe PH and LVDD were not associated with worse outcomes. However, hemodynamic stratification of PH revealed higher postoperative complications and worse long-term outcomes for those with cpcPH and ipcPH. Preoperative stratification of PH by hemodynamic subtype in valve replacement surgery may improve our risk stratification in this heterogenous condition. Further evaluation of the significance of LVDD and PH in other cardiac operations is warranted.
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Affiliation(s)
- Tom X Liu
- School of Medicine, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, United States
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, United States
| | - Mira T Tanenbaum
- School of Medicine, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, United States
| | - Claire H Seo
- School of Medicine, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, United States
| | - Dan Park
- School of Medicine, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, United States
| | - John C Lystash
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, United States
| | - Mark Joseph
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, United States
| | - William S Arnold
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, United States
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11
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Angellotti D, Immobile Molaro M, Simonetti F, Ilardi F, Castiello DS, Mariani A, Manzo R, Avvedimento M, Leone A, Nappa D, Piccolo R, Losi MA, Franzone A, Esposito G. Is There Still a Role for Invasive Assessment of Aortic Gradient? Diagnostics (Basel) 2023; 13:diagnostics13101698. [PMID: 37238182 DOI: 10.3390/diagnostics13101698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 04/30/2023] [Accepted: 05/09/2023] [Indexed: 05/28/2023] Open
Abstract
Advances in technology and imaging have expanded the range of tools for diagnosing aortic stenosis (AS). The accurate assessment of aortic valve area and mean pressure gradient is crucial to determine which patients are appropriate candidates for aortic valve replacement. Nowadays, these values can be obtained noninvasively or invasively, with similar results. Contrariwise, in the past, cardiac catheterization played a major role in the evaluation of AS severity. In this review, we will discuss the historical role of the invasive assessment of AS. Moreover, we will specifically focus on tips and tricks for properly performing cardiac catheterization in patients with AS. We will also elucidate the role of invasive methods in current clinical practice and their additional value to the information provided through non-invasive techniques.
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Affiliation(s)
- Domenico Angellotti
- Department of Advanced Biomedical Sciences, Division of Cardiology, University of Naples Federico II, 80131 Naples, Italy
| | - Maddalena Immobile Molaro
- Department of Advanced Biomedical Sciences, Division of Cardiology, University of Naples Federico II, 80131 Naples, Italy
| | - Fiorenzo Simonetti
- Department of Advanced Biomedical Sciences, Division of Cardiology, University of Naples Federico II, 80131 Naples, Italy
| | - Federica Ilardi
- Department of Advanced Biomedical Sciences, Division of Cardiology, University of Naples Federico II, 80131 Naples, Italy
| | - Domenico Simone Castiello
- Department of Advanced Biomedical Sciences, Division of Cardiology, University of Naples Federico II, 80131 Naples, Italy
| | - Andrea Mariani
- Department of Advanced Biomedical Sciences, Division of Cardiology, University of Naples Federico II, 80131 Naples, Italy
| | - Rachele Manzo
- Department of Advanced Biomedical Sciences, Division of Cardiology, University of Naples Federico II, 80131 Naples, Italy
| | - Marisa Avvedimento
- Department of Advanced Biomedical Sciences, Division of Cardiology, University of Naples Federico II, 80131 Naples, Italy
| | - Attilio Leone
- Department of Advanced Biomedical Sciences, Division of Cardiology, University of Naples Federico II, 80131 Naples, Italy
| | - Dalila Nappa
- Department of Advanced Biomedical Sciences, Division of Cardiology, University of Naples Federico II, 80131 Naples, Italy
| | - Raffaele Piccolo
- Department of Advanced Biomedical Sciences, Division of Cardiology, University of Naples Federico II, 80131 Naples, Italy
| | - Maria Angela Losi
- Department of Advanced Biomedical Sciences, Division of Cardiology, University of Naples Federico II, 80131 Naples, Italy
| | - Anna Franzone
- Department of Advanced Biomedical Sciences, Division of Cardiology, University of Naples Federico II, 80131 Naples, Italy
| | - Giovanni Esposito
- Department of Advanced Biomedical Sciences, Division of Cardiology, University of Naples Federico II, 80131 Naples, Italy
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12
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Dahiya G, Kyvernitakis A, Elhamdani A, Begg A, Doyle M, Elsayed M, Bailey S, Raina A, Kanwar M, Biederman RWW, Benza RL. Prognostic role of pulmonary hemodynamics before transcatheter aortic valve replacement among patients with severe aortic stenosis. J Heart Lung Transplant 2023; 42:275-282. [PMID: 36437170 DOI: 10.1016/j.healun.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 08/17/2022] [Accepted: 10/02/2022] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Pulmonary hypertension (PH) frequently co-exists in patients with severe aortic stenosis (AS). In this study, we sought to identify the implications of invasive pulmonary hemodynamics on major adverse cardiac events (MACE), biventricular function and NYHA functional class after transcatheter aortic valve replacement (TAVR). METHODS Invasive hemodynamics via right heart catheterization (RHC) were performed pre-TAVR. Patients were stratified per mean PA pressure (mPAP), diastolic pulmonary gradient (DPG) and pulmonary vascular resistance (PVR), and followed at 1-month and 1-year intervals up to 6 years. MACE outcomes included cardiovascular death and heart failure hospitalizations post-TAVR. RESULTS Among 215 patients, Kaplan-Meir estimates demonstrated an increased 1-year risk of MACE from 8% among those without pre-TAVR PH to 27% among patients with pre-existing PH. Specifically, the MACE risk was 32% among PH patients with PVR ≥ 3WU (p = .04) and 53% among PH patients with DPG ≥ 7 mm Hg (p < .01). On univariate Cox regression, RV stroke work index (RVSWI) (HR,1.02; p = .02), and pulmonary hemodynamic index (PHI) (HR,1.27; p = .047) were identified as additional predictors of MACE post-TAVR. On multivariable Cox regression analysis, SvO2 (HR, 0.95; p = .01) and PVR (HR, 1.2; p = .04) were demonstrated as predictive of MACE post-TAVR. A significant improvement in LVEF (2-Factor ANOVA, p < .01) and RV fractional area change (RVFAC%) (p < .01) was noted as assessed at baseline, 1-month and 1-year follow up post-TAVR. There was a significant interaction between pre-TAVR PH status and time post procedure with respect to NYHA functional class (p = .03), that is, the manner and degree of change in NYHA class over time depended on pre-TAVR PH status. CONCLUSIONS Defining invasive pulmonary hemodynamics, such as mPAP, PVR, and DPG among patients with severe AS undergoing TAVR has significant prognostic implications. Routine risk stratification by utilizing invasive hemodynamics can better identify patients who will have functional improvement and improved outcomes post-TAVR.
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Affiliation(s)
- Garima Dahiya
- Division of Cardiovascular Disease, Department of Medicine, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - Andreas Kyvernitakis
- Division of Cardiovascular Disease, Department of Medicine, Allegheny Health Network Education Consortium, Pittsburgh, Pennsylvania
| | - Adee Elhamdani
- Department of Internal Medicine, Allegheny Health Network Education Consortium, Pittsburgh, Pennsylvania
| | - Andrew Begg
- Department of Internal Medicine, Allegheny Health Network Education Consortium, Pittsburgh, Pennsylvania
| | - Mark Doyle
- Division of Cardiovascular Disease, Department of Medicine, Allegheny Health Network Education Consortium, Pittsburgh, Pennsylvania
| | - Mahmoud Elsayed
- Division of Cardiovascular Disease, Department of Medicine, Allegheny Health Network Education Consortium, Pittsburgh, Pennsylvania
| | - Stephen Bailey
- Department of Thoracic and Cardiovascular Surgery, Allegheny Health Network Education Consortium, Pittsburgh, Pennsylvania
| | - Amresh Raina
- Division of Cardiovascular Disease, Department of Medicine, Allegheny Health Network Education Consortium, Pittsburgh, Pennsylvania
| | - Manreet Kanwar
- Division of Cardiovascular Disease, Department of Medicine, Allegheny Health Network Education Consortium, Pittsburgh, Pennsylvania
| | - Robert W W Biederman
- Division of Cardiovascular Disease, Department of Medicine, Allegheny Health Network Education Consortium, Pittsburgh, Pennsylvania
| | - Raymond L Benza
- Division of Cardiovascular Medicine and Pulmonary Hypertension, Department of Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio.
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13
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Muacevic A, Adler JR, Jamil A, Csendes D, Gutlapalli SD, Prakash K, Swarnakari KM, Bai M, Manoharan MP, Raja R, Khan S. Outcomes of Preprocedural Pulmonary Hypertension on All-Cause and Cardiac Mortality in Patients Undergoing Transcatheter Aortic Valve Implantation: A Systematic Review. Cureus 2023; 15:e34300. [PMID: 36860229 PMCID: PMC9969809 DOI: 10.7759/cureus.34300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 01/27/2023] [Indexed: 01/30/2023] Open
Abstract
Patients with symptomatic aortic stenosis (AS) commonly have an associated finding of pulmonary hypertension (PH), and it has been previously shown to have increased morbidity and mortality following surgical aortic valve repair (SAVR) as well as transcatheter aortic valve implantation (TAVI). There are no guidelines stating the cut-off point for PH at which the patient can safely undergo TAVI with benefits outweighing the risks. This is partly due to the lack of uniformity in the PH definition used in various studies. This systematic review sought to study the effect of preprocedural pulmonary hypertension on early and late all-cause and cardiac mortality in patients undergoing TAVI. We performed a systematic review of studies comparing patients with AS undergoing TAVI having PH. The review was undertaken as per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Articles were identified from PubMed, Pubmed Central (PMC), Cochrane, and Medline on January 10, 2022, for literature published until January 10, 2022. MeSH strategy was used on PubMed to search the literature, and filters were applied to search only Observational Studies, randomized controlled trials (RCT), and meta-analysis. A total of 170 unique articles were identified and screened. Of the 33 full-text articles that were reviewed, 18 articles, including duplicates, were excluded. Fifteen articles fulfilled the selection criteria and were included in this review. The study design included two meta-analyses, one randomized control trial, one prospective cohort study, and 11 retrospective cohort studies. The studies involved a total of approximately 30,000 patients. The observational studies in our review were of good to fair quality, the RCT had a low to moderate bias, and the meta-analysis was of moderate quality. Baseline PH and persistence of PH post-TAVI are strongly associated with all-cause and cardiac mortality. Few studies have shown that a decrease in post-TAVI PH carries mortality benefits. Therefore, efforts should be made to identify mechanisms of persistent PH post-TAVI and whether interventions to reduce PH pre-TAVI will have any clinical implications or not by conducting RCT.
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14
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Miyamoto J, Ohno Y, Kamioka N, Ikari Y, Otsuka T, Tada N, Naganuma T, Yamawaki M, Yamanaka F, Shirai S, Mizutani K, Tabata M, Ueno H, Takagi K, Watanabe Y, Yamamoto M, Hayashida K. Impact of Periprocedural Pulmonary Hypertension on Outcomes After Transcatheter Aortic Valve Replacement. J Am Coll Cardiol 2022; 80:1601-1613. [DOI: 10.1016/j.jacc.2022.08.757] [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: 07/12/2022] [Revised: 08/02/2022] [Accepted: 08/10/2022] [Indexed: 11/05/2022]
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15
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Généreux P. Pulmonary Hypertension and Aortic Stenosis. J Am Coll Cardiol 2022; 80:1614-1616. [DOI: 10.1016/j.jacc.2022.09.005] [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: 09/08/2022] [Accepted: 09/09/2022] [Indexed: 01/07/2023]
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16
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Boxhammer E, Gharibeh SX, Wernly B, Kelm M, Franz M, Kretzschmar D, Hoppe UC, Lauten A, Lichtenauer M. Conundrum of Classifying Subtypes of Pulmonary Hypertension-Introducing a Novel Approach to Classify "Borderline" Patients in a Population with Severe Aortic Stenosis Undergoing TAVI. J Cardiovasc Dev Dis 2022; 9:jcdd9090294. [PMID: 36135439 PMCID: PMC9505198 DOI: 10.3390/jcdd9090294] [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: 07/31/2022] [Revised: 08/23/2022] [Accepted: 08/31/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Transcatheter aortic valve implantation (TAVI) is an established therapeutic option in patients with severe aortic valve stenosis (AS) and a high surgical risk profile. Pulmonary hypertension (PH)—often co-existing with severe AS—is associated with a limited factor for prognosis and survival. The purpose of this study was to evaluate the prevalence of PH in patients undergoing TAVI, classify these patients based on right heart catheter (RHC) measurements in different PH subtypes, and analyze prognostic values on survival after TAVI. Methods: 284 patients with severe AS underwent an RHC examination for hemodynamic assessment prior to TAVI and were categorized into subtypes of PH according to the 2015 European Society of Cardiology (ESC) guidelines. TAVI patients were followed-up with for one year with regard to 30-days and 1-year mortality as primary endpoints. Results: 74 of 284 participants showed a diastolic pressure gradient (DPG) < 7 mmHg and a pulmonary vascular resistance (PVR) > 3 Wood units (WU) and could not be formally allocated to either isolated post-capillary PH (ipc-PH) or combined pre- and post-capillary PH (cpc-PH). Therefore, a new subgroup called “borderline post-capillary PH” (borderlinepc-PH) was introduced. Compared with TAVI patients with pre-capillary PH (prec-PH), ipc-PH patients suffering from borderlinepc-PH (HR 7.114; 95% CI 2.015−25.119; p = 0.002) or cpc-PH (HR 56.459; 95% CI 7.738−411.924; p < 0.001) showed a significantly increased 1-year mortality. Conclusions: Postcapillary PH was expanded to include the so-called “borderlinepc-PH” variant in addition to the ipc-PH and cpc-PH subtypes. The one-year survival after TAVI was significantly different between the subgroups, with the worst prognosis for borderlinepc-PH and cpc-PH.
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Affiliation(s)
- Elke Boxhammer
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, Müllner Hauptstraße 48, 5020 Salzburg, Austria
| | - Sarah X. Gharibeh
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, Müllner Hauptstraße 48, 5020 Salzburg, Austria
| | - Bernhard Wernly
- Department of Internal Medicine, General Hospital Oberndorf, Teaching Hospital of the Paracelsus Medical University Salzburg, 5110 Oberndorf, Austria
| | - Malte Kelm
- Division of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty, University Düsseldorf, 40225 Düsseldorf, Germany
| | - Marcus Franz
- Universitätsherzzentrum Thüringen, Clinic of Internal Medicine I, Departement of Cardiology, Friedrich Schiller University, 07737 Jena, Germany
| | - Daniel Kretzschmar
- Universitätsherzzentrum Thüringen, Clinic of Internal Medicine I, Departement of Cardiology, Friedrich Schiller University, 07737 Jena, Germany
| | - Uta C. Hoppe
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, Müllner Hauptstraße 48, 5020 Salzburg, Austria
| | - Alexander Lauten
- Department of General and Interventional Cardiology and Rhythmology, Helios Clinic, 99084 Erfurt, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), Standort Berlin, 10115 Berlin, Germany
| | - Michael Lichtenauer
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, Müllner Hauptstraße 48, 5020 Salzburg, Austria
- Correspondence:
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17
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Adamopoulos D, Pagoulatou S, Rovas G, Bikia V, Müller H, Giannakopoulos G, Mauler-Wittwer S, Licker MJ, Stergiopulos N, Lador F, Noble S. Prognostic Implications of the Novel Pulmonary Hypertension Definition in Patients with Aortic Stenosis after Transcatheter Valve Replacement. J Clin Med 2022; 11:jcm11154279. [PMID: 35893367 PMCID: PMC9332728 DOI: 10.3390/jcm11154279] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 07/08/2022] [Accepted: 07/15/2022] [Indexed: 02/04/2023] Open
Abstract
Introduction: Pulmonary hypertension (PH), traditionally defined as a mean pulmonary artery pressure (PAP) ≥ 25 mmHg, is associated with poor outcomes in patients undergoing a transcatheter aortic valve replacement (TAVR) for severe aortic stenosis (AS). Recently, a novel definition for PH has been proposed, placing the cut-off value of mean PAP at 20 mmHg, and introducing pulmonary vascular resistance as an exclusive indicator for the pre-capillary involvement. In light of the novel criteria, whether PH still preserves its prognostic significance remains unknown. Methods: The study population consisted of 380 patients with AS, who underwent a right heart catheterization before TAVR. The cohort was divided according to the presence of PH (n = 174, 45.7%) or not. Patients with PH were further divided into the following groups: (1) Pre-capillary PH ((Pre-capPH), n = 46, 12.1%); (2) Isolated post-capillary PH ((IpcPH), n = 78, 20.5%); (3) Combined pre and post-capillary PH ((CpcPH), n = 82, 21.6%). The primary endpoint was all-cause mortality at 1 year. Results: A total of 246 patients (64.7%) exhibited mean PAP > 20 mmHg. Overall, the presence of PH was associated with higher 1-year mortality rates (hazard ratio (HR) 2.8, 95% CI: 1.4−5.8, p = 0.004). Compared to patients with no PH, Pre-capPH and CpcPH (but not IpcPH) were related to higher 1-year mortality (HR 2.7, 95% CI: 1.0−7.2, p = 0.041 and HR 3.9, 95% CI: 1.8−8.5, p = 0.001, respectively). This remained significant even after the adjustment for baseline comorbidities. Conclusions: Pre-interventional PH according to the novel hemodynamic criteria, is linked with poor outcomes in patients undergoing TAVR for severe AS. However, this is mainly driven by patients with mean PAP ≥ 25 mmHg. Patients with a pre-capillary PH component as defined by increased PVR present an even worse prognosis as compared to patients with isolated post-capillary or no PH who present comparable 1-year mortality rates.
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Affiliation(s)
- Dionysios Adamopoulos
- Faculty of Medicine, Department of Medicine, Geneva University, 1206 Geneva, Switzerland; (M.-J.L.); (F.L.); (S.N.)
- Department of Internal Medicine, Division of Cardiology, Hôpitaux Universitaires de Genève (HUG), 1205 Geneva, Switzerland; (H.M.); (G.G.); (S.M.-W.)
- Correspondence:
| | - Stamatia Pagoulatou
- Laboratory of Hemodynamics and Cardiovascular Technology, Ecole Polytechnique Fédérale de Lausanne (EPFL), 1015 Lausanne, Switzerland; (S.P.); (G.R.); (V.B.); (N.S.)
| | - Georgios Rovas
- Laboratory of Hemodynamics and Cardiovascular Technology, Ecole Polytechnique Fédérale de Lausanne (EPFL), 1015 Lausanne, Switzerland; (S.P.); (G.R.); (V.B.); (N.S.)
| | - Vasiliki Bikia
- Laboratory of Hemodynamics and Cardiovascular Technology, Ecole Polytechnique Fédérale de Lausanne (EPFL), 1015 Lausanne, Switzerland; (S.P.); (G.R.); (V.B.); (N.S.)
| | - Hajo Müller
- Department of Internal Medicine, Division of Cardiology, Hôpitaux Universitaires de Genève (HUG), 1205 Geneva, Switzerland; (H.M.); (G.G.); (S.M.-W.)
| | - Georgios Giannakopoulos
- Department of Internal Medicine, Division of Cardiology, Hôpitaux Universitaires de Genève (HUG), 1205 Geneva, Switzerland; (H.M.); (G.G.); (S.M.-W.)
| | - Sarah Mauler-Wittwer
- Department of Internal Medicine, Division of Cardiology, Hôpitaux Universitaires de Genève (HUG), 1205 Geneva, Switzerland; (H.M.); (G.G.); (S.M.-W.)
| | - Marc-Joseph Licker
- Faculty of Medicine, Department of Medicine, Geneva University, 1206 Geneva, Switzerland; (M.-J.L.); (F.L.); (S.N.)
- Department of Acute Medicine, Division of Anaesthesiology, Hôpitaux Universitaires de Genève (HUG), 1205 Geneva, Switzerland
| | - Nikolaos Stergiopulos
- Laboratory of Hemodynamics and Cardiovascular Technology, Ecole Polytechnique Fédérale de Lausanne (EPFL), 1015 Lausanne, Switzerland; (S.P.); (G.R.); (V.B.); (N.S.)
| | - Frédéric Lador
- Faculty of Medicine, Department of Medicine, Geneva University, 1206 Geneva, Switzerland; (M.-J.L.); (F.L.); (S.N.)
- Department of Internal Medicine, Division of Pneumology, Hôpitaux Universitaires de Genève (HUG), 1205 Geneva, Switzerland
- Pulmonary Hypertension Program, Hôpitaux Universitaires de Genève (HUG), 1205 Geneva, Switzerland
| | - Stéphane Noble
- Faculty of Medicine, Department of Medicine, Geneva University, 1206 Geneva, Switzerland; (M.-J.L.); (F.L.); (S.N.)
- Department of Internal Medicine, Division of Cardiology, Hôpitaux Universitaires de Genève (HUG), 1205 Geneva, Switzerland; (H.M.); (G.G.); (S.M.-W.)
- Pulmonary Hypertension Program, Hôpitaux Universitaires de Genève (HUG), 1205 Geneva, Switzerland
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18
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Boxhammer E, Mirna M, Bäz L, Alushi B, Franz M, Kretzschmar D, Hoppe UC, Lauten A, Lichtenauer M. Comparison of PCWP and LVEDP Measurements in Patients with Severe Aortic Stenosis Undergoing TAVI-Same Same but Different? J Clin Med 2022; 11:jcm11112978. [PMID: 35683367 PMCID: PMC9181042 DOI: 10.3390/jcm11112978] [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: 05/01/2022] [Revised: 05/18/2022] [Accepted: 05/23/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Pulmonary capillary wedge pressure (PCWP) and left ventricular end-diastolic pressure (LVEDP) are often used as equivalents for determination of pulmonary hypertension (PH). PH is a comorbidity in patients with severe aortic valve stenosis (AS) and associated with limited prognosis. The aim of the study was to examine the role of differentiated classification basis of PCWP and LVEDP in patients planning for transcatheter aortic valve implantation (TAVI). METHODS 284 patients with severe AS completed a combined left (LHC) and right heart catheterization (RHC) as part of a TAVI planning procedure. Patients were categorized twice into subtypes of PH according to 2015 European Society of Cardiology (ESC) guidelines-on the one hand with PCWP and on the other hand with LVEDP as classification basis. PCWP-LVEDP relationships were figured out using Kaplan-Meier curves, linear regressions and Bland-Altman analysis. RESULTS Regarding 1-year mortality, Kaplan-Meier analyses showed similar curves in spite of different classification bases of PH subtypes according to PCWP or LVEDP with exception of pre-capillary PH subtype. PCWP-LVEDP association in the overall cohort was barely present (R = 0.210, R2 = 0.044). When focusing analysis on PH patients only a slightly increased linear regression was noted compared to the overall cohort (R = 0.220, R2 = 0.048). The strongest regression was observed in patients with creatinine ≥ 132 µmol/L (R = 0.357, R2 = 0.127) and in patients with mitral regurgitation ≥ II° (R = 0.326, R2 = 0.106). CONCLUSIONS In patients with severe AS, there is a weak association between hemodynamic parameters measured by LHC and RHC. RHC measurements alone are not suitable for risk stratification with respect to one-year mortality. If analysis of hemodynamic parameters is necessary in patients with severe AS scheduled for TAVI, measurement results of LHC and RHC should be combined and LVEDP could serve as a helpful indicator for risk assessment.
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Affiliation(s)
- Elke Boxhammer
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria; (E.B.); (M.M.); (U.C.H.)
| | - Moritz Mirna
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria; (E.B.); (M.M.); (U.C.H.)
| | - Laura Bäz
- Universitäts-Herzzentrum Thüringen, Clinic of Internal Medicine I, Department of Cardiology, Friedrich Schiller University, 07743 Jena, Germany; (L.B.); (M.F.); (D.K.)
| | - Brunilda Alushi
- Department of General and Interventional Cardiology and Rhythmology, Helios Hospital Erfurt, 99089 Erfurt, Germany; (B.A.); (A.L.)
| | - Marcus Franz
- Universitäts-Herzzentrum Thüringen, Clinic of Internal Medicine I, Department of Cardiology, Friedrich Schiller University, 07743 Jena, Germany; (L.B.); (M.F.); (D.K.)
| | - Daniel Kretzschmar
- Universitäts-Herzzentrum Thüringen, Clinic of Internal Medicine I, Department of Cardiology, Friedrich Schiller University, 07743 Jena, Germany; (L.B.); (M.F.); (D.K.)
| | - Uta C. Hoppe
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria; (E.B.); (M.M.); (U.C.H.)
| | - Alexander Lauten
- Department of General and Interventional Cardiology and Rhythmology, Helios Hospital Erfurt, 99089 Erfurt, Germany; (B.A.); (A.L.)
- Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), Standort Berlin, 10785 Berlin, Germany
| | - Michael Lichtenauer
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria; (E.B.); (M.M.); (U.C.H.)
- Correspondence:
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19
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Soluble ST2 as a Potential Biomarker for Risk Assessment of Pulmonary Hypertension in Patients Undergoing TAVR? Life (Basel) 2022; 12:life12030389. [PMID: 35330140 PMCID: PMC8954652 DOI: 10.3390/life12030389] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 03/03/2022] [Accepted: 03/04/2022] [Indexed: 12/12/2022] Open
Abstract
Background: Severe aortic valve stenosis (AS) is associated with pulmonary hypertension (PH) and has been shown to limit patient survival. Soluble suppression of tumorigenicity-2 (sST2) is a cardiovascular biomarker that has proven to be an important prognostic marker for survival in patients undergoing transcatheter aortic valve replacement (TAVR). The aim of this study was to assess the importance of the sST2 biomarker for risk stratification in patients with severe AS in presence or absence of PH. Methods: In 260 patients with severe AS undergoing TAVR procedure, sST2 serum level concentrations were analyzed. Right heart catheter measurements were performed in 152 patients, with no PH detection in 43 patients and with PH detection in 109 patients. Correlation analyses according to Spearman, AUROC analyses and Kaplan–Meier curves were calculated. Results: Patients with severe AS and PH showed significantly higher serum sST2 concentrations (p = 0.006). The sST2 cut-off value for non-PH patients regarding 1-year survival yielded 5521.15 pg/mL, whereas the cut-off value of PH patients was at a considerably higher level of 10,268.78 pg/mL. A cut-off value of 6990.12 pg/mL was related with a significant probability of PH presence. Survival curves showed that patients with severe AS and PH not only had higher 1-year mortality, but also that increased levels of sST2 plasma concentration were associated with earlier death. Conclusion: sST2 definitely has the potential to provide information about the presence of PH in patients with severe AS, in a noninvasive way.
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20
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Fortmeier V, Lachmann M, Körber MI, Unterhuber M, von Scheidt M, Rippen E, Harmsen G, Gerçek M, Friedrichs KP, Roder F, Rudolph TK, Yuasa S, Joner M, Laugwitz KL, Baldus S, Pfister R, Lurz P, Rudolph V. Solving the Pulmonary Hypertension Paradox in Patients With Severe Tricuspid Regurgitation by Employing Artificial Intelligence. JACC Cardiovasc Interv 2022; 15:381-394. [PMID: 35210045 DOI: 10.1016/j.jcin.2021.12.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 11/30/2021] [Accepted: 12/21/2021] [Indexed: 12/20/2022]
Abstract
OBJECTIVES This study aimed to improve echocardiographic assessment of pulmonary hypertension (PH) in patients presenting with severe tricuspid regurgitation (TR). BACKGROUND Echocardiographic assessment of PH in patients with severe TR carries several pitfalls for underestimation, hence concealing the true severity of PH in very sick patients in particular, and ultimately obscuring the impact of PH on survival after transcatheter tricuspid valve intervention (TTVI). METHODS All patients in this study underwent TTVI for severe TR between 2016 and 2020. To predict the mean pulmonary artery pressure (mPAP) solely based on echocardiographic parameters, we trained an extreme gradient boosting (XGB) algorithm. The derivation cohort was constituted by 116 out of 162 patients with both echocardiography and right heart catheterization data, preprocedurally obtained, from a bicentric registry. Moreover, 142 patients from an independent institution served for external validation. RESULTS Systolic pulmonary artery pressure was consistently underestimated by echocardiography in comparison to right heart catheterization (40.3 ± 15.9 mm Hg vs 44.1 ± 12.9 mm Hg; P = 0.0066), and the assessment was most discrepant among patients with severe defects of the tricuspid valve and impaired right ventricular systolic function. Using 9 echocardiographic parameters as input variables, an XGB algorithm could reliably predict mPAP levels (R = 0.96, P < 2.2 × 10-16). Moreover, patients with elevations in predicted mPAP levels ≥29.9 mm Hg showed significantly reduced 2-year survival after TTVI (58.3% [95% CI: 41.7%-81.6%] vs 78.8% [95% CI: 68.7%-90.5%]; P = 0.026). Importantly, the poor prognosis associated with elevation in predicted mPAP levels was externally confirmed (HR for 2-year mortality: 2.9 [95% CI: 1.5-5.7]; P = 0.002). CONCLUSIONS PH in patients with severe TR can be reliably assessed based on echocardiographic parameters in conjunction with an XGB algorithm, and elevations in predicted mPAP levels translate into increased mortality after TTVI.
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Affiliation(s)
- Vera Fortmeier
- Department of General and Interventional Cardiology, Heart and Diabetes Center North Rhine-Westphalia, Ruhr University Bochum, Bad Oeynhausen, Germany
| | - Mark Lachmann
- First Department of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany; German Center for Cardiovascular Research, partner site Munich Heart Alliance, Munich, Germany
| | - Maria I Körber
- Department of Cardiology, Heart Center, University of Cologne, Cologne, Germany
| | - Matthias Unterhuber
- Department of Cardiology, Heart Center Leipzig, University of Leipzig, Leipzig, Germany
| | - Moritz von Scheidt
- German Center for Cardiovascular Research, partner site Munich Heart Alliance, Munich, Germany; Department of Cardiology, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Elena Rippen
- First Department of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany; German Center for Cardiovascular Research, partner site Munich Heart Alliance, Munich, Germany
| | - Gerhard Harmsen
- Department of Physics, University of Johannesburg, Auckland Park, South Africa
| | - Muhammed Gerçek
- Department of General and Interventional Cardiology, Heart and Diabetes Center North Rhine-Westphalia, Ruhr University Bochum, Bad Oeynhausen, Germany
| | - Kai Peter Friedrichs
- Department of General and Interventional Cardiology, Heart and Diabetes Center North Rhine-Westphalia, Ruhr University Bochum, Bad Oeynhausen, Germany
| | - Fabian Roder
- Department of General and Interventional Cardiology, Heart and Diabetes Center North Rhine-Westphalia, Ruhr University Bochum, Bad Oeynhausen, Germany
| | - Tanja K Rudolph
- Department of General and Interventional Cardiology, Heart and Diabetes Center North Rhine-Westphalia, Ruhr University Bochum, Bad Oeynhausen, Germany
| | - Shinsuke Yuasa
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Michael Joner
- German Center for Cardiovascular Research, partner site Munich Heart Alliance, Munich, Germany; Department of Cardiology, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Karl-Ludwig Laugwitz
- First Department of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany; German Center for Cardiovascular Research, partner site Munich Heart Alliance, Munich, Germany
| | - Stephan Baldus
- Department of Cardiology, Heart Center, University of Cologne, Cologne, Germany
| | - Roman Pfister
- Department of Cardiology, Heart Center, University of Cologne, Cologne, Germany
| | - Philipp Lurz
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Volker Rudolph
- Department of General and Interventional Cardiology, Heart and Diabetes Center North Rhine-Westphalia, Ruhr University Bochum, Bad Oeynhausen, Germany.
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21
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Impact of Pulmonary Artery Dilatation on Clinical Outcomes in Patients Undergoing Transcatheter Aortic Valve Replacement. JACC Cardiovasc Interv 2021; 14:2560-2569. [PMID: 34774478 DOI: 10.1016/j.jcin.2021.08.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 08/04/2021] [Accepted: 08/10/2021] [Indexed: 12/20/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate the clinical impact of computed tomography (CT)-derived pulmonary artery dilatation (PAD) in patients undergoing transcatheter aortic valve replacement (TAVR). BACKGROUND Several studies have reported an association between pulmonary hypertension and cardiovascular events, but the prognostic value of PAD in patients undergoing TAVR remains unclear. METHODS The preprocedural computed tomographic studies of patients who underwent TAVR at Cedars-Sinai Medical Center between November 2013 and December 2017 were analyzed. Patients were divided into 2 groups according to the presence of PAD assessed on CT (pulmonary artery [PA] diameter ≥29 mm). The primary endpoint was all-cause mortality at 2 years. RESULTS A total of 895 patients were included (mean age 81.3 ± 8.5 years), with a mean Society of Thoracic Surgeons score of 4.8%. The median PA diameter was 28.0 mm, and PAD was observed in 369 patients (41.2%). Compared with the no-PAD group, the PAD group had higher Society of Thoracic Surgeons scores and higher rates of atrial fibrillation, chronic kidney disease, and chronic obstructive pulmonary disease. The PAD group had higher 2-year all-cause mortality than the no-PAD group (28.9% vs 12.8%; P < 0.001), and PAD was independently associated with mortality (adjusted HR: 2.21; 95% CI: 1.44-3.39; P < 0.001). Furthermore, PAD had strong prognostic power in the subgroup analysis, stratified according to PA pressure (>36 mm Hg). CONCLUSIONS CT-derived PAD is a significant prognostic factor in patients undergoing TAVR.
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22
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Sakata K, Takamura M. Hemodynamic Stratification of the Pulmonary Vasculature in Patients Undergoing Transcatheter Aortic Valve Replacement. Circ J 2021; 86:391-392. [PMID: 34759122 DOI: 10.1253/circj.cj-21-0820] [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: 11/09/2022]
Affiliation(s)
- Kenji Sakata
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kanazawa University
| | - Masayuki Takamura
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kanazawa University
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23
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Lachmann M, Rippen E, Schuster T, Xhepa E, von Scheidt M, Pellegrini C, Trenkwalder T, Rheude T, Stundl A, Thalmann R, Harmsen G, Yuasa S, Schunkert H, Kastrati A, Laugwitz KL, Kupatt C, Joner M. Subphenotyping of Patients With Aortic Stenosis by Unsupervised Agglomerative Clustering of Echocardiographic and Hemodynamic Data. JACC Cardiovasc Interv 2021; 14:2127-2140. [PMID: 34620391 DOI: 10.1016/j.jcin.2021.08.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 07/26/2021] [Accepted: 08/03/2021] [Indexed: 01/29/2023]
Abstract
OBJECTIVES The aim of this retrospective analysis was to categorize patients with severe aortic stenosis (AS) according to clinical presentation by applying unsupervised machine learning. BACKGROUND Patients with severe AS present with heterogeneous clinical phenotypes, depending on disease progression and comorbidities. METHODS Unsupervised agglomerative clustering was applied to preprocedural data from echocardiography and right heart catheterization from 366 consecutively enrolled patients undergoing transcatheter aortic valve replacement for severe AS. RESULTS Cluster analysis revealed 4 distinct phenotypes. Patients in cluster 1 (n = 164 [44.8%]), serving as a reference, presented with regular cardiac function and without pulmonary hypertension (PH). Accordingly, estimated 2-year survival was 90.6% (95% CI: 85.8%-95.6%). Clusters 2 (n = 66 [18.0%]) and 4 (n = 91 [24.9%]) both comprised patients with postcapillary PH. Yet patients in cluster 2 with preserved left and right ventricular structure and function showed a similar survival as those in cluster 1 (2-year survival 85.8%; 95% CI: 76.9%-95.6%), whereas patients in cluster 4 with dilatation of all heart chambers and a high prevalence of mitral and tricuspid regurgitation (12.5% and 14.8%, respectively) died more often (2-year survival 74.9% [95% CI: 65.9%-85.2%]; HR for 2-year mortality: 2.8 [95% CI: 1.4-5.5]). Patients in cluster 3, the smallest (n = 45 [12.3%]), displayed the most extensive disease characteristics (ie, left and right heart dysfunction together with combined pre- and postcapillary PH), and 2-year survival was accordingly reduced (77.3% [95% CI: 65.2%-91.6%]; HR for 2-year mortality: 2.6 [95% CI: 1.1-6.2]). CONCLUSIONS Unsupervised machine learning aids in capturing complex clinical presentations as observed in patients with severe AS. Importantly, structural alterations in left and right heart morphology, possibly due to genetic predisposition, constitute an equally sensitive indicator of poor prognosis compared with high-grade PH.
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Affiliation(s)
- Mark Lachmann
- First Department of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Elena Rippen
- First Department of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Tibor Schuster
- Department of Family Medicine, McGill University, Montreal, Quebec, Canada
| | - Erion Xhepa
- Department of Cardiology, Deutsches Herzzentrum München, Technical University of Munich, Munich, Germany; DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Moritz von Scheidt
- Department of Cardiology, Deutsches Herzzentrum München, Technical University of Munich, Munich, Germany; DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Costanza Pellegrini
- Department of Cardiology, Deutsches Herzzentrum München, Technical University of Munich, Munich, Germany
| | - Teresa Trenkwalder
- Department of Cardiology, Deutsches Herzzentrum München, Technical University of Munich, Munich, Germany
| | - Tobias Rheude
- Department of Cardiology, Deutsches Herzzentrum München, Technical University of Munich, Munich, Germany
| | - Anja Stundl
- First Department of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Ruth Thalmann
- First Department of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Gerhard Harmsen
- Department of Physics, University of Johannesburg, Auckland Park, South Africa
| | - Shinsuke Yuasa
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Heribert Schunkert
- Department of Cardiology, Deutsches Herzzentrum München, Technical University of Munich, Munich, Germany; DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Adnan Kastrati
- Department of Cardiology, Deutsches Herzzentrum München, Technical University of Munich, Munich, Germany; DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Karl-Ludwig Laugwitz
- First Department of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany; DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Christian Kupatt
- First Department of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany; DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany.
| | - Michael Joner
- Department of Cardiology, Deutsches Herzzentrum München, Technical University of Munich, Munich, Germany; DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
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24
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Imamura T, Narang N, Sobajima M, Tanaka S, Ushijima R, Fukuda N, Ueno H, Kinugawa K. Decoupling Between Pulmonary Artery Diastolic and Wedge Pressure Following Transcatheter Aortic Valve Replacement. Circ J 2021; 86:383-390. [PMID: 34602582 DOI: 10.1253/circj.cj-21-0573] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Coexistent pulmonary hypertension with severe aortic stenosis confers a greater risk of mortality for patients undergoing transcatheter aortic valve replacement (TAVR). In this patient population, the impact of significant decoupling between pulmonary artery diastolic and pulmonary capillary wedge, as it relates to clinical risk, remained uncertain.Methods and Results:Patients with severe aortic stenosis who underwent TAVR and completed pre-procedural and post-procedural invasive hemodynamic assessments with right heart catheterization were retrospectively assessed. The impact of post-TAVR decoupling, defined as a pressure difference ≥3 mmHg, on 2-year all-cause mortality or risk of heart failure admission was analyzed. Among 77 included patients (median age 86 years, 23 men), 16 had post-TAVR decoupling. The existence of post-TAVR decoupling was associated with a higher cumulative incidence of the primary endpoint (44% vs. 7%, P=0.001), with an adjusted hazard ratio of 5.87 (95% confidence interval 1.58-21.9, P=0.008). CONCLUSIONS A greater risk of worse outcomes in those with post-TAVR decoupling was observed. A therapeutic strategy for post-TAVR decoupling and its clinical implication need to be created and investigated in the future.
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Affiliation(s)
| | - Nikhil Narang
- Advocate Heart Institute, Advocate Christ Medical Center
| | - Mitsuo Sobajima
- Second Department of Internal Medicine, University of Toyama
| | - Shuhei Tanaka
- Second Department of Internal Medicine, University of Toyama
| | | | - Nobuyuki Fukuda
- Second Department of Internal Medicine, University of Toyama
| | - Hiroshi Ueno
- Second Department of Internal Medicine, University of Toyama
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25
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Turner VL, Jubran A, Kim JB, Maret E, Moneghetti KJ, Haddad F, Amsallem M, Codari M, Hinostroza V, Mastrodicasa D, Sailer AM, Kobayashi Y, Nishi T, Yeung AC, Watkins AC, Lee AM, Miller DC, Fischbein MP, Fearon WF, Willemink MJ, Fleischmann D. CTA pulmonary artery enlargement in patients with severe aortic stenosis: Prognostic impact after TAVR. J Cardiovasc Comput Tomogr 2021; 15:431-440. [PMID: 33795188 PMCID: PMC10017114 DOI: 10.1016/j.jcct.2021.03.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 02/09/2021] [Accepted: 03/13/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Identifying high-risk patients who will not derive substantial survival benefit from TAVR remains challenging. Pulmonary hypertension is a known predictor of poor outcome in patients undergoing TAVR and correlates strongly with pulmonary artery (PA) enlargement on CTA. We sought to evaluate whether PA enlargement, measured on pre-procedural computed tomography angiography (CTA), is associated with 1-year mortality in patients undergoing TAVR. METHODS We retrospectively included 402 patients undergoing TAVR between July 2012 and March 2016. Clinical parameters, including Society of Thoracic Surgeons (STS) score and right ventricular systolic pressure (RVSP) estimated by transthoracic echocardiography were reviewed. PA dimensions were measured on pre-procedural CTAs. Association between PA enlargement and 1-year mortality was analyzed. Kaplan-Meier and Cox proportional hazards regression analyses were performed. RESULTS The median follow-up time was 433 (interquartiles 339-797) days. A total of 56/402 (14%) patients died within 1 year after TAVR. Main PA area (area-MPA) was independently associated with 1-year mortality (hazard ratio per standard deviation equal to 2.04 [95%-confidence interval (CI) 1.48-2.76], p < 0.001). Area under the curve (95%-CI) of the clinical multivariable model including STS-score and RVSP increased slightly from 0.67 (0.59-0.75) to 0.72 (0.72-0.89), p = 0.346 by adding area-MPA. Although the AUC increased, differences were not significant (p = 0.346). Kaplan-Meier analysis showed that mortality was significantly higher in patients with a pre-procedural non-indexed area-MPA of ≥7.40 cm2 compared to patients with a smaller area-MPA (mortality 23% vs. 9%; p < 0.001). CONCLUSIONS Enlargement of MPA on pre-procedural CTA is independently associated with 1-year mortality after TAVR.
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Affiliation(s)
- Valery L Turner
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA.
| | - Ayman Jubran
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA; Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA.
| | - Juyong Brian Kim
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA; Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA.
| | - Eva Maret
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA; Department of Clinical Physiology, Karolinska University Hospital, Karolinska Institute, Stockholm.
| | - Kegan J Moneghetti
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA.
| | - Francois Haddad
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA; Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA.
| | - Myriam Amsallem
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA; Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA.
| | - Marina Codari
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA.
| | - Virginia Hinostroza
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA.
| | - Domenico Mastrodicasa
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA; Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA.
| | - Anna M Sailer
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA.
| | - Yukari Kobayashi
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA; Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA.
| | - Takeshi Nishi
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA; Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA.
| | - Alan C Yeung
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA; Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA.
| | - Amelia C Watkins
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA, USA.
| | - Anson M Lee
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA; Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA, USA.
| | - D Craig Miller
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA; Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA, USA.
| | - Michael P Fischbein
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA; Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA, USA.
| | - William F Fearon
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA; Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA.
| | - Martin J Willemink
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA.
| | - Dominik Fleischmann
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA; Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA.
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Hemodynamics Prior to Valve Replacement for Severe Aortic Stenosis and Pulmonary Hypertension during Long-Term Follow-Up. J Clin Med 2021; 10:jcm10173878. [PMID: 34501326 PMCID: PMC8432010 DOI: 10.3390/jcm10173878] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 08/22/2021] [Accepted: 08/26/2021] [Indexed: 11/17/2022] Open
Abstract
(1) Background: Pulmonary hypertension after aortic valve replacement (AVR; post-AVR PH) carries a poor prognosis. We assessed the pre-AVR hemodynamic characteristics of patients with versus without post-AVR PH. (2) Methods: We studied 205 patients (mean age 75 ± 10 years) with severe AS (indexed aortic valve area 0.42 ± 0.12 cm2/m2, left ventricular ejection fraction 58 ± 11%) undergoing right heart catheterization (RHC) prior to surgical (70%) or transcatheter (30%) AVR. Echocardiography to assess post-AVR PH, defined as estimated systolic pulmonary artery pressure > 45 mmHg, was performed after a median follow-up of 15 months. (3) Results: There were 83/205 (40%) patients with pre-AVR PH (defined as mean pulmonary artery pressure (mPAP) ≥ 25 mmHg by RHC), and 24/205 patients (12%) had post-AVR PH (by echocardiography). Among the patients with post-AVR PH, 21/24 (88%) had already had pre-AVR PH. Despite similar indexed aortic valve area, patients with post-AVR PH had higher mPAP, mean pulmonary artery wedge pressure (mPAWP) and pulmonary vascular resistance (PVR), and lower pulmonary artery capacitance (PAC) than patients without. (4) Conclusions: Patients presenting with PH roughly one year post-AVR already had worse hemodynamic profiles in the pre-AVR RHC compared to those without, being characterized by higher mPAP, mPAWP, and PVR, and lower PAC despite similar AS severity.
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Maeder MT, Weber L, Weilenmann D, Chronis J, Joerg L, Pohle S, Haager PK, Brutsche M, Neumann T, Schoch OD, Rickli H. Impact of the new pulmonary hypertension definition on long-term mortality in patients with severe aortic stenosis undergoing valve replacement. Clin Cardiol 2021; 44:1276-1285. [PMID: 34219245 PMCID: PMC8428068 DOI: 10.1002/clc.23685] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 06/20/2021] [Accepted: 06/24/2021] [Indexed: 11/21/2022] Open
Abstract
Background The new 2018 pulmonary hypertension (PH) definition includes a lower mean pulmonary artery pressure (mPAP) cut‐off (>20 mmHg rather than ≥25 mmHg) and the compulsory requirement of a pulmonary vascular resistance (PVR) ≥3 Wood units (WU) to define precapillary PH. We assessed the clinical impact of the 2018 compared to the 2015 PH definition in aortic stenosis (AS) patients undergoing aortic valve replacement (AVR). Methods Severe AS patients (n = 487) undergoing pre‐AVR right heart catheterization were classified according to the 2015 and 2018 definitions. Post‐AVR mortality (median follow‐up 44 months) was assessed. Results Based on the 2015 definition, 66 (13%) patients exhibited combined pre and postcapillary PH (CpcPH), 116 (24%) isolated post‐capillary PH (IpcPH), 28 (6%) precapillary PH, and 277 (57%) no PH at all. Overall, 52 (11%) patients were reclassified: 23 no PH into IpcPH; 8 no PH into precapillary PH; 20 precapillary PH into no PH; 1 CpcPH into IpcPH. By the 2015 definition, only CpcPH patients displayed increased mortality, whereas by the 2018 definition, precapillary PH patients also experienced higher mortality than those without PH. Among the PH definition components, PVR ≥3 WU was the strongest predictor of death (hazard ratio > 4). Conclusions In severe AS, a higher number of IpcPH patients are diagnosed by the 2018 definition, even though they have the same prognosis as those without PH. Patients with true precapillary PH are more accurately identified by the 2018 definition that includes a pulmonary vascular disease criterion, that is, PVR ≥3 WU, a strong mortality predictor.
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Affiliation(s)
- Micha T Maeder
- Cardiology Division, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Lukas Weber
- Cardiology Division, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Daniel Weilenmann
- Cardiology Division, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Joannis Chronis
- Cardiology Division, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Lucas Joerg
- Cardiology Division, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Susanne Pohle
- Respiratory Medicine Division, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Philipp K Haager
- Cardiology Division, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Martin Brutsche
- Respiratory Medicine Division, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Thomas Neumann
- Rheumatology Division, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Otto D Schoch
- Respiratory Medicine Division, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Hans Rickli
- Cardiology Division, Kantonsspital St. Gallen, St. Gallen, Switzerland
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Okuno T, Heg D, Lanz J, Praz F, Brugger N, Stortecky S, Windecker S, Pilgrim T. Refined Staging Classification of Cardiac Damage Associated with Aortic Stenosis and Outcomes after Transcatheter Aortic Valve Implantation. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2021; 7:532-541. [PMID: 34086888 DOI: 10.1093/ehjqcco/qcab041] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 05/04/2021] [Accepted: 06/03/2021] [Indexed: 01/07/2023]
Abstract
AIMS A new staging classification of aortic stenosis (AS) characterizing the extent of cardiac damage was established and validated in patients undergoing transcatheter aortic valve implantation (TAVI). We aimed to validate an updated classification system in patients undergoing TAVI. METHODS AND RESULTS In a prospective TAVI registry, AS patients were categorized into the following stages: no cardiac damage (Stage 0), left ventricular damage (Stage 1), left atrial or mitral valve damage (Stage 2), pulmonary vasculature or tricuspid valve damage (Stage 3), or right ventricular (RV) damage or low-flow state (Stage 4). Stage 3 was sub-divided into Stage 3a (≤moderate pulmonary hypertension) and Stage 3b (severe pulmonary hypertension). Stage 4 was sub-divided into Stage 4a (low-flow without RV dysfunction), Stage 4b (RV dysfunction without low-flow), and Stage 4c (RV dysfunction with low-flow). The primary endpoint was all-cause death at 1 year. Among 1,156 eligible patients, 14 were classified as Stage 0, 38 as Stage 1, 105 as Stage 2, 278 as Stage 3, and 721 as Stage 4. There was a stepwise increase in mortality according to advancing stages of cardiac damage: 3.9% (Stage 0-1), 9.6% (Stage 2), 14.1% (Stage 3), and 17.4% (Stage 4) (p = 0.002). After multivariable adjustment, only Stage 3b, Stage 4b, and Stage 4c conferred a significantly increased risk of mortality compared to Stage 0-1. CONCLUSION More than one third of patients had advanced cardiac damage (severe pulmonary hypertension or RV dysfunction) before TAVI, associating with a 5- to 7-fold increased risk of mortality at 1 year.
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Affiliation(s)
- Taishi Okuno
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Dik Heg
- CTU, University of Bern, Bern, Switzerland
| | - Jonas Lanz
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Fabien Praz
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Nicolas Brugger
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Stefan Stortecky
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Stephan Windecker
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Thomas Pilgrim
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
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Schewel J, Kuck KH, Frerker C, Schmidt T, Schewel D. Outcome of aortic stenosis according to invasive cardiac damage staging after transcatheter aortic valve replacement. Clin Res Cardiol 2021; 110:699-710. [PMID: 33744987 DOI: 10.1007/s00392-021-01835-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Accepted: 03/01/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND In recent studies, a 5-stage cardiac damage classification in severe aortic stenosis (AS) based on echocardiographic parameters has shown to provide predictive value regarding clinical outcome. The objective of this study was to investigate the prognostic impact of a cardiac damage classification based on invasive hemodynamics in patients with AS undergoing transcatheter aortic valve replacement (TAVR). METHODS A total of 1400 patients with symptomatic AS and full invasive hemodynamic assessment before TAVR were included. Patients were categorized according to their cardiac damage stage into five groups that are defined as: stage 0, no cardiac damage; stage 1, left ventricular damage; stage 2, left atrial and/or mitral valve damage; stage 3, pulmonary vasculature and/or tricuspid valve damage; stage 4, right ventricular damage. RESULTS 9.9% patients were classified as stage 0, 23.6% as stage 1, the majority of patients as stage 2 (33.5%), 23.1% as stage 3 and 10% as stage 4. One- and 4-year mortality were 10.1%/29.5% in stage 0, 16.1%/60.6% in stage 1, 17.3%/39.4% in stage 2, 22%/54.6% in stage 3, 27.1%/62.2% in stage 4 (p = 0.001/p < 0.001). The extent of cardiac damage was independently associated with increased mortality after TAVR (HR 1.16 per each increment in stage, 95% confidence interval 1.03-1.18; p = 0.018). CONCLUSIONS Cardiac damage staging in severe AS patients based on invasive hemodynamics appears to show strong association between the extent of cardiac damage and post-TAVR mortality. This staging classification provides predictive value and may improve risk stratification, therapy management and decision-making in patients with AS. Invasive Staging Classification of Cardiac Damage in Severe Symptomatic Aortic Stenosis has an Impact on Outcome after TAVR. (Top) Invasive staging criteria for cardiac damage in five stages using left ventricular end-diastolic pressure (LVEDP) for stage 1 (red), post-capillary wedge pressure (PCWP) for stage 2 (green), systolic pulmonary artery pressure (SPAP) for stage 3 (purple) and right atrial pressure (RAP) for stage 4 (yellow). The cake chart shows the distribution of the different stage in the whole cohort. (Bottom) Survival Analyses According to Stage of Cardiac Damage after Transcatheter Aortic Valve Replacement using Invasive Criteria. Kaplan-Meier plots comparing overall (left) and cardiovascular (right) 4-year survival showing with the more advancing stage a higher mortality rate.
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Affiliation(s)
- Jury Schewel
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany. .,Department of Cardiology, Marienkrankenhaus Hamburg, Alfredstr. 9, 22087, Hamburg, Germany.
| | - Karl-Heinz Kuck
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany.,Department of Cardiology, University Heart Center Lübeck, Lübeck, Germany.,Cardiology, Lanserhof GmbH, Hamburg, Germany
| | - Christian Frerker
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany.,Department of Cardiology, University Heart Center Lübeck, Lübeck, Germany
| | - Tobias Schmidt
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany.,Department of Cardiology, University Heart Center Lübeck, Lübeck, Germany
| | - Dimitry Schewel
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany.,Department of Cardiology, Marienkrankenhaus Hamburg, Alfredstr. 9, 22087, Hamburg, Germany
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Gupta T, Joseph DT, Goel SS, Kleiman NS. Predicting and measuring mortality risk after transcatheter aortic valve replacement. Expert Rev Cardiovasc Ther 2021; 19:247-260. [PMID: 33560150 DOI: 10.1080/14779072.2021.1888715] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: Over the last decade, transcatheter aortic valve replacement (TAVR) has emerged as a treatment option for most patients with severe symptomatic aortic stenosis (AS). With growing indications and exponential increase in the number of TAVR procedures, it is important to be able to accurately predict mortality after TAVR.Areas covered: Herein, we review the surgical and TAVR-specific mortality prediction models (MPMs) and their performance in their original derivation and external validation cohorts. We then discuss the role of other important risk assessment tools such as frailty, echocardiographic parameters, and biomarkers in patients, being considered for TAVR.Expert opinion: Conventional surgical MPMs have suboptimal predictive performance and are mis-calibrated when applied to TAVR populations. Although a number of TAVR-specific MPMs have been developed, their utility is also limited by their modest discriminative ability when applied to populations external to their original derivation cohorts. There is an unmet need for robust TAVR MPMs that accurately predict post TAVR mortality. In the interim, heart teams should utilize the currently available TAVR-specific MPMs in conjunction with other prognostic factors, such as frailty, echocardiographic or computed tomography (CT) imaging parameters, and biomarkers for risk assessment of patients, being considered for TAVR.
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Affiliation(s)
- Tanush Gupta
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, USA
| | - Denny T Joseph
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, USA
| | - Sachin S Goel
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, USA
| | - Neal S Kleiman
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, USA
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Tastet L, Généreux P, Bernard J, Pibarot P. The Role of Extravalvular Cardiac Damage Staging in Aortic Valve Disease Management. Can J Cardiol 2021; 37:1004-1015. [PMID: 33539990 DOI: 10.1016/j.cjca.2021.01.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 01/19/2021] [Accepted: 01/22/2021] [Indexed: 10/22/2022] Open
Abstract
Current management of patients with aortic valve disease, including aortic valve stenosis (AS), aortic valve regurgitation (AR), and mixed aortic valve disease (MAVD), remains challenging. American and European guideline recommendations regarding the timing of intervention are mainly based on the assessment of disease severity (ie, grading), presence of symptoms related to aortic valve disease, left ventricular systolic dysfunction, or LV enlargement. Furthermore, the decision regarding the type of intervention (ie, surgical vs transcatheter) is primarily based on risk assessment from surgical risk scores. There is, however, less emphasis on the importance of the assessment of anatomic and functional cardiac repercussions of aortic valve disease to guide the clinical management of these patients. Recently, a novel approach has been proposed to improve the management of aortic valve disease with 2 main components for risk stratification of the disease: 1) grading the severity of aortic valve disease, and 2) staging the extent of extravalvular cardiac damage associated with aortic valve disease with the use of echocardiography. To date, this novel approach of extravalvular cardiac damage staging was proposed and validated only in the context of AS but could be extended to other valvular heart diseases, including AR and MAVD. Further studies are also needed to test the incremental value of additional imaging parameters (eg, myocardial fibrosis by magnetic resonance) as well as blood biomarkers (eg, natriuretic peptide, cardiac troponin, and others) to the existing cardiac damage staging schemes.
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Affiliation(s)
- Lionel Tastet
- Institut universitaire de cardiologie et de pneumologie de Québec-Université Laval, Québec City, Québec, Canada
| | - Philippe Généreux
- Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, New Jersey, USA; Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA; Hôpital du Sacré-Cœur de Montréal, Montréal, Québec, Canada
| | - Jérémy Bernard
- Institut universitaire de cardiologie et de pneumologie de Québec-Université Laval, Québec City, Québec, Canada
| | - Philippe Pibarot
- Institut universitaire de cardiologie et de pneumologie de Québec-Université Laval, Québec City, Québec, Canada.
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32
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Pulmonary hypertension in aortic valve stenosis. Trends Cardiovasc Med 2020; 32:73-81. [DOI: 10.1016/j.tcm.2020.12.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 11/26/2020] [Accepted: 12/12/2020] [Indexed: 01/09/2023]
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Maeder MT, Weber L, Weilenmann D, Haager PK, Joerg L, Rohner F, Ammann P, Chronis J, Rigger J, Rickli H. Impact of a volume challenge on haemodynamics and prognosis in patients with severe aortic stenosis. ESC Heart Fail 2020; 8:508-517. [PMID: 33179419 PMCID: PMC7835590 DOI: 10.1002/ehf2.13108] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 10/15/2020] [Accepted: 10/24/2020] [Indexed: 11/11/2022] Open
Abstract
Aims A volume challenge can unmask pulmonary hypertension (PH) and its mechanism. We evaluated the impact of a volume challenge on mean pulmonary artery pressure (mPAP) and mean pulmonary artery wedge pressure (mPAWP) and its prognostic implications in patients with severe aortic stenosis (AS) undergoing aortic valve replacement (AVR). Methods and results In 285 patients with severe AS (indexed aortic valve area 0.41 ± 0.13 cm2/m2), mPAP and mPAWP were measured before and after administration of 150 ± 58 mL of low‐osmolal or iso‐osmolal contrast. Following contrast, mPAP and mPAWP rose from 25 ± 10 and 16 ± 8 mmHg by 5 ± 4 and 4 ± 4 mmHg to 30 ± 11 and 20 ± 8 mmHg. There were 112 (39%) patients with pre‐contrast PH and 70 (40% of those without pre‐contrast PH) patients with post‐contrast PH only. Post‐contrast PH patients were intermediate between pre‐contrast PH and no PH in terms of AS severity, cardiac dysfunction, and haemodynamics. After a median follow‐up of 43 months post‐AVR, pre‐contrast PH patients had numerically the highest mortality driven by those with pre‐contrast combined pre‐capillary and post‐capillary PH (n = 35), while post‐contrast changes in mPAP and mPAWP were not related to mortality. Patients with any post‐contrast mPAWP > 18 mmHg had significantly higher mortality than those with post‐contrast mPAWP ≤ 18 mmHg, Conclusions In severe AS, a contrast challenge leads to post‐contrast PH in ~40% of patients without pre‐contrast PH. However, post‐contrast haemodynamic changes do not adversely affect outcomes in patients undergoing AVR. Post‐contrast PH represents an intermediate stage of ‘cardiac damage’, which may be attenuated or reversible after AVR.
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Affiliation(s)
- Micha T Maeder
- Cardiology Division, Kantonsspital St. Gallen, Rorschacherstrasse 95, 9007, St. Gallen, Switzerland
| | - Lukas Weber
- Cardiology Division, Kantonsspital St. Gallen, Rorschacherstrasse 95, 9007, St. Gallen, Switzerland
| | - Daniel Weilenmann
- Cardiology Division, Kantonsspital St. Gallen, Rorschacherstrasse 95, 9007, St. Gallen, Switzerland
| | - Philipp K Haager
- Cardiology Division, Kantonsspital St. Gallen, Rorschacherstrasse 95, 9007, St. Gallen, Switzerland
| | - Lucas Joerg
- Cardiology Division, Kantonsspital St. Gallen, Rorschacherstrasse 95, 9007, St. Gallen, Switzerland
| | - Franziska Rohner
- Cardiology Division, Kantonsspital St. Gallen, Rorschacherstrasse 95, 9007, St. Gallen, Switzerland
| | - Peter Ammann
- Cardiology Division, Kantonsspital St. Gallen, Rorschacherstrasse 95, 9007, St. Gallen, Switzerland
| | - Joannis Chronis
- Cardiology Division, Kantonsspital St. Gallen, Rorschacherstrasse 95, 9007, St. Gallen, Switzerland
| | - Johannes Rigger
- Cardiology Division, Kantonsspital St. Gallen, Rorschacherstrasse 95, 9007, St. Gallen, Switzerland
| | - Hans Rickli
- Cardiology Division, Kantonsspital St. Gallen, Rorschacherstrasse 95, 9007, St. Gallen, Switzerland
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Ennezat PV, Malergue MC, Le Jemtel TH, Abergel E. Watchful waiting care or early intervention in asymptomatic severe aortic stenosis: Where we are. Arch Cardiovasc Dis 2020; 114:59-72. [PMID: 33153947 DOI: 10.1016/j.acvd.2020.07.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 07/22/2020] [Accepted: 07/28/2020] [Indexed: 11/17/2022]
Abstract
Aortic stenosis, the most common valvular heart disease in Western countries, affects predominantly older people. Prompt aortic valve replacement is undoubtedly indicated in symptomatic patients. Management of asymptomatic patients is nowadays shifting from a conservative approach to early aortic valve replacement, as multimodality imaging is increasingly available. However, multimodality imaging has led to multiple prognostic parameters and complex algorithms, as well as a new staging classification that has left patients and physicians somewhat puzzled. We highlight the value of thorough serial clinical examinations, Doppler echocardiography and exercise testing when caring for a growing aortic stenosis population, including that has no or limited access to multimodality imaging. Evidence for early aortic valve replacement versus conservative management in asymptomatic patients with severe aortic stenosis is biased by the lack of serial stress testing evaluation; 30% of so-called asymptomatic patients were in fact symptomatic, and thus were clear candidates for aortic valve replacement in the above-mentioned studies. Randomized trials of aortic valve replacement versus conservative management that include serial stress testing evaluation are needed to ascertain whether early aortic valve replacement actually improves clinical outcome in asymptomatic patients with severe aortic stenosis. Less interventional medicine and healthcare resource utilization can result in better health.
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Affiliation(s)
- Pierre Vladimir Ennezat
- Department of cardiology, centre hospitalier universitaire de Grenoble-Alpes, 38700 La Tronche, France
| | | | - Thierry H Le Jemtel
- Section of cardiology, department of medicine, Tulane university school of medicine, Tulane university heart and vascular institute, 70112 New Orleans, LA, USA
| | - Eric Abergel
- Department of cardiology and cardiovascular surgery, clinique Saint-Augustin, 114, avenue d'Ares, 33200 Bordeaux, France.
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35
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Mujeeb FA, Mostafa MR, Alqahtani F, Trabulsi AM, Chundrigar M, Rawasia WF. Burden of Pulmonary Hypertension in Transcatheter Aortic Valve Implantation. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 29:93-94. [PMID: 32814674 DOI: 10.1016/j.carrev.2020.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 08/04/2020] [Accepted: 08/04/2020] [Indexed: 10/23/2022]
Affiliation(s)
| | | | - Fahad Alqahtani
- Gill Heart and Vascular Institute, University of Kentucky, Lexington, KY, United States of America
| | | | | | - Wasiq F Rawasia
- River Region Cardiology Associates, Montgomery, AL, United States of America.
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36
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Tastet L, Vincent F, Pibarot P. Cardiac Damage Staging in Aortic Stenosis: A Perspective From the Cardiac Catheterization Laboratory. Can J Cardiol 2020; 36:1583-1586. [PMID: 32634394 DOI: 10.1016/j.cjca.2020.03.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 03/22/2020] [Accepted: 03/22/2020] [Indexed: 10/24/2022] Open
Affiliation(s)
- Lionel Tastet
- Institut universitaire de cardiologie et de pneumologie de Québec-Université Laval/Québec Heart & Lung Institute-Laval University, Québec City, Québec, Canada
| | - Flavien Vincent
- Institut universitaire de cardiologie et de pneumologie de Québec-Université Laval/Québec Heart & Lung Institute-Laval University, Québec City, Québec, Canada; CHU Lille, Institut Coeur Poumon, Cardiology, Department of Interventional Cardiology for Coronary, Valves and Structural Heart Diseases, Inserm, U1011, Institut Pasteur de Lille, EGID, Université de Lille, Lille, France
| | - Philippe Pibarot
- Institut universitaire de cardiologie et de pneumologie de Québec-Université Laval/Québec Heart & Lung Institute-Laval University, Québec City, Québec, Canada.
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Schewel J, Schlüter M, Schmidt T, Kuck K, Frerker C, Schewel D. Correlation between Doppler echocardiography and right heart catheterization assessment of systolic pulmonary artery pressure in patients with severe aortic stenosis. Echocardiography 2020; 37:380-387. [DOI: 10.1111/echo.14611] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Revised: 01/12/2020] [Accepted: 01/21/2020] [Indexed: 12/12/2022] Open
Affiliation(s)
- Jury Schewel
- Department of Cardiology Asklepios Klinik St. Georg Hamburg Germany
| | | | - Tobias Schmidt
- Department of Cardiology Asklepios Klinik St. Georg Hamburg Germany
| | - Karl‐Heinz Kuck
- Department of Cardiology Asklepios Klinik St. Georg Hamburg Germany
| | | | - Dimitry Schewel
- Department of Cardiology Asklepios Klinik St. Georg Hamburg Germany
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38
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Pibarot P, Iung B, Cavalcante JL. Risk Stratification in Patients With Aortic Stenosis. JACC Cardiovasc Interv 2019; 12:2169-2172. [DOI: 10.1016/j.jcin.2019.08.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 08/20/2019] [Indexed: 01/06/2023]
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