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Tastet L, Shen M, Capoulade R, Arsenault M, Bédard É, Abdoun K, Fleury MA, Côté N, Pibarot P, Clavel MA. Sex-Specific Functional Status Decline and Outcomes in Mild-to-Moderate Aortic Stenosis: Results From the PROGRESSA Study. JACC. ADVANCES 2024; 3:101267. [PMID: 39296821 PMCID: PMC11408378 DOI: 10.1016/j.jacadv.2024.101267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 07/17/2024] [Accepted: 08/06/2024] [Indexed: 09/21/2024]
Abstract
Background Little is known about the effect of sex on functional status decline in aortic valve stenosis (AS) patients. Objectives The purpose of this study was to examine the changes in functional status according to sex in patients with mild-to-moderate AS and its association with the composite of death or aortic valve replacement (AVR). Methods We included patients with mild-to-moderate AS prospectively recruited in the PROGRESSA (Metabolic Determinants of the Progression of Aortic Stenosis) study (NCT01679431). Functional status was assessed using the New York Heart Association classification and the Duke Activity Status Index (DASI). Results A total of 244 patients (mean age 64 ± 14 years, 29% women) were included. The mean follow-up was 4.3 ± 2.4 years. Women with intermediate-to-fast AS progression rate (median change in peak aortic jet velocity ≥0.11 m/s/year) had significantly faster decline in DASI score compared to men with similar progression rate (P < 0.05). In linear mixed analysis adjusted for several clinical and echocardiographic factors, female sex and change in peak aortic jet velocity remained strongly associated with the worsening of New York Heart Association class and the decline of DASI score (all, P < 0.001). The composite of death or AVR occurred in 115 patients (16 deaths and 99 AVRs). In multivariable Cox regression analyses, functional status decline during follow-up remained significantly associated with the composite of death or AVR (HR: 2.13; 95% CI: 1.22-3.73; P = 0.008). Conclusions In patients with mild-to-moderate AS at baseline, intermediate-to-fast progression rate of AS was associated with a more rapid decline of functional status during follow-up, particularly in women. Functional status decline during follow-up was strongly associated with the incidence of death or AVR, with comparable effect in both women and men.
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Affiliation(s)
- Lionel Tastet
- Institut universitaire de cardiologie et de pneumologie de Québec, Université Laval, Québec city, Québec, Canada
- Department of Medicine (Cardiovascular Division), University of California, San Francisco, California, USA
| | - Mylène Shen
- Institut universitaire de cardiologie et de pneumologie de Québec, Université Laval, Québec city, Québec, Canada
| | - Romain Capoulade
- Nantes Université, CHU Nantes, CNRS, INSERM, l'institut du thorax, Nantes, France
| | - Marie Arsenault
- Institut universitaire de cardiologie et de pneumologie de Québec, Université Laval, Québec city, Québec, Canada
| | - Élisabeth Bédard
- Institut universitaire de cardiologie et de pneumologie de Québec, Université Laval, Québec city, Québec, Canada
| | - Kathia Abdoun
- Institut universitaire de cardiologie et de pneumologie de Québec, Université Laval, Québec city, Québec, Canada
| | - Marie-Ange Fleury
- Institut universitaire de cardiologie et de pneumologie de Québec, Université Laval, Québec city, Québec, Canada
| | - Nancy Côté
- 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
| | - Marie-Annick Clavel
- Institut universitaire de cardiologie et de pneumologie de Québec, Université Laval, Québec city, Québec, Canada
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Mannina C, Chopra L, Maenza J, Prandi FR, Argulian E, Hadley M, Halperin J, Sharma SK, Kini A, Lerakis S. Left Ventricular Remodeling in Patients with Low Flow Aortic Stenosis Undergoing Transcatheter Aortic Valve Replacement. Am J Cardiol 2024; 225:125-133. [PMID: 38925261 DOI: 10.1016/j.amjcard.2024.06.021] [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: 04/30/2024] [Revised: 05/22/2024] [Accepted: 06/18/2024] [Indexed: 06/28/2024]
Abstract
Low-flow (LF) aortic stenosis (AS) is common among older adults and associated with worse outcomes than AS with normal stroke volume. It is unknown whether left ventricular (LV) remodeling identifies patients with LF AS at higher risk of complications. LV remodeling was evaluated in 463 patients with severe LF AS referred for transcatheter aortic valve replacement (TAVR) and classified as adaptive (normal geometry and concentric remodeling) or maladaptive (concentric and eccentric hypertrophy) using the American Society of Echocardiography gender-specific criteria. Of these, the 390 patients who underwent TAVR were followed for the end points of heart failure (HF) hospitalization and all-cause mortality. The mean patient age was 79 (74.5 to 84) years. LV remodeling was adaptive in 57.4% (62 normal geometry, 162 concentric remodeling) and maladaptive in 42.6% (127 concentric hypertrophy, 39 eccentric hypertrophy). During a median follow-up of 3 years, 45 patients (11.5%) were hospitalized for HF and 73 (18.7%) died. After adjustment for widely used echocardiographic parameters, maladaptive remodeling was independently associated with HF hospitalization and death (adjusted hazard ratio 1.75, confidence interval 1.03 to 3.00). There was no significant difference between men and women in the association of maladaptive LV remodeling with the composite outcome (p = 0.40 for men and p = 0.06 for women). In conclusion, in patients with LF AS, maladaptive LV remodeling before TAVR is independently associated with higher incidences of postprocedural HF rehospitalization and death in both men and women. Assessment of LV remodeling has prognostic value over and above LV ejection fraction and may improve risk stratification for patients with LF AS.
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Affiliation(s)
| | | | | | - Francesca R Prandi
- The Zena and Michael A. Wiener Cardiovascular Institute, The Mount Sinai Hospital
| | - Edgar Argulian
- Division of Cardiology, Mount Sinai Morningside, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Michael Hadley
- The Zena and Michael A. Wiener Cardiovascular Institute, The Mount Sinai Hospital
| | - Jonathan Halperin
- The Zena and Michael A. Wiener Cardiovascular Institute, The Mount Sinai Hospital
| | - Samin K Sharma
- The Zena and Michael A. Wiener Cardiovascular Institute, The Mount Sinai Hospital
| | - Annapoorna Kini
- The Zena and Michael A. Wiener Cardiovascular Institute, The Mount Sinai Hospital
| | - Stamatios Lerakis
- The Zena and Michael A. Wiener Cardiovascular Institute, The Mount Sinai Hospital.
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3
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Khoury S, Zornitzki L, Laufer-Perl M, Bhatia RT, Marwaha S, Tome M, Granot Y, Gvili Perelman M, Avivi I, Shacham Y, Szekely Y, Banai S, Hochstadt A, Flint N, Topilsky Y. Sex-related differences in the association between septal wall thickness and survival. IJC HEART & VASCULATURE 2024; 53:101427. [PMID: 38846157 PMCID: PMC11152968 DOI: 10.1016/j.ijcha.2024.101427] [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: 03/24/2024] [Revised: 05/08/2024] [Accepted: 05/11/2024] [Indexed: 06/09/2024]
Abstract
Background In many conditions characterised by septal hypertrophy, females have been shown to have worse outcomes compared to males. In clinical practice and research, similar cutoff points for septal hypertrophy are still used for both sexes. Here, we explore the association between different cutoff points for septal hypertrophy and survival in relation to sex. Methods and results We performed a retrospective analysis of consecutive patients undergoing echocardiography between March 2010 and February 2021 in a large tertiary referral centre. A total of 70,965 individuals were included. Over a mean follow-up period of 59.1 ± 37 months, 9631 (25 %) males and 8429 (26 %) females died. When the same cutoff point for septal hypertrophy was used for both sexes, females had worse prognosis than males. The impact of septal hypotrophy on survival became statistically significant at a lower threshold in females compared to males: 11.1 mm (HR 1.13, CI 95 %:1.03-1.23, p = 0.01) vs 13.1 mm (HR 1.21, CI 95 %: 1.12-1.32, p < 0.001). However, when indexed wall thickness was used, the cutoff points were 6 mm/body surface area (BSA) (HR 1.08, CI 95 %: 1-1.18, p = 0.04) and 6.2 mm/BSA (HR 1.07, CI 95 %: 1-1.15, p = 0.05) for females and males, respectively. Conclusions Septal hypertrophy is associated with increased mortality at a lower threshold in females than in males. This may account for the worse prognosis reported in females in many conditions characterised by septal hypertrophy. Applying a lower absolute value or using indexed measurements may facilitate early diagnosis and improve prognostication in females.
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Affiliation(s)
- Shafik Khoury
- Department of Cardiology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Tel Aviv University, Tel Aviv, Israel
| | - Lior Zornitzki
- Department of Cardiology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Tel Aviv University, Tel Aviv, Israel
| | - Michal Laufer-Perl
- Department of Cardiology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Tel Aviv University, Tel Aviv, Israel
| | - Raghav T. Bhatia
- Cardiovascular Clinical Academic Group, St. George’s, University of London, St. George’s University Hospitals NHS Foundation Trust, United Kingdom
| | - Sarandeep Marwaha
- Cardiovascular Clinical Academic Group, St. George’s, University of London, St. George’s University Hospitals NHS Foundation Trust, United Kingdom
| | - Maite Tome
- Cardiovascular Clinical Academic Group, St. George’s, University of London, St. George’s University Hospitals NHS Foundation Trust, United Kingdom
| | - Yoav Granot
- Department of Cardiology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Tel Aviv University, Tel Aviv, Israel
| | - Moran Gvili Perelman
- Department of Cardiology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Tel Aviv University, Tel Aviv, Israel
| | - Ido Avivi
- Department of Cardiology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Tel Aviv University, Tel Aviv, Israel
| | - Yacov Shacham
- Department of Cardiology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Tel Aviv University, Tel Aviv, Israel
| | - Yishay Szekely
- Department of Cardiology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Tel Aviv University, Tel Aviv, Israel
| | - Shmuel Banai
- Department of Cardiology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Tel Aviv University, Tel Aviv, Israel
| | - Aviram Hochstadt
- Department of Cardiology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Tel Aviv University, Tel Aviv, Israel
| | - Nir Flint
- Department of Cardiology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Tel Aviv University, Tel Aviv, Israel
| | - Yan Topilsky
- Department of Cardiology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Tel Aviv University, Tel Aviv, Israel
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4
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Springhetti P, Abdoun K, Clavel MA. Sex Differences in Aortic Stenosis: From the Pathophysiology to the Intervention, Current Challenges, and Future Perspectives. J Clin Med 2024; 13:4237. [PMID: 39064275 PMCID: PMC11278486 DOI: 10.3390/jcm13144237] [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: 06/24/2024] [Revised: 07/16/2024] [Accepted: 07/17/2024] [Indexed: 07/28/2024] Open
Abstract
Calcific aortic stenosis (AS) is a major cause of morbidity and mortality in high-income countries. AS presents sex-specific features impacting pathophysiology, outcomes, and management strategies. In women, AS often manifests with a high valvular fibrotic burden, small valvular annuli, concentric left ventricular (LV) remodeling/hypertrophy, and, frequently, supernormal LV ejection fraction coupled with diastolic dysfunction. Paradoxical low-flow low-gradient AS epitomizes these traits, posing significant challenges post-aortic valve replacement due to limited positive remodeling and significant risk of patient-prosthesis mismatch. Conversely, men present more commonly with LV dilatation and dysfunction, indicating the phenotype of classical low-flow low-gradient AS, i.e., with decreased LV ejection fraction. However, these distinctions have not been fully incorporated into guidelines for AS management. The only treatment for AS is aortic valve replacement; women are frequently referred late, leading to increased heart damage caused by AS. Therefore, it is important to reassess surgical planning and timing to minimize irreversible cardiac damage in women. The integrity and the consideration of sex differences in the management of AS is critical. Further research, including sufficient representation of women, is needed to investigate these differences and to develop individualized, sex-specific management strategies.
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Affiliation(s)
- Paolo Springhetti
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, QC G1V 4G5, Canada; (P.S.); (K.A.)
- Department of Medicine, Division of Cardiology, University of Verona, 37129 Verona, Italy
| | - Kathia Abdoun
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, QC G1V 4G5, Canada; (P.S.); (K.A.)
| | - Marie-Annick Clavel
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, QC G1V 4G5, Canada; (P.S.); (K.A.)
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5
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Mohanty S, Wessler BS. Guidelines Reinforce Treatment Disparities for Patients with Aortic Stenosis. J Am Soc Echocardiogr 2024:S0894-7317(24)00348-1. [PMID: 38986918 DOI: 10.1016/j.echo.2024.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2024] [Revised: 07/01/2024] [Accepted: 07/02/2024] [Indexed: 07/12/2024]
Affiliation(s)
- Sharanya Mohanty
- Division of Cardiology, Tufts Medical Center, Boston, Massachusetts.
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6
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Martin TG, Leinwand LA. Hearts apart: sex differences in cardiac remodeling in health and disease. J Clin Invest 2024; 134:e180074. [PMID: 38949027 PMCID: PMC11213513 DOI: 10.1172/jci180074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2024] Open
Abstract
Biological sex is an important modifier of physiology and influences pathobiology in many diseases. While heart disease is the number one cause of death worldwide in both men and women, sex differences exist at the organ and cellular scales, affecting clinical presentation, diagnosis, and treatment. In this Review, we highlight baseline sex differences in cardiac structure, function, and cellular signaling and discuss the contribution of sex hormones and chromosomes to these characteristics. The heart is a remarkably plastic organ and rapidly responds to physiological and pathological cues by modifying form and function. The nature and extent of cardiac remodeling in response to these stimuli are often dependent on biological sex. We discuss organ- and molecular-level sex differences in adaptive physiological remodeling and pathological cardiac remodeling from pressure and volume overload, ischemia, and genetic heart disease. Finally, we offer a perspective on key future directions for research into cardiac sex differences.
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Affiliation(s)
- Thomas G. Martin
- Department of Molecular, Cellular, and Developmental Biology and
- BioFrontiers Institute, University of Colorado Boulder, Boulder, Colorado, USA
| | - Leslie A. Leinwand
- Department of Molecular, Cellular, and Developmental Biology and
- BioFrontiers Institute, University of Colorado Boulder, Boulder, Colorado, USA
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7
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Troger F, Kremser C, Pamminger M, Reinstadler SJ, Thurner GC, Henninger B, Klug G, Metzler B, Mayr A. Functional aortic valve area differs significantly between sexes: A phase-contrast cardiac MRI study in patients with severe aortic stenosis. IJC HEART & VASCULATURE 2024; 51:101357. [PMID: 38356930 PMCID: PMC10863308 DOI: 10.1016/j.ijcha.2024.101357] [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: 01/03/2024] [Revised: 02/01/2024] [Accepted: 02/02/2024] [Indexed: 02/16/2024]
Abstract
Background Aortic stenosis (AS) is one of the most prevalent valvular heart-diseases in Europe. Currently, diagnosis and classification are not sex-sensitive; however, due to a distinctly different natural history of AS, further investigations of sex-differences in AS-patients are needed. Thus, this study aimed to detect sex-differences in severe AS, especially concerning flow-patterns, via phase-contrast cardiac magnetic resonance imaging (PC-CMR). Methods Forty-four severe AS-patients (20 women, 45 % vs. 24 men, 55 %) with a median age of 72 years underwent transthoracic echocardiography (TTE), cardiac catheterization (CC) and CMR. Aortic valve area (AVA) and stroke volume (SV) were determined in all modalities, with CMR yielding geometrical AVA via cine-planimetry and functional AVA via PC-CMR, the latter being also used to examine flow-properties. Results Geometrical AVA showed no sex-differences (0.91 cm2, IQR: 0.61-1.14 vs. 0.94 cm2, IQR: 0.77-1.22, p = 0.322). However, functional AVA differed significantly between sexes in all three modalities (TTE: p = 0.044; CC/PC-CMR: p < 0.001). In men, no significant intermethodical biases in functional AVA-measurements between modalities were found (p = 0.278); yet, in women the particular measurements differed significantly (p < 0.001). Momentary flowrate showed sex-differences depending on momentary opening-degree (at 50 %, 75 % and 90 % of peak-AVA, all p < 0.001), with men showing higher flowrates with increasing opening-area. In women, flowrate did not differ between 75 % and 90 % of peak-AVA (p = 0.191). Conclusions In severe AS-patients, functional AVA showed marked sex-differences in all modalities, whilst geometrical AVA did not differ. Inter-methodical biases were negligible in men, but not in women. Lastly, significant sex-differences in flow-patterns fit in with the different pathogenesis of AS.
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Affiliation(s)
- Felix Troger
- University Clinic of Radiology, Medical University of Innsbruck, Anichstrasse 35 6020, Innsbruck, Austria
| | - Christian Kremser
- University Clinic of Radiology, Medical University of Innsbruck, Anichstrasse 35 6020, Innsbruck, Austria
| | - Mathias Pamminger
- University Clinic of Radiology, Medical University of Innsbruck, Anichstrasse 35 6020, Innsbruck, Austria
| | - Sebastian J Reinstadler
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35 6020, Innsbruck, Austria
| | - Gudrun C Thurner
- Institute of Pathology, Neuropathology and Molecular Pathology, Medical University of Innsbruck, Müllerstraße 44 6020, Innsbruck, Austria
| | - Benjamin Henninger
- University Clinic of Radiology, Medical University of Innsbruck, Anichstrasse 35 6020, Innsbruck, Austria
| | - Gert Klug
- Department of Internal Medicine, County Hospital Bruck an der Mur, Tragoesser Strasse 1 8600, Bruck an der Mur, Austria
| | - Bernhard Metzler
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35 6020, Innsbruck, Austria
| | - Agnes Mayr
- University Clinic of Radiology, Medical University of Innsbruck, Anichstrasse 35 6020, Innsbruck, Austria
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8
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Ram C, Yousef S, Ma WG, Vallabhajosyula I, Singh S, Agarwal R, Milewski RK, Assi R, Patel PA, Williams M, Geirsson A, Vallabhajosyula P. Living in disadvantaged neighborhoods linked to less intervention for severe aortic stenosis. Sci Rep 2024; 14:4952. [PMID: 38418864 PMCID: PMC10902341 DOI: 10.1038/s41598-024-52660-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 01/22/2024] [Indexed: 03/02/2024] Open
Abstract
To investigate the association between area deprivation index (ADI) and aortic valve replacement (AVR) in patients with severe aortic stenosis (AS). Patients aged 40-95 years with severe AS confirmed by echocardiography were included. The 9-digit zip code of patient residence address was used to identify the ADI ranking, based on which patients were divided into 5 groups (with Group E being most deprived). The rates of AV intervention were compared among 5 groups using competing risks analysis, with death as a competing event. We included 1751 patients with severe AS from 2013 to 2018 followed for a median 2.8 (interquartile range, 1.5-4.8) years. The more distressed ADI groups tended to be younger (P = 0.002), female (P < 0.001), and of African American race (P < 0.001), have higher presentation of sepsis (P = 0.031), arrhythmia (P = 0.022), less likely to have previous diagnosis of AS (P < 0.001); and were less likely to undergo AVR (52.5% vs 46.9% vs 46.1% vs 48.9% vs 39.7%, P = 0.023). Using competing risk analysis, the highest ADI group (E) were the least and the lowest ADI group (A) the most likely to undergo AVR (Gray's test, P = 0.025). The association between ADI ranking and AVR rates was influenced by sex and race. Within group analysis, there was significant association between race and AVR (Gray's test, P < 0.001), and between sex and AVR (Gray's test, P < 0.001). Patients with severe AS living in more deprived neighborhoods were less likely to undergo aortic valve interventions, which was influenced by female gender, and African American race.
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Affiliation(s)
- Chirag Ram
- Division of Cardiac Surgery, Yale Aortic Institute, Yale School of Medicine, 330 Cedar Street BB204, New Haven, CT, 06520, USA
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Sameh Yousef
- Division of Cardiac Surgery, Yale Aortic Institute, Yale School of Medicine, 330 Cedar Street BB204, New Haven, CT, 06520, USA
| | - Wei-Guo Ma
- Division of Cardiac Surgery, Yale Aortic Institute, Yale School of Medicine, 330 Cedar Street BB204, New Haven, CT, 06520, USA
| | - Ishani Vallabhajosyula
- Division of Cardiac Surgery, Yale Aortic Institute, Yale School of Medicine, 330 Cedar Street BB204, New Haven, CT, 06520, USA
| | - Saket Singh
- Division of Cardiac Surgery, Yale Aortic Institute, Yale School of Medicine, 330 Cedar Street BB204, New Haven, CT, 06520, USA
| | - Ritu Agarwal
- Joint Data Analytics Team, Information Technology Service, Yale University, New Haven, USA
| | - Rita K Milewski
- Division of Cardiac Surgery, Yale Aortic Institute, Yale School of Medicine, 330 Cedar Street BB204, New Haven, CT, 06520, USA
| | - Roland Assi
- Division of Cardiac Surgery, Yale Aortic Institute, Yale School of Medicine, 330 Cedar Street BB204, New Haven, CT, 06520, USA
| | - Prakash A Patel
- Division of Cardiac Anesthesiology, Yale School of Medicine, New Haven, CT, USA
| | - Matthew Williams
- Division of Cardiac Surgery, Yale Aortic Institute, Yale School of Medicine, 330 Cedar Street BB204, New Haven, CT, 06520, USA
| | - Arnar Geirsson
- Division of Cardiac Surgery, Yale Aortic Institute, Yale School of Medicine, 330 Cedar Street BB204, New Haven, CT, 06520, USA
| | - Prashanth Vallabhajosyula
- Division of Cardiac Surgery, Yale Aortic Institute, Yale School of Medicine, 330 Cedar Street BB204, New Haven, CT, 06520, USA.
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9
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Dattani A, Brady EM, Kanagala P, Stoma S, Parke KS, Marsh AM, Singh A, Arnold JR, Moss AJ, Zhao L, Cvijic ME, Fronheiser M, Du S, Costet P, Schafer P, Carayannopoulos L, Chang CP, Gordon D, Ramirez-Valle F, Jerosch-Herold M, Nelson CP, Squire IB, Ng LL, Gulsin GS, McCann GP. Is atrial fibrillation in HFpEF a distinct phenotype? Insights from multiparametric MRI and circulating biomarkers. BMC Cardiovasc Disord 2024; 24:94. [PMID: 38326736 PMCID: PMC10848361 DOI: 10.1186/s12872-024-03734-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 01/17/2024] [Indexed: 02/09/2024] Open
Abstract
BACKGROUND Heart failure with preserved ejection fraction (HFpEF) and atrial fibrillation (AF) frequently co-exist. There is a limited understanding on whether this coexistence is associated with distinct alterations in myocardial remodelling and mechanics. We aimed to determine if patients with atrial fibrillation (AF) and heart failure with preserved ejection fraction (HFpEF) represent a distinct phenotype. METHODS In this secondary analysis of adults with HFpEF (NCT03050593), participants were comprehensively phenotyped with stress cardiac MRI, echocardiography and plasma fibroinflammatory biomarkers, and were followed for the composite endpoint (HF hospitalisation or death) at a median of 8.5 years. Those with AF were compared to sinus rhythm (SR) and unsupervised cluster analysis was performed to explore possible phenotypes. RESULTS 136 subjects were included (SR = 75, AF = 61). The AF group was older (76 ± 8 vs. 70 ± 10 years) with less diabetes (36% vs. 61%) compared to the SR group and had higher left atrial (LA) volumes (61 ± 30 vs. 39 ± 15 mL/m2, p < 0.001), lower LA ejection fraction (EF) (31 ± 15 vs. 51 ± 12%, p < 0.001), worse left ventricular (LV) systolic function (LVEF 63 ± 8 vs. 68 ± 8%, p = 0.002; global longitudinal strain 13.6 ± 2.9 vs. 14.7 ± 2.4%, p = 0.003) but higher LV peak early diastolic strain rates (0.73 ± 0.28 vs. 0.53 ± 0.17 1/s, p < 0.001). The AF group had higher levels of syndecan-1, matrix metalloproteinase-2, proBNP, angiopoietin-2 and pentraxin-3, but lower level of interleukin-8. No difference in clinical outcomes was observed between the groups. Three distinct clusters were identified with the poorest outcomes (Log-rank p = 0.029) in cluster 2 (hypertensive and fibroinflammatory) which had equal representation of SR and AF. CONCLUSIONS Presence of AF in HFpEF is associated with cardiac structural and functional changes together with altered expression of several fibro-inflammatory biomarkers. Distinct phenotypes exist in HFpEF which may have differing clinical outcomes.
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Affiliation(s)
- Abhishek Dattani
- Department of Cardiovascular Sciences, University of Leicester and the National Institute for Health Research Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK.
| | - Emer M Brady
- Department of Cardiovascular Sciences, University of Leicester and the National Institute for Health Research Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | | | - Svetlana Stoma
- Department of Cardiovascular Sciences, University of Leicester and the National Institute for Health Research Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Kelly S Parke
- Department of Cardiovascular Sciences, University of Leicester and the National Institute for Health Research Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Anna-Marie Marsh
- Department of Cardiovascular Sciences, University of Leicester and the National Institute for Health Research Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Anvesha Singh
- Department of Cardiovascular Sciences, University of Leicester and the National Institute for Health Research Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Jayanth R Arnold
- Department of Cardiovascular Sciences, University of Leicester and the National Institute for Health Research Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Alastair J Moss
- Department of Cardiovascular Sciences, University of Leicester and the National Institute for Health Research Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Lei Zhao
- Bristol Myers Squibb, Princeton, NJ, USA
| | | | | | - Shuyan Du
- Bristol Myers Squibb, Princeton, NJ, USA
| | | | | | | | | | | | | | | | - Christopher P Nelson
- Department of Cardiovascular Sciences, University of Leicester and the National Institute for Health Research Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Iain B Squire
- Department of Cardiovascular Sciences, University of Leicester and the National Institute for Health Research Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Leong L Ng
- Department of Cardiovascular Sciences, University of Leicester and the National Institute for Health Research Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Gaurav S Gulsin
- Department of Cardiovascular Sciences, University of Leicester and the National Institute for Health Research Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Gerry P McCann
- Department of Cardiovascular Sciences, University of Leicester and the National Institute for Health Research Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
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10
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Hariri EH, El Halabi J, Kassis N, Al Hammoud MM, Badwan OZ, Layoun H, Kassab J, Al Shuab W, Bansal A, Farwati M, Harb SC, Popović ZB, Svensson L, Menon V, Kapadia SR. Sex Differences in the Progression and Long-Term Outcomes of Native Mild to Moderate Aortic Stenosis. JACC Cardiovasc Imaging 2024; 17:1-12. [PMID: 37498256 DOI: 10.1016/j.jcmg.2023.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 06/01/2023] [Accepted: 06/02/2023] [Indexed: 07/28/2023]
Abstract
BACKGROUND There are limited data on the sex differences in the hemodynamic progression and outcomes of early-stage aortic stenosis (AS). OBJECTIVES The authors sought to determine sex differences in hemodynamic progression and outcomes of mild to moderate native AS. METHODS This was a retrospective observational cohort study including patients with mild to moderate native tricuspid AS from the Cleveland Clinic echocardiographic database between 2008 and 2016 and followed until 2018. All-cause mortality, aortic valve replacement (AVR), and disease progression assessed by annualized changes in echocardiographic parameters were analyzed based on sex. RESULTS The authors included 2,549 patients (mean age, 74 ± 7 years and 42.5% women) followed over a median duration of 5.7 years. There was no difference in all-cause mortality between sexes irrespective of age, baseline disease severity, progression to severe AS, and receipt of AVR. Relative to men, women had similar all-cause mortality but lower risk of AVR (adjusted HR: 0.81 [95% CI: 0.67-0.91]; P = 0.009) at 10 years. On 1:1 propensity-matched analysis, men had a significantly faster disease progression represented by greater increases in the median of annualized change in mean gradient (2.10 vs 1.15 mm Hg/y, respectively, P < 0.001), maximum transvalvular velocity (0.42 vs 0.28 m/s/y), left ventricular end-diastolic diameters (0.15 vs 0.048 mm/m2.7/y) (P = 0.014). Women have significantly higher left ventricular ejection fraction, filling pressures, and left ventricular septum thickness over time on follow-up echocardiograms compared with men. CONCLUSIONS Women with mild to moderate AS had slower hemodynamic progression of AS, were more likely to have preserved left ventricular ejection fraction and concentric left ventricular hypertrophy in addition to lower incidence of AVR compared with men despite similar mortality. These findings provide further evidence that there are distinct sex-specific longitudinal echocardiographic and clinical profiles in patients with AS.
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Affiliation(s)
- Essa H Hariri
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Jessica El Halabi
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Nicholas Kassis
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Mazen M Al Hammoud
- Gilbert and Rose-Marie Chagoury School of Medicine, Lebanese American University, Byblos, Lebanon
| | - Osamah Z Badwan
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Habib Layoun
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Joseph Kassab
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Wael Al Shuab
- New York Institute of Technology College of Osteopathic Medicine, Old Westbury, New York
| | - Agam Bansal
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio; Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Medhat Farwati
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio; Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Serge C Harb
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Zoran B Popović
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Lars Svensson
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Venu Menon
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Samir R Kapadia
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio.
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11
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Sevilla T, Ramos N, Carnero M, Amat-Santos IJ, Carrasco-Moraleja M, Revilla A, Vilacosta I, San Román JA. Sex Differences in Clinical Outcomes after Aortic Valve Intervention for Isolated Severe Aortic Stenosis. J Clin Med 2023; 12:7025. [PMID: 38002639 PMCID: PMC10672289 DOI: 10.3390/jcm12227025] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 10/26/2023] [Accepted: 11/07/2023] [Indexed: 11/26/2023] Open
Abstract
There are known pathophysiologic and clinical differences according to sex in patients with aortic stenosis (AS). To evaluate if these differences persist after valve replacement, we conducted an observational study including 451 patients with symptomatic AS who survived aortic valve intervention (AVI) in two centers. Clinical data and mortality were evaluated at a mean follow-up of 5 years. 56% of patients were women. At baseline, women were older (80.6 vs. 78 years, p = 0.013), presented higher mean gradient (48 vs. 45 mmHg, p = 0.023), lower aortic valve area (0.70 vs. 0.74 cm2, p = 0.002) and higher systolic pulmonary artery pressure (36 vs. 33 mmHg, p = 0.016). They underwent percutaneous aortic valve replacement more frequently than men (47 vs. 35.9%, p = 0.017). At 5 years follow-up, women required more admissions due to heart failure (23 vs. 9%, p = 0.046) but they did not present higher cardiovascular nor overall mortality (27.7% vs. 29.8%, p = 0.741; 11.1 vs. 10.1%, p = 0.619, respectively). Female sex was an independent predictor of heart failure hospitalization at follow-up (HR 95% 1.16-4.22, p = 0.016). Women undergo AVI at a more advanced stage than men, resulting in a higher frequency of readmissions due to heart failure during the follow-up period, but not in higher mortality.
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Affiliation(s)
- Teresa Sevilla
- Cardiology Department, Hospital Clínico Universitario de Valladolid, 47003 Valladolid, Spain; (I.J.A.-S.); (M.C.-M.); (A.R.); (J.A.S.R.)
- Consorcio de Investigación Bioméidica en Red de Enfermedades Cardiovasculares, CIBER-CV, 28029 Madrid, Spain
| | - Noemí Ramos
- Cardiology Department, Hospital Clínico San Carlos, 28040 Madrid, Spain; (N.R.); (I.V.)
| | - Manuel Carnero
- Cardiac Surgery Department, Hospital Clínico San Carlos, 28040 Madrid, Spain;
| | - Ignacio J. Amat-Santos
- Cardiology Department, Hospital Clínico Universitario de Valladolid, 47003 Valladolid, Spain; (I.J.A.-S.); (M.C.-M.); (A.R.); (J.A.S.R.)
- Consorcio de Investigación Bioméidica en Red de Enfermedades Cardiovasculares, CIBER-CV, 28029 Madrid, Spain
| | - Manuel Carrasco-Moraleja
- Cardiology Department, Hospital Clínico Universitario de Valladolid, 47003 Valladolid, Spain; (I.J.A.-S.); (M.C.-M.); (A.R.); (J.A.S.R.)
- Consorcio de Investigación Bioméidica en Red de Enfermedades Cardiovasculares, CIBER-CV, 28029 Madrid, Spain
| | - Ana Revilla
- Cardiology Department, Hospital Clínico Universitario de Valladolid, 47003 Valladolid, Spain; (I.J.A.-S.); (M.C.-M.); (A.R.); (J.A.S.R.)
- Consorcio de Investigación Bioméidica en Red de Enfermedades Cardiovasculares, CIBER-CV, 28029 Madrid, Spain
| | - Isidre Vilacosta
- Cardiology Department, Hospital Clínico San Carlos, 28040 Madrid, Spain; (N.R.); (I.V.)
| | - J. Alberto San Román
- Cardiology Department, Hospital Clínico Universitario de Valladolid, 47003 Valladolid, Spain; (I.J.A.-S.); (M.C.-M.); (A.R.); (J.A.S.R.)
- Consorcio de Investigación Bioméidica en Red de Enfermedades Cardiovasculares, CIBER-CV, 28029 Madrid, Spain
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12
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Arrieta V, Jover E, Navarro A, Martín-Núñez E, Garaikoetxea M, Matilla L, García-Peña A, Fernández-Celis A, Gainza A, Álvarez V, Sádaba R, López-Andrés N. Soluble ST2 levels are related to replacement myocardial fibrosis in severe aortic stenosis. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2023; 76:679-689. [PMID: 36565751 DOI: 10.1016/j.rec.2022.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 12/02/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION AND OBJECTIVES Patients with aortic stenosis (AS) exhibit left ventricular (LV) remodeling and replacement myocardial fibrosis (RMF). Whether sST2 is associated with RMF measured by cardiac magnetic resonance and with sex remains unknown. METHODS We recruited 79 consecutive patients (73.0 [68.0-78.0] years; 61% men) with severe isolated AS underdoing valve replacement. RMF was identified and quantified by late gadolinium enhancement (LGE). Serum sST2 levels were determined. RESULTS RMF was associated with higher circulating sST2 levels, LV hypertrophy and dilation, and lower LV ejection fraction. All patients with LV dysfunction had RMF. Circulating levels of sST2 ≥ 28.8 ng/mL were associated with RMF and greater LV hypertrophy. LGE mass was correlated with LV remodeling and sST2. Of note, sST2 levels were also associated with the RMF pattern, being higher in midwall than in subendocardial fibrosis. Multivariate analyses showed that only LV ejection fraction and sST2 levels were associated with RMF. Moreover, men had higher levels of sST2 and RMF. RMF was associated with higher LV dilation and hypertrophy only in men and was correlated with LGE mass. CONCLUSIONS SST2 was an independent factor for RMF in patients with severe isolated AS. The presence of RMF was predicted by sST2 ≥ 28.2 ng/mL, and was associated with greater LV hypertrophy. sST2 expression and clinical associations may be sex-specific.
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Affiliation(s)
- Vanessa Arrieta
- Cardiovascular Translational Research, Navarrabiomed, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), IdiSNA, Pamplona, Spain
| | - Eva Jover
- Cardiovascular Translational Research, Navarrabiomed, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), IdiSNA, Pamplona, Spain
| | - Adela Navarro
- Cardiovascular Translational Research, Navarrabiomed, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), IdiSNA, Pamplona, Spain
| | - Ernesto Martín-Núñez
- Cardiovascular Translational Research, Navarrabiomed, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), IdiSNA, Pamplona, Spain
| | - Mattie Garaikoetxea
- Cardiovascular Translational Research, Navarrabiomed, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), IdiSNA, Pamplona, Spain
| | - Lara Matilla
- Cardiovascular Translational Research, Navarrabiomed, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), IdiSNA, Pamplona, Spain
| | - Amaia García-Peña
- Cardiovascular Translational Research, Navarrabiomed, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), IdiSNA, Pamplona, Spain
| | - Amaya Fernández-Celis
- Cardiovascular Translational Research, Navarrabiomed, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), IdiSNA, Pamplona, Spain
| | - Alicia Gainza
- Cardiovascular Translational Research, Navarrabiomed, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), IdiSNA, Pamplona, Spain
| | - Virginia Álvarez
- Cardiovascular Translational Research, Navarrabiomed, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), IdiSNA, Pamplona, Spain
| | - Rafael Sádaba
- Cardiovascular Translational Research, Navarrabiomed, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), IdiSNA, Pamplona, Spain
| | - Natalia López-Andrés
- Cardiovascular Translational Research, Navarrabiomed, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), IdiSNA, Pamplona, Spain.
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13
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Dattani A, Brady EM, Alfuhied A, Gulsin GS, Steadman CD, Yeo JL, Aslam S, Banovic M, Jerosch-Herold M, Xue H, Kellman P, Costet P, Cvijic ME, Zhao L, Ebert C, Liu L, Gunawardhana K, Gordon D, Chang CP, Arnold JR, Yates T, Kelly D, Hogrefe K, Dawson D, Greenwood J, Ng LL, Singh A, McCann GP. Impact of diabetes on remodelling, microvascular function and exercise capacity in aortic stenosis. Open Heart 2023; 10:e002441. [PMID: 37586847 PMCID: PMC10432628 DOI: 10.1136/openhrt-2023-002441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 08/04/2023] [Indexed: 08/18/2023] Open
Abstract
OBJECTIVE To characterise cardiac remodelling, exercise capacity and fibroinflammatory biomarkers in patients with aortic stenosis (AS) with and without diabetes, and assess the impact of diabetes on outcomes. METHODS Patients with moderate or severe AS with and without diabetes underwent echocardiography, stress cardiovascular magnetic resonance (CMR), cardiopulmonary exercise testing and plasma biomarker analysis. Primary endpoint for survival analysis was a composite of cardiovascular mortality, myocardial infarction, hospitalisation with heart failure, syncope or arrhythmia. Secondary endpoint was all-cause death. RESULTS Diabetes (n=56) and non-diabetes groups (n=198) were well matched for age, sex, ethnicity, blood pressure and severity of AS. The diabetes group had higher body mass index, lower estimated glomerular filtration rate and higher rates of hypertension, hyperlipidaemia and symptoms of AS. Biventricular volumes and systolic function were similar, but the diabetes group had higher extracellular volume fraction (25.9%±3.1% vs 24.8%±2.4%, p=0.020), lower myocardial perfusion reserve (2.02±0.75 vs 2.34±0.68, p=0.046) and lower percentage predicted peak oxygen consumption (68%±21% vs 77%±17%, p=0.002) compared with the non-diabetes group. Higher levels of renin (log10renin: 3.27±0.59 vs 2.82±0.69 pg/mL, p<0.001) were found in diabetes. Multivariable Cox regression analysis showed diabetes was not associated with cardiovascular outcomes, but was independently associated with all-cause mortality (HR 2.04, 95% CI 1.05 to 4.00; p=0.037). CONCLUSIONS In patients with moderate-to-severe AS, diabetes is associated with reduced exercise capacity, increased diffuse myocardial fibrosis and microvascular dysfunction, but not cardiovascular events despite a small increase in mortality.
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Affiliation(s)
- Abhishek Dattani
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Emer M Brady
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Aseel Alfuhied
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Gaurav S Gulsin
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Christopher D Steadman
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
- Department of Cardiology, Poole Hospital NHS Foundation Trust, Poole, UK
| | - Jian L Yeo
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Saadia Aslam
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Marko Banovic
- Cardiology Department, Clinical Centre of Serbia, Belgrade, Serbia
| | | | - Hui Xue
- National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Peter Kellman
- National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | | | | | - Lei Zhao
- Bristol Myers Squibb Co, Princeton, New Jersey, USA
| | | | - Laura Liu
- Bristol Myers Squibb Co, Princeton, New Jersey, USA
| | | | - David Gordon
- Bristol Myers Squibb Co, Princeton, New Jersey, USA
| | | | - J Ranjit Arnold
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Thomas Yates
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Damian Kelly
- Cardiology Department, Royal Derby Hospital, Derby, UK
| | - Kai Hogrefe
- Cardiology Department, Kettering General Hospital NHS Foundation Trust, Kettering, UK
| | - Dana Dawson
- Cardiovascular Medicine Research Unit, University of Aberdeen, Aberdeen, UK
| | - John Greenwood
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- Department of Biomedical Imaging Sciences, University of Leeds, Leeds, UK
| | - Leong L Ng
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Anvesha Singh
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Gerry P McCann
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
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14
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Malahfji M, Senapati A, Debs D, Saeed M, Tayal B, Nguyen DT, Graviss EA, Shah DJ. Sex differences in myocardial remodeling and extracellular volume in aortic regurgitation. Sci Rep 2023; 13:11334. [PMID: 37443191 PMCID: PMC10344872 DOI: 10.1038/s41598-023-37444-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 06/21/2023] [Indexed: 07/15/2023] Open
Abstract
Whether sex differences exist in the cardiac remodeling related to aortic regurgitation (AR) is unclear. Cardiac magnetic resonance (CMR) is the current non-invasive reference standard for cardiac remodeling assessment and can evaluate tissue characteristics. This prospective cohort included patients with AR undergoing CMR between 2011 and 2020. We excluded patients with confounding causes of remodeling. We quantified left ventricular (LV) volume, mass, AR severity, replacement fibrosis by late Gadolinium enhancement (LGE), and extracellular expansion by extracellular volume fraction (ECV). We studied 280 patients (109 women), median age 59.5 (47.2, 68.6) years (P for age = 0.25 between sexes). Women had smaller absolute LV volume and mass than men across the spectrum of regurgitation volume (RVol) (P ≤ 0.01). In patients with ≥ moderate AR and with adjustment for body surface area, indexed LV end-diastolic volume and mass were not significantly different between sexes (all P > 0.5) but men had larger indexed LV end systolic volume and lower LV ejection fraction (P ≥ 0.01). Women were more likely to have NYHA class II or greater symptoms than men but underwent surgery at a similar rate. Prevalence and extent of LGE was not significantly different between sexes or across RVol. Increasing RVol was independently associated with increasing ECV in women, but not in men (adjusted P for interaction = 0.03). In conclusion, women had lower LV volumes and mass than men across AR severity but their ECV increased with higher regurgitant volume, while ECV did not change in men. Indexing to body surface area did not fully correct for the cardiac remodeling differences between men and women. Women were more likely to have symptoms but underwent surgery at a similar rate to men. Further research is needed to determine if differences in ECV would translate to differences in the course of AR and outcomes.
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Affiliation(s)
- Maan Malahfji
- Cardiovascular MRI Laboratory, Division of Cardiovascular Imaging, Houston Methodist DeBakey Heart & Vascular Center, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA
| | - Alpana Senapati
- Cardiovascular MRI Laboratory, Division of Cardiovascular Imaging, Houston Methodist DeBakey Heart & Vascular Center, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA
| | - Dany Debs
- Cardiovascular MRI Laboratory, Division of Cardiovascular Imaging, Houston Methodist DeBakey Heart & Vascular Center, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA
| | - Mujtaba Saeed
- Cardiovascular MRI Laboratory, Division of Cardiovascular Imaging, Houston Methodist DeBakey Heart & Vascular Center, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA
| | - Bhupendar Tayal
- Cardiovascular MRI Laboratory, Division of Cardiovascular Imaging, Houston Methodist DeBakey Heart & Vascular Center, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA
| | - Duc T Nguyen
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital Research Institute, Houston, TX, USA
| | - Edward A Graviss
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital Research Institute, Houston, TX, USA
| | - Dipan J Shah
- Cardiovascular MRI Laboratory, Division of Cardiovascular Imaging, Houston Methodist DeBakey Heart & Vascular Center, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA.
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15
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Foulkes SJ, Howden EJ, Dillon HT, Janssens K, Beaudry R, Mitchell AM, Lindqvist A, Wallace I, Wright L, Costello BT, Claessen G, Haykowsky MJ, La Gerche A. Too Little of a Good Thing: Strong Associations Between Cardiac Size and Fitness Among Women. JACC Cardiovasc Imaging 2023; 16:768-778. [PMID: 36881424 DOI: 10.1016/j.jcmg.2022.12.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 11/07/2022] [Accepted: 12/02/2022] [Indexed: 02/10/2023]
Abstract
BACKGROUND Cardiorespiratory fitness (CRF) is associated with functional impairment and cardiac events, particularly heart failure (HF). However, the factors predisposing women to low CRF and HF remain unclear. OBJECTIVES This study sought to evaluate the association between CRF and measures of ventricular size and function and to examine the potential mechanism linking these factors. METHODS A total of 185 healthy women aged >30 years (51 ± 9 years) underwent assessment of CRF (peak volume of oxygen uptake [Vo2peak]) and biventricular volumes at rest and during exercise by using cardiac magnetic resonance (CMR). The relationships among Vo2peak, cardiac volumes, and echocardiographic measures of systolic and diastolic function were assessed using linear regression. The effect of cardiac size on cardiac reserve (change in cardiac function during exercise) was assessed by comparing quartiles of resting left ventricular end-diastolic volume (LVEDV). RESULTS Vo2peak was strongly associated with resting measures of LVEDV and right ventricular end-diastolic volume (R2 = 0.58-0.63; P < 0.0001), but weakly associated with measures of resting left ventricular (LV) systolic and diastolic function (R2 = 0.01-0.06; P < 0.05). Increasing LVEDV quartiles were positively associated with cardiac reserve, with the smallest quartile showing the smallest reduction in LV end-systolic volume (quartile [Q]1: -4 mL vs Q4: -12 mL), smallest augmentation in LV stroke volume (Q1: +11 mL vs Q4: +20 mL) and cardiac output (Q1: +6.6 L/min vs Q4: +10.3 L/min) during exercise (interaction P < 0.001 for all). CONCLUSIONS A small ventricle is strongly associated with low CRF because of the combined effect of a smaller resting stroke volume and an attenuated capacity to increase with exercise. The prognostic implications of low CRF in midlife highlight the need for further longitudinal studies to determine whether women with small ventricles are predisposed to functional impairment, exertional intolerance, and HF later in life.
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Affiliation(s)
- Stephen J Foulkes
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia; Baker Department of Cardiometabolic Health, University of Melbourne, Parkville, Victoria, Australia
| | - Erin J Howden
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia; Baker Department of Cardiometabolic Health, University of Melbourne, Parkville, Victoria, Australia
| | - Hayley T Dillon
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia; Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Geelong, Victoria, Australia
| | - Kristel Janssens
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia; Baker Department of Cardiometabolic Health, University of Melbourne, Parkville, Victoria, Australia
| | - Rhys Beaudry
- Faculty of Medicine and Dentistry, College of Health Sciences, Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - Amy M Mitchell
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | | | - Imogen Wallace
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Leah Wright
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia; Baker Department of Cardiometabolic Health, University of Melbourne, Parkville, Victoria, Australia
| | - Benedict T Costello
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia; Cardiology Department, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Guido Claessen
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia; Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium; University Hospitals Leuven, Leuven, Belgium
| | - Mark J Haykowsky
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia; College of Health Sciences, Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - André La Gerche
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia; Baker Department of Cardiometabolic Health, University of Melbourne, Parkville, Victoria, Australia; Cardiology Department, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.
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16
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Does Gender Influence the Indication of Treatment and Long-Term Prognosis in Severe Aortic Stenosis? J Cardiovasc Dev Dis 2023; 10:jcdd10020038. [PMID: 36826534 PMCID: PMC9963043 DOI: 10.3390/jcdd10020038] [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: 11/30/2022] [Revised: 01/05/2023] [Accepted: 01/17/2023] [Indexed: 01/24/2023] Open
Abstract
INTRODUCTION It is a matter of controversy whether the therapeutic strategy for severe aortic stenosis (AS) differs according to gender. METHODS Retrospective study of patients diagnosed with severe AS (transvalvular mean gradient ≥ 40 mmHg and/or aortic valvular area < 1 cm2) between 2009 and 2019. Our aim was to assess the association of sex on AVR or medical management and outcomes in patients with severe AS. RESULTS 452 patients were included. Women (51.1%) were older than men (80 ± 8.4 vs. 75.8 ± 9.9 years; p < 0.001). Aortic valve replacement (AVR) was performed less frequently in women (43.4% vs. 53.2%; p = 0.03), but multivariate analyses showed that sex was not an independent predictor factor for AVR. Age, Charlson index and symptoms were predictive factors (OR 0.81 [0.82-0.89], OR 0.81 [0.71-0.93], OR 22.02 [6.77-71.64]). Survival analysis revealed no significant association of sex within all-cause and cardiovascular mortalities (log-rank p = 0.63 and p = 0.07). Cox proportional hazards analyses showed AVR (HR: 0.1 [0.06-0.15]), Charlson index (HR: 1.13 [1.06-1.21]) and reduced LVEF (HR: 1.9 [1.32-2.73]) to be independent cardiovascular mortality predictors. CONCLUSIONS Gender is not associated with AVR or long-term prognosis. Cardiovascular mortality was associated with older age, more comorbidity and worse LVEF.
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17
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Singh GK, Delgado V, Delgado V. Multimodality Imaging to Explore Sex Differences in Aortic Stenosis. Eur Cardiol 2022; 17:e26. [PMID: 36845220 PMCID: PMC9947932 DOI: 10.15420/ecr.2022.26] [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: 06/06/2022] [Accepted: 09/30/2022] [Indexed: 02/11/2023] Open
Abstract
The aim of this article is to review sex differences in aortic stenosis (AS) assessed with multimodality imaging. Echocardiography remains the mainstay imaging technique to diagnose AS and provides important insights into the differences between men and women in relation to valve haemodynamic and left-ventricular response. However, echocardiography does not have adequate resolution to provide important insights into sex differences in the degenerative, calcific pathophysiological process of the aortic valve. CT shows that women with AS have more fibrotic changes of the aortic valve whereas men show more calcific deposits. Cardiac magnetic resonance shows that women have left ventricles that are less hypertrophic and smaller compared with those of men, while men have more replacement myocardial fibrosis. These differences may lead to different responses to aortic valve replacement because myocardial diffuse fibrosis but not replacement myocardial fibrosis may regress after the procedure. Sex differences in the pathophysiological process of AS can be assessed using multimodality imaging, assisting in decisionmaking in these patients.
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Affiliation(s)
- Gurpreet K Singh
- Department of Cardiology, Leiden University Medical CenterLeiden, the Netherlands
| | - Victoria Delgado
- Department of Cardiology, Leiden University Medical CenterLeiden, the Netherlands,Heart Institute, Department of Cardiology, Hospital University Germans Trias i PujolBarcelona, Spain
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18
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Luke P, Alkhalil M, Eggett C. Current and novel echocardiographic assessment of left ventricular systolic function in aortic stenosis-A comprehensive review. Echocardiography 2022; 39:1470-1480. [PMID: 36447299 PMCID: PMC10098594 DOI: 10.1111/echo.15497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 10/16/2022] [Accepted: 11/06/2022] [Indexed: 12/02/2022] Open
Abstract
Aortic stenosis (AS) is a complex and progressive condition that can significantly reduce the quality of life and increase the incidence of premature mortality. Transthoracic echocardiography (TTE) is the gold standard imaging modality for the assessment of AS severity. While left ventricular ejection fraction (LVEF) derived from TTE is a very well-understood parameter, limitations such as high inter and intra-observer variability, insensitivity to sub-clinical dysfunction, and influence of loading conditions make LVEF a complicated and unreliable parameter. Myocardial deformation imaging has been identified as a promising parameter for identifying subclinical left ventricular dysfunction, however, this parameter is still afterload dependent. Myocardial Work is a promising novel assessment technique that accounts for afterload by combining the use of myocardial deformation imaging and non-invasive blood pressure to provide a more comprehensive assessment of mechanics beyond LVEF. This review evaluates the evidence for various echocardiographic assessment parameters used to quantify left ventricular function including myocardial work in patients with AS.
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Affiliation(s)
- Peter Luke
- School of Biomedical ScienceNutritional and Sport SciencesNewcastle UniversityNewcastle upon TyneUK
- Newcastle upon Tyne Hospital TrustFreeman HospitalNewcastle upon TyneUK
| | - Mohammad Alkhalil
- Newcastle upon Tyne Hospital TrustFreeman HospitalNewcastle upon TyneUK
- Translational and Clinical Research InstituteNewcastle UniversityNewcastle upon TyneUK
| | - Christopher Eggett
- School of Biomedical ScienceNutritional and Sport SciencesNewcastle UniversityNewcastle upon TyneUK
- Newcastle upon Tyne Hospital TrustFreeman HospitalNewcastle upon TyneUK
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19
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Cramariuc D, Bahlmann E, Gerdts E. Grading of Aortic Stenosis: Is it More Complicated in Women? Eur Cardiol 2022; 17:e21. [PMID: 36643071 PMCID: PMC9820123 DOI: 10.15420/ecr.2022.13] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 06/29/2022] [Indexed: 12/14/2022] Open
Abstract
Aortic stenosis (AS) is the most common valvular heart disease and the main indication for valvular replacement in older women. Correct AS grading is mandatory for an adequate selection of patients for both surgical and transcatheter aortic valve replacement. Women and men have different AS severity grades at the same level of aortic valve calcification. Moreover, besides having smaller cardiac volumes, left ventricular outflow tract and aortic size, women have a specific pattern of left ventricular structural and functional remodelling in response to the AS-related chronic pressure overload. Here, the sex-specific cardiac changes in AS that make AS grading more challenging in women, with consequences for the management and outcome of this group of patients, are reviewed.
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Affiliation(s)
- Dana Cramariuc
- Department of Heart Disease, Haukeland University HospitalBergen, Norway,Department of Clinical Science, University of BergenBergen, Norway
| | - Edda Bahlmann
- Department of Cardiology, Asklepios Kliniken St. GeorgHamburg, Germany
| | - Eva Gerdts
- Department of Clinical Science, University of BergenBergen, Norway
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20
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Masiero G, Paradies V, Franzone A, Bellini B, De Biase C, Karam N, Sanguineti F, Mamas MA, Eltchaninoff H, Fraccaro C, Castiglioni B, Attisano T, Esposito G, Chieffo A. Sex-Specific Considerations in Degenerative Aortic Stenosis for Female-Tailored Transfemoral Aortic Valve Implantation Management. J Am Heart Assoc 2022; 11:e025944. [PMID: 36172929 DOI: 10.1161/jaha.121.025944] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The impact of sex on pathophysiological processes, clinical presentation, treatment options, as well as outcomes of degenerative aortic stenosis remain poorly understood. Female patients are well represented in transfemoral aortic valve implantation (TAVI) trials and appear to derive favorable outcomes with TAVI. However, higher incidences of major bleeding, vascular complications, and stroke have been reported in women following TAVI. The anatomical characteristics and pathophysiological features of aortic stenosis in women might guide a tailored planning of the percutaneous approach. We highlight whether a sex-based TAVI management strategy might impact on clinical outcomes. This review aimed to evaluate the impact of sex from diagnosis to treatment of degenerative aortic stenosis, discussing the latest evidence on epidemiology, pathophysiology, clinical presentation, therapeutic options, and outcomes. Furthermore, we focused on technical sex-oriented considerations in TAVI including the preprocedural screening, device selection, implantation strategy, and postprocedural management.
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Affiliation(s)
- Giulia Masiero
- Department of Cardiac, Thoracic Vascular Science and Public Health, University of Padova Italy
| | - Valeria Paradies
- Department of Cardiology Maasstad Hospital Rotterdam The Netherlands
| | - Anna Franzone
- Department of Advanced Biomedical Sciences Federico II University of Naples Italy
| | - Barbara Bellini
- Interventional Cardiology Unit IRCCS San Raffaele Scientific Institute Milan Italy
| | - Chiara De Biase
- Groupe CardioVasculaire Interventionnel Clinique Pasteur Toulouse France
| | - Nicole Karam
- Cardiology Department European Hospital Georges Pompidou Paris France
| | | | - Mamas A Mamas
- Keele Cardiovascular Research Group School of Medicine, Keele University Stoke-on-Trent United Kingdom.,Department of Cardiology Royal Stoke University Hospital Stoke-on-Trent United Kingdom.,Department of Medicine Thomas Jefferson University Philadelphia PA
| | | | - Chiara Fraccaro
- Department of Cardiac, Thoracic Vascular Science and Public Health, University of Padova Italy
| | | | - Tiziana Attisano
- Division of Interventional Cardiology Cardiovascular and Thoracic Department, San Giovanni di Dio e Ruggi Salerno Italy
| | - Giovanni Esposito
- Department of Advanced Biomedical Sciences Federico II University of Naples Italy
| | - Alaide Chieffo
- Interventional Cardiology Unit IRCCS San Raffaele Scientific Institute Milan Italy
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21
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Iribarren AC, AlBadri A, Wei J, Nelson MD, Li D, Makkar R, Merz CNB. Sex differences in aortic stenosis: Identification of knowledge gaps for sex-specific personalized medicine. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2022; 21:100197. [PMID: 36330169 PMCID: PMC9629620 DOI: 10.1016/j.ahjo.2022.100197] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 08/18/2022] [Accepted: 08/20/2022] [Indexed: 06/16/2023]
Abstract
Objectives This review summarizes sex-based differences in aortic stenosis (AS) and identifies knowledge gaps that should be addressed by future studies. Background AS is the most common valvular heart disease in developed countries. Sex-specific differences have not been fully appreciated, as a result of widespread under diagnosis of AS in women. Summary Studies including sex-stratified analyses have shown differences in pathophysiology with less calcification and more fibrosis in women's aortic valve. Women have impaired myocardial perfusion reserve and different compensatory response of the left ventricle (LV) to pressure overload, with concentric remodeling and more diffuse fibrosis, in contrast to men with more focal fibrosis and more dilated/eccentrically remodeled LV. There is sex difference in clinical presentation and anatomical characteristics, with women having more paradoxical low-flow/low-gradient AS, under-diagnosis and severity underestimated, with less referral to aortic valve replacement (AVR) compared to men. The response to therapies is also different: women have more adverse events with surgical AVR and greater survival benefit with transcatheter AVR. After AVR, women would have more favorable LV remodeling, but sex-related differences in changes in myocardial reserve flow need future research. Conclusions Investigation into these described sex-related differences in AS offers potential utility for improving prevention and treatment of AS in women and men. To better understand sex-based differences in pathophysiology, clinical presentation, and response to therapies, sex-specific critical knowledge gaps should be addressed in future research for sex-specific personalized medicine.
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Affiliation(s)
- Ana C. Iribarren
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, United States of America
| | - Ahmed AlBadri
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, United States of America
| | - Janet Wei
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, United States of America
- Cedars-Sinai Biomedical Imaging Research Institute, Los Angeles, CA, United States of America
| | - Michael D. Nelson
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, United States of America
| | - Debiao Li
- Cedars-Sinai Biomedical Imaging Research Institute, Los Angeles, CA, United States of America
| | - Raj Makkar
- Cedars-Sinai Cardiovascular Intervention Center, Smidt Heart Institute, Los Angeles, CA, United States of America
| | - C. Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, United States of America
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22
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Dela Justina V, Miguez JSG, Priviero F, Sullivan JC, Giachini FR, Webb RC. Sex Differences in Molecular Mechanisms of Cardiovascular Aging. FRONTIERS IN AGING 2022; 2:725884. [PMID: 35822017 PMCID: PMC9261391 DOI: 10.3389/fragi.2021.725884] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 08/25/2021] [Indexed: 12/12/2022]
Abstract
Cardiovascular disease (CVD) is still the leading cause of illness and death in the Western world. Cardiovascular aging is a progressive modification occurring in cardiac and vascular morphology and physiology where increased endothelial dysfunction and arterial stiffness are observed, generally accompanied by increased systolic blood pressure and augmented pulse pressure. The effects of biological sex on cardiovascular pathophysiology have long been known. The incidence of hypertension is higher in men, and it increases in postmenopausal women. Premenopausal women are protected from CVD compared with age-matched men and this protective effect is lost with menopause, suggesting that sex-hormones influence blood pressure regulation. In parallel, the heart progressively remodels over the course of life and the pattern of cardiac remodeling also differs between the sexes. Lower autonomic tone, reduced baroreceptor response, and greater vascular function are observed in premenopausal women than men of similar age. However, postmenopausal women have stiffer arteries than their male counterparts. The biological mechanisms responsible for sex-related differences observed in cardiovascular aging are being unraveled over the last several decades. This review focuses on molecular mechanisms underlying the sex-differences of CVD in aging.
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Affiliation(s)
- Vanessa Dela Justina
- Graduate Program in Biological Sciences, Federal University of Goiás, Goiânia, Brazil
| | | | - Fernanda Priviero
- Cardiovascular Translational Research Center, University of South Carolina, Columbia, SC, United States
| | - Jennifer C Sullivan
- Department of Physiology, Medical College of Georgia at Augusta University, Augusta, GA, United States
| | - Fernanda R Giachini
- Graduate Program in Biological Sciences, Federal University of Goiás, Goiânia, Brazil.,Institute of Biological Sciences and Health, Federal University of Mato Grosso, Barra do Garças, Brazil
| | - R Clinton Webb
- Cardiovascular Translational Research Center, University of South Carolina, Columbia, SC, United States
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23
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Ito S, Miranda WR, Nkomo VT, Lewis BR, Oh JK. Sex Differences in LV Remodeling and Hemodynamics in Aortic Stenosis. JACC Cardiovasc Imaging 2022; 15:1175-1189. [DOI: 10.1016/j.jcmg.2022.02.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 02/07/2022] [Accepted: 02/10/2022] [Indexed: 12/15/2022]
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24
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Thornton GD, Musa TA, Rigolli M, Loudon M, Chin C, Pica S, Malley T, Foley JRJ, Vassiliou VS, Davies RH, Captur G, Dobson LE, Moon JC, Dweck MR, Myerson SG, Prasad SK, Greenwood JP, McCann GP, Singh A, Treibel TA. Association of Myocardial Fibrosis and Stroke Volume by Cardiovascular Magnetic Resonance in Patients With Severe Aortic Stenosis With Outcome After Valve Replacement: The British Society of Cardiovascular Magnetic Resonance AS700 Study. JAMA Cardiol 2022; 7:513-520. [PMID: 35385057 PMCID: PMC8988025 DOI: 10.1001/jamacardio.2022.0340] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 02/09/2022] [Indexed: 01/03/2023]
Abstract
Importance Low-flow severe aortic stenosis (AS) has higher mortality than severe AS with normal flow. The conventional definition of low-flow AS is an indexed stroke volume (SVi) by echocardiography less than 35 mL/m2. Cardiovascular magnetic resonance (CMR) is the reference standard for quantifying left ventricular volumes and function from which SVi by CMR can be derived. Objective To determine the association of left ventricular SVi by CMR with myocardial remodeling and survival among patients with severe AS after valve replacement. Design, Setting, and Participants This multicenter longitudinal cohort study was conducted between January 2003 and May 2015 across 6 UK cardiothoracic centers. Patients with severe AS listed for either surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR) were included. Patients underwent preprocedural echocardiography and CMR. Patients were stratified by echocardiography-derived aortic valve mean and/or peak gradient and SVi by CMR into 4 AS endotypes: low-flow, low-gradient AS; low-flow, high-gradient AS; normal-flow, low-gradient AS; and normal-flow, high-gradient AS. Patients were observed for a median of 3.6 years. Data were analyzed from September to November 2021. Exposures SAVR or TAVR. Main Outcomes and Measures All-cause and cardiovascular (CV) mortality after aortic valve intervention. Results Of 674 included patients, 425 (63.1%) were male, and the median (IQR) age was 75 (66-80) years. The median (IQR) aortic valve area index was 0.4 (0.3-0.4) cm2/m2. Patients with low-flow AS endotypes (low gradient and high gradient) had lower left ventricular ejection fraction, mass, and wall thickness and increased all-cause and CV mortality than patients with normal-flow AS (all-cause mortality: hazard ratio [HR], 2.08; 95% CI, 1.37-3.14; P < .001; CV mortality: HR, 3.06; 95% CI, 1.79-5.25; P < .001). CV mortality was independently associated with lower SVi (HR, 1.64; 95% CI, 1.08-2.50; P = .04), age (HR, 2.54; 95% CI, 1.29-5.01; P = .001), and higher quantity of late gadolinium enhancement (HR, 2.93; 95% CI, 1.68-5.09; P < .001). CV mortality hazard increased more rapidly in those with an SVI less than 45 mL/m2. SVi by CMR was independently associated with age, atrial fibrillation, focal scar (by late gadolinium enhancement), and parameters of cardiac remodeling (left ventricular mass and left atrial volume). Conclusions and Relevance In this cohort study, SVi by CMR was associated with CV mortality after aortic valve replacement, independent of age, focal scar, and ejection fraction. The unique capability of CMR to quantify myocardial scar, combined with other prognostically important imaging biomarkers, such as SVi by CMR, may enable comprehensive stratification of postoperative risk in patients with severe symptomatic AS.
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Affiliation(s)
- George D. Thornton
- Institute of Cardiovascular Science, University College London, London, United Kingdom
- Barts Heart Centre, London, United Kingdom
| | - Tarique A. Musa
- Royal Surrey NHS Foundation Trust, Guildford, United Kingdom
| | - Marzia Rigolli
- University of Oxford Centre for Clinical Magnetic Resonance Research, BHF Centre of Research Excellence, NIHR Biomedical Research Centre, Oxford, United Kingdom
| | - Margaret Loudon
- University Hospitals Plymouth NHS Trust, Plymouth, United Kingdom
| | | | | | | | - James R. J. Foley
- Multidisciplinary Cardiovascular Research Centre and The Division of Biomedical Imaging, Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | | | - Rhodri H. Davies
- Institute of Cardiovascular Science, University College London, London, United Kingdom
- Barts Heart Centre, London, United Kingdom
| | - Gabriella Captur
- Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Laura E. Dobson
- University Hospital of South Manchester NHS Foundation Trust, Manchester, United Kingdom
| | - James C. Moon
- Institute of Cardiovascular Science, University College London, London, United Kingdom
- Barts Heart Centre, London, United Kingdom
| | - Marc R. Dweck
- Centre for Cardiovascular Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Saul G. Myerson
- University of Oxford Centre for Clinical Magnetic Resonance Research, BHF Centre of Research Excellence, NIHR Biomedical Research Centre, Oxford, United Kingdom
| | | | - John P. Greenwood
- Multidisciplinary Cardiovascular Research Centre and The Division of Biomedical Imaging, Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - Gerry P. McCann
- Department of Cardiovascular Sciences, NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, United Kingdom
| | - Anvesha Singh
- Department of Cardiovascular Sciences, NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, United Kingdom
| | - Thomas A. Treibel
- Institute of Cardiovascular Science, University College London, London, United Kingdom
- Barts Heart Centre, London, United Kingdom
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25
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Cho L, Kibbe MR, Bakaeen F, Aggarwal NR, Davis MB, Karmalou T, Lawton JS, Ouzounian M, Preventza O, Russo AM, Shroyer ALW, Zwischenberger BA, Lindley KJ. Cardiac Surgery in Women in the Current Era: What Are the Gaps in Care? Circulation 2021; 144:1172-1185. [PMID: 34606298 DOI: 10.1161/circulationaha.121.056025] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Cardiovascular disease remains the leading cause of morbidity and mortality for women in United States and worldwide. One in 3 women dies from cardiovascular disease, and 45% of women >20 years old have some form of CVD. Historically, women have had higher morbidity and mortality after cardiac surgery. Sex influences pathogenesis, pathophysiology, presentation, postoperative complications, surgical outcomes, and survival. This review summarizes current cardiovascular surgery outcomes as they pertain to women. Specifically, this article seeks to address whether sex disparities in research, surgical referral, and outcomes still exist and to provide strategies to close these gaps. In addition, with the growing population of women of reproductive age with cardiovascular disease and cardiovascular risk factors, indications for cardiac surgery arise in pregnant women. The current review will also address the unique issues associated with this special population.
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Affiliation(s)
- Leslie Cho
- Cleveland Clinic Heart and Vascular Institute, Ohio (L.C., F.B.,T.K.)
| | - Melina R Kibbe
- University of North Caroline Medical School, Chapel Hill (M.R.K.)
| | - Faisal Bakaeen
- Cleveland Clinic Heart and Vascular Institute, Ohio (L.C., F.B.,T.K.)
| | | | | | - Tara Karmalou
- Cleveland Clinic Heart and Vascular Institute, Ohio (L.C., F.B.,T.K.)
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26
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Gender specific differences in functional capacity in asymptomatic patients with severe aortic stenosis. COR ET VASA 2021. [DOI: 10.33678/cor.2020.107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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27
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Abstract
Aortic valve stenosis has become the most common valvular heart disease on account of aging population and increasing life expectancy. Echocardiography is the primary diagnosis tool for this, but it still has many flaws. Therefore, advanced cardiovascular multimodal imaging techniques are continuously being developed in order to overcome these limitations. Cardiac magnetic resonance imaging (CMR) allows a comprehensive morphological and functional evaluation of the aortic valve and provides important data for the diagnosis and risk stratification in patients with aortic stenosis. CMR can functionally assess the aortic flow using two-dimensional and time-resolved three-dimensional velocity-encoded phase-contrast techniques. Furthermore, by late gadolinium enhancement and T1-mapping, CMR can reveal the presence of both irreversible replacement and diffuse interstitial myocardial fibrosis. Moreover, its role in guiding aortic valve replacement procedures is beginning to take shape. Recent studies have rendered the importance of active and passive biomechanics in risk stratification and prognosis prediction in patients with aortic stenosis, but more work is required is just in its infancy, but data are promising. In addition, cardiac computed tomography is particularly useful for the diagnosis of aortic valve stenosis, and in preprocedural evaluation of the aorta, while positron emission tomography can be also used to assess valvular inflammation and active calcification. The purpose of this review is to provide a comprehensive overview of current available data regarding advanced cardiovascular multimodal imaging in aortic stenosis.
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28
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Regional Replacement and Diffuse Interstitial Fibrosis in Aortic Regurgitation: Prognostic Implications From Cardiac Magnetic Resonance. JACC Cardiovasc Imaging 2021; 14:2170-2182. [PMID: 34274265 DOI: 10.1016/j.jcmg.2021.04.028] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 04/21/2021] [Accepted: 04/30/2021] [Indexed: 02/06/2023]
Abstract
OBJECTIVES This study used cardiac magnetic resonance (CMR) to assess left ventricular (LV) remodeling in chronic aortic regurgitation (AR) to identify both forms of myocardial fibrosis and examine its association with clinical outcomes. BACKGROUND Chronic AR leads to LV remodeling, which is associated with 2 forms of myocardial fibrosis: regional replacement fibrosis that is directly imaged by late gadolinium enhancement (LGE) CMR; and diffuse interstitial fibrosis, which can be inferred by T1 mapping techniques. METHODS Patients with chronic AR who were undergoing contrast CMR with T1 mapping for valve assessment from 2011 to 2018 were enrolled. Patients with a confounding etiology of myocardial fibrosis were excluded. In addition to quantification of AR severity and LV volumetrics, LGE and T1 mapping pre- and post-contrast were performed to measure extracellular volume (ECV) and indexed ECV (iECV). Patients were followed up longitudinally to assess for the composite event of death and the need for aortic valve replacement. RESULTS A total of 177 patients with isolated chronic AR were included (66% males, median age 58 years [47.0 years-68.0 years]) with a median follow up of 2.5 years (1.07 years-3.56 years). The iECV significantly increased with AR severity (P < 0.001), whereas ECV and replacement fibrosis did not (P = NS). On multivariate analysis, iECV remained associated with the composite event (P = 0.01). On Kaplan-Meier analysis stratified by AR regurgitant fraction (RF) and iECV, patients with AR RF severity ≥30% and iECV ≥24 mL/m2 demonstrated the highest event rate. CONCLUSIONS Among CMR biomarkers of fibrosis, iECV was more closely associated than replacement fibrosis or ECV with survival free of aortic valve replacement.
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29
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Elevated Apolipoprotein B/A-1 Ratio is Associated With an Increased Risk of Aortic Stenosis: Experience From the AMORIS Cohort. Heart Lung Circ 2021; 30:1050-1057. [DOI: 10.1016/j.hlc.2020.12.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 10/29/2020] [Accepted: 12/03/2020] [Indexed: 11/22/2022]
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30
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Sarajlic P, Plunde O, Franco-Cereceda A, Bäck M. Artificial Intelligence Models Reveal Sex-Specific Gene Expression in Aortic Valve Calcification. JACC Basic Transl Sci 2021; 6:403-412. [PMID: 34095631 PMCID: PMC8165113 DOI: 10.1016/j.jacbts.2021.02.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 02/03/2021] [Accepted: 02/03/2021] [Indexed: 12/13/2022]
Abstract
Differences in the clinical presentation and physiology of aortic stenosis in men and women complicate the management of the condition. By combining traditional inferential statistics, artificial intelligence predictive modeling, and genetic pathway analysis, one can gain further insight into sex-specific gene expression patterns, potentially driving the valvular phenotype differences between the sexes. Results from this study, implementing a mixed and comprehensive methodological approach, offer a foundation for further exploration of potential drug targets.
Male and female aortic stenosis patients have distinct valvular phenotypes, increasing the complexities in the evaluation of valvular pathophysiology. In this study, we present cutting-edge artificial intelligence analyses of transcriptome-wide array data from stenotic aortic valves to highlight differences in gene expression patterns between the sexes, using both sex-differentiated transcripts and unbiased gene selections. This approach enabled the development of efficient models with high predictive ability and determining the most significant sex-dependent contributors to calcification. In addition, analyses of function-related gene groups revealed enriched fibrotic pathways among female patients. Ultimately, we demonstrate that artificial intelligence models can be used to accurately predict aortic valve calcification by carefully analyzing sex-specific gene transcripts.
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Affiliation(s)
- Philip Sarajlic
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Oscar Plunde
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Anders Franco-Cereceda
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Theme Heart and Vessels, Division of Valvular and Coronary Disease, Karolinska University Hospital, Stockholm, Sweden
| | - Magnus Bäck
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden.,Theme Heart and Vessels, Division of Valvular and Coronary Disease, Karolinska University Hospital, Stockholm, Sweden
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31
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Steeds RP, Messika-Zeitoun D, Thambyrajah J, Serra A, Schulz E, Maly J, Aiello M, Rudolph TK, Lloyd G, Bortone AS, Clerici A, Delle-Karth G, Rieber J, Indolfi C, Mancone M, Belle L, Lauten A, Arnold M, Bouma BJ, Lutz M, Deutsch C, Kurucova J, Thoenes M, Bramlage P, Frey N. IMPULSE: the impact of gender on the presentation and management of aortic stenosis across Europe. Open Heart 2021; 8:openhrt-2020-001443. [PMID: 33419934 PMCID: PMC7798778 DOI: 10.1136/openhrt-2020-001443] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 11/09/2020] [Accepted: 12/01/2020] [Indexed: 11/10/2022] Open
Abstract
Aims There is an increasing awareness of gender-related differences in patients with severe aortic stenosis and their outcomes after surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI). Methods Data from the IMPULSE registry were analysed. Patients with severe aortic stenosis (AS) were enrolled between March 2015 and April 2017 and stratified by gender. A subgroup analysis was performed to assess the impact of age. Results Overall, 2171 patients were enrolled, and 48.0% were female. Women were characterised by a higher rate of renal impairment (31.7 vs 23.3%; p<0.001), were at higher surgical risk (EuroSCORE II: 4.5 vs 3.6%; p=0.001) and more often in a critical preoperative state (7.0vs 4.2%; p=0.003). Men had an increased rate of previous cardiac surgery (9.4 vs 4.7%; p<0.001) and a reduced left ventricular ejection fraction (4.9 vs 1.3%; p<0.001). Concomitant mitral and tricuspid valve disease was substantially more common among women. Symptoms were highly prevalent in both women and men (83.6 vs 77.3%; p<0.001). AVR was planned in 1379 cases. Women were more frequently scheduled to undergo TAVI (49.3 vs 41.0%; p<0.001) and less frequently for SAVR (20.3 vs 27.5%; p<0.001). Conclusions The present data show that female patients with severe AS have a distinct patient profile and are managed in a different way to males. Gender-based differences in the management of patients with severe AS need to be taken into account more systematically to improve outcomes, especially for women.
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Affiliation(s)
- Richard Paul Steeds
- Queen Elizabeth Hospital & Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | | | | | - Antonio Serra
- Interventional Cardiology Unit, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | | | - Jiri Maly
- Department of Cardiovascular Surgery, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
- Department of Cardiovascular Surgery, Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Marco Aiello
- Department of Cardiothoracic Surgery, Foundation IRCCS Policlinico S.Matteo, Pavia, Italy
| | - Tanja K Rudolph
- Department of Cardiology, Heart and Diabetes Center Bad Oeynhausen, Ruhr-University of Bochum, Bad Oeynhausen, Germany
| | - Guy Lloyd
- St Bartholomew's Hospital, London, UK
| | | | | | | | - Johannes Rieber
- Herzkatheterlabor Nymphenburg and Department of Cardiology, University of Munich, Munich, Germany
| | - Ciro Indolfi
- Division of Cardiology and URT CNR of IFC, University Magna Graecia, Catanzaro, Italy
| | | | - Loic Belle
- Centre Hospital d'Annecy, Annecy, France
| | - Alexander Lauten
- Department for Cardiology, Helios Erfurt Clinic, Erfurt, Germany
| | - Martin Arnold
- Department of Cardiology, University of Erlangen, Erlangen, Germany
| | | | - Matthias Lutz
- Department of Cardiology and Angiology, University of Kiel, Kiel, Germany
| | - Cornelia Deutsch
- Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany
| | | | | | - Peter Bramlage
- Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany
| | - Norbert Frey
- Department of Cardiology and Angiology, University of Kiel, Kiel, Germany
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Guzzetti E, Poulin A, Annabi MS, Zhang B, Kalavrouziotis D, Couture C, Dagenais F, Pibarot P, Clavel MA. Transvalvular Flow, Sex, and Survival After Valve Replacement Surgery in Patients With Severe Aortic Stenosis. J Am Coll Cardiol 2021; 75:1897-1909. [PMID: 32327100 DOI: 10.1016/j.jacc.2020.02.065] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 01/21/2020] [Accepted: 02/24/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND The respective impacts of transvalvular flow, gradient, sex, and their interactions on mortality in patients with severe aortic stenosis undergoing surgical aortic valve replacement (AVR) are unknown. OBJECTIVES This study sought to compare the impact of pre-operative flow-gradient patterns on mortality after AVR and to examine whether there are sex differences. METHODS This study analyzed clinical, echocardiographic, and outcome data prospectively collected in 1,490 patients (544 women [37%]), with severe aortic stenosis and preserved left ventricular ejection fraction who underwent AVR. RESULTS In this cohort, 601 patients (40%) had normal flow (NF) with high gradient (HG), 405 (27%) NF with low gradient (LG), 246 (17%) paradoxical low flow (LF)/HG, and 238 (16%) LF/LG. During a median follow-up of 2.42 years (interquartile range: 1.04 to 4.29 years), 167 patients died. Patients with LF/HG exhibited the highest mortality after AVR (hazard ratio [HR]: 2.01; 95% confidence interval [CI]: 1.33 to 3.03; p < 0.01), which remained significant after multivariate adjustment (HR: 1.96; 95% CI: 1.29 to 2.98; p < 0.01). Both LF/LG and NF/LG patients had comparable outcome to NF/HG (p ≥ 0.47). Optimal thresholds of stroke volume index were obtained for men (40 ml/m2) and women (32 ml/m2). Using these sex-specific cutpoints, paradoxical LF was independently associated with increased mortality in both women (adjusted HR: 2.05; 95% CI: 1.21 to 3.47; p < 0.01) and men (adjusted HR: 1.54; 95% CI: 1.02 to 2.32; p = 0.042), whereas guidelines' threshold (35 ml/m2) does not. CONCLUSIONS Paradoxical LF/HG was associated with higher mortality following AVR, suggesting that a reduced flow is a marker of disease severity even in patients with HG aortic stenosis. Early surgical AVR (i.e., before gradient attains 40 mm Hg) might be preferable in these patients. Furthermore, the use of sex-specific thresholds (<40 ml/m2 for men and <32 ml/m2 for women) to define low-flow outperforms the guidelines' threshold of 35 ml/m2 in risk stratification after AVR.
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Affiliation(s)
- Ezequiel Guzzetti
- Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec City, Quebec, Canada
| | - Anthony Poulin
- Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec City, Quebec, Canada
| | - Mohamed-Salah Annabi
- Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec City, Quebec, Canada
| | - Bin Zhang
- Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec City, Quebec, Canada
| | - Dimitri Kalavrouziotis
- Department of Cardiac Surgery, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec City, Quebec, Canada
| | - Christian Couture
- Department of Anatomo-Pathology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec City, Quebec, Canada
| | - François Dagenais
- Department of Cardiac Surgery, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec City, Quebec, Canada
| | - Philippe Pibarot
- Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec City, Quebec, Canada. https://twitter.com/PPibarot
| | - Marie-Annick Clavel
- Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec City, Quebec, Canada.
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Yeo JL, Brady EM, McCann GP, Gulsin GS. Sex and ethnic differences in the cardiovascular complications of type 2 diabetes. Ther Adv Endocrinol Metab 2021; 12:20420188211034297. [PMID: 34408835 PMCID: PMC8365016 DOI: 10.1177/20420188211034297] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 07/05/2021] [Indexed: 12/14/2022] Open
Abstract
Diabetes mellitus represents a global health concern affecting 463 million adults and is projected to rapidly rise to 700 million people by 2045. Amongst those with type 2 diabetes (T2D), there are recognised differences in the impact of the disease on different sex and ethnic groups. The relative risk of cardiovascular complications between individuals with and without T2D is higher in females than males. People of South Asian heritage are two to four times more likely to develop T2D than white people, but conversely not more likely to experience cardiovascular complications. Differences in the pathophysiological responses in these groups may identify potential areas for intervention beyond glycaemic control. In this review, we highlight key differences of diabetes-associated cardiovascular complications by sex and ethnic background, with a particular emphasis on South Asians. Evidence assessing therapeutic efficacy of new glucose lowering drugs in minority groups is limited and many major cardiovascular outcomes trials do not report ethnic specific data. Conversely, lifestyle intervention and bariatric surgery appear to have similar benefits regardless of sex and ethnic groups. We encourage future studies with better representation of women and ethnic minorities that will provide valuable data to allow better risk stratification and tailored prevention and management strategies to improve cardiovascular outcomes in T2D.
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Affiliation(s)
- Jian L Yeo
- Department of Cardiovascular Sciences, University of Leicester and the Leicester NIHR Biomedical Research Centre, Glenfield Hospital, Groby Road, Leicester, LE3 9QP, UK
| | - Emer M Brady
- Department of Cardiovascular Sciences, University of Leicester and the Leicester NIHR Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Gerry P McCann
- Department of Cardiovascular Sciences, University of Leicester and the Leicester NIHR Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Gaurav S Gulsin
- Department of Cardiovascular Sciences, University of Leicester and the Leicester NIHR Biomedical Research Centre, Glenfield Hospital, Leicester, UK
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Abstract
PURPOSE OF THE REVIEW This review summarizes sex-related changes in the heart and vasculature that occur with aging, both in the presence and absence of cardiovascular disease (CVD). RECENT FINDINGS In the presence of CVD risk factors and/or overt CVD, sex-specific changes in the number of cardiomyocytes, extent of the myocardial extracellular matrix, and myocellular hypertrophy promote unique patterns of LV remodeling in men and women. In addition, age- and sex-specific vascular stiffening is also well established, driven by changes in endothelial dysfunction, elastin-collagen content, microvascular dysfunction, and neurohormonal signaling. Together, these changes in LV chamber geometry and morphology, coupled with heightened vascular stiffness, appear to drive both age-related increases in systolic function and declines in diastolic function, particularly in postmenopausal women. Accordingly, estrogen has been implicated as a key mediator, given its direct vasodilating properties, association with nitric oxide excretion, and involvement in myocellular Ca2+ handling, mitochondrial energy production, and oxidative stress. The culmination of the abovementioned sex-specific cardiac and vascular changes across the lifespan provides important insight into heart failure development, particularly of the preserved ejection fraction variety, while offering promise for future preventive strategies and therapeutic approaches.
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Affiliation(s)
- Andrew Oneglia
- Applied Physiology and Advanced Imaging Lab, University of Texas at Arlington, 655 West Mitchell St, Arlington, TX, 76010, USA
| | - Michael D Nelson
- Applied Physiology and Advanced Imaging Lab, University of Texas at Arlington, 655 West Mitchell St, Arlington, TX, 76010, USA
- Barbra Streisand Women's Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, 127 S San Vicente Blvd, AHSP Suite A3206, Los Angeles, CA, 90048, USA
| | - C Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, 127 S San Vicente Blvd, AHSP Suite A3206, Los Angeles, CA, 90048, USA.
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CMR in Evaluating Valvular Heart Disease: Diagnosis, Severity, and Outcomes. JACC Cardiovasc Imaging 2020; 14:2020-2032. [PMID: 33248967 DOI: 10.1016/j.jcmg.2020.09.029] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 09/04/2020] [Accepted: 09/14/2020] [Indexed: 01/20/2023]
Abstract
Cardiac magnetic resonance (CMR) is a versatile imaging tool that brings much to the assessment of valvular heart disease. Although it is best known for myocardial imaging (even in valve disease), it provides excellent assessment of all 4 heart valves, with some distinct advantages, including a free choice of image planes and accurate flow and volumetric quantification. These allow the severity of each valve lesion to be characterized, in addition to optimal visualization of the surrounding outflow tracts and vessels, to deliver a comprehensive package. It can assess each valve lesion separately (in multiple valve disease) and is not affected by hemodynamic status. The accurate quantitation of regurgitant lesions and the ability to characterize myocardial changes also provides an ability to predict future clinical outcomes in asymptomatic patients. This review outlines how CMR can be used in cardiac valve disease to compliment echocardiography and enhance the patient assessment. It covers the main CMR methods used, their strengths and limitations, and the optimal way to apply them to evaluate valve disease.
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Updates to a Modern Dilemma: a Practical Approach to the Workup and Management of Low-Gradient Severe Aortic Stenosis Using Transvalvular Flow Rate. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2020. [DOI: 10.1007/s11936-020-00865-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Gamaza S, Díaz-Retamino E, Gaitero JC, Giráldez A, Zafra FM, Martín-Santana A, Oneto J. Outcome implication of sex-related effective orifice area normalized to body size in aortic stenosis. Echocardiography 2020; 37:1732-1740. [PMID: 33070386 DOI: 10.1111/echo.14868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 08/10/2020] [Accepted: 09/01/2020] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION Although several echocardiographic parameters have different values according to sex, there are no studies in echocardiographic variables of aortic stenosis (AS) severity. Our aim was to evaluate the sex-related prognosis of several echocardiographic parameters in AS. METHODS Two hundred and twenty-five patients with at least moderate AS (effective orifice area [EOA] ≤ 1.50 cm2 ) were prospectively enrolled. EOA was normalized to body surface area (BSA), height, and body mass index (BMI). Receiver operating characteristic curves, in women and men separately, were plotted to determine the best cutoff value for predicting cardiovascular death. RESULTS The largest area under the curve (AUC) to predict cardiovascular death was EOA in men (AUC 0.74, P < .001) and EOA/height in women (AUC 0.81, P < .001). An EOA/height cutoff value of 0.55 cm2 /m in women had a sensitivity of 100% and specificity of 61%; a cutoff of 0.50 cm2 /m in men obtained a sensitivity of 92% and a specificity of 56%. During a mean follow-up of 247 ± 183 days, there were 33 cardiovascular deaths. Women with EOA/height ≤ 0.55 cm2 /m had higher cardiovascular mortality (22% vs 0%, P < .001) and men with EOA/height ≤ 0.50 cm2 /m (21% vs 2%, P < .001). One-year survival in women with EOA/height ≤ 0.55 cm2 /m was 67 ± 8% and 100 ± 0% in EOA/height > 0.55 cm2 /m (P < .001). In men, 1-year survival was 70 ± 8% in EOA/height ≤ 0.50 cm2 /m, and 93 ± 6% in EOA/height > 0.50 cm2 /m (P = .004). CONCLUSIONS Normalization of EOA is useful in AS, especially in women. We recommend using an EOA/height cutoff value of 0.55 cm2 /m in women, and 0.50 cm2 /m in men to identify a subgroup with higher cardiovascular risk.
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Affiliation(s)
- Sergio Gamaza
- Cardiology Department, Hospital de Jerez, Jerez de la Frontera, Spain
| | | | | | - Alberto Giráldez
- Cardiology Department, Hospital de Jerez, Jerez de la Frontera, Spain
| | | | | | - Jesús Oneto
- Cardiology Department, Hospital de Jerez, Jerez de la Frontera, Spain
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Kanagala P, Arnold JR, Khan JN, Singh A, Gulsin GS, Eltayeb M, Gupta P, Squire IB, McCann GP, Ng LL. Fibroblast-growth-factor-23 in heart failure with preserved ejection fraction: relation to exercise capacity and outcomes. ESC Heart Fail 2020; 7:4089-4099. [PMID: 32935918 PMCID: PMC7755022 DOI: 10.1002/ehf2.13020] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 08/28/2020] [Accepted: 09/01/2020] [Indexed: 12/15/2022] Open
Abstract
AIMS This study aimed to assess plasma fibroblast growth factor 23 (FGF23) in patients with heart failure with preserved ejection fraction (HFpEF) and its relation to inflammation, renal function, clinical and imaging characteristics, exercise capacity, and prognosis. METHODS AND RESULTS We performed a prospective, observational study of 172 age-matched and sex-matched subjects (HFpEF n = 130; controls n = 42, age 73 ± 9, female 50%) who underwent plasma biomarker sampling, echocardiography, cardiac magnetic resonance imaging, and 6 min walk testing (6MWT). The primary endpoint was the composite of all-cause death or HF hospitalization. FGF23 was higher in HFpEF compared with controls (62 [42-105] vs. 34 [22-41] pg/mL, P < 0.0001). In HFpEF, FGF23 correlated with greater symptom burden (New York Heart Association class: r = 0.308), poorer exercise capacity (6MWT distance: r = -0.345), and plasma biomarkers reflecting inflammation (highly sensitive C-reactive protein: r = 0.207, myeloperoxidase: r = 0.311), bone metabolism (osteoprotegerin: r = 0.446), renal dysfunction (urea: r = 0.267, creatinine: r = 0.351, estimated glomerular filtration rate: r = -0.367), and echocardiographic E/e' (r = 0.298); P < 0.05. Following multivariable linear regression modelling, FGF23 remained independently associated with shorter 6MWT distance (P = 0.012) in addition to age, body mass index, and lower haemoglobin. During follow-up (median 1428 days), there were 61 composite events (21 deaths, 40 HF hospitalizations) in patients with HFpEF. In multivariable Cox regression analysis, FGF23 [adjusted hazard ratio (HR) 1.665; 95% confidence interval (CI) (1.284-2.160; P < 0.0001)], B-type natriuretic peptide (HR 1.433; CI 1.053-1.951; P = 0.022), and prior HF hospitalization (HR 2.058; CI 1.074-3.942; P = 0.030) were independent predictors of the composite endpoint. CONCLUSIONS Plasma FGF23 is higher in HFpEF compared with age-matched and sex-matched controls and is strongly associated with exercise incapacity and prognosis. FGF23 correlates with plasma markers of inflammation and renal impairment.
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Affiliation(s)
- Prathap Kanagala
- Department of Cardiovascular Sciences, University of Leicester, National Institute for Health Research (NIHR) Leicester Biomedical Research Centre, Leicester, UK.,Aintree University Hospital, Liverpool, UK.,Liverpool Centre for Cardiovascular Science, Liverpool, UK
| | - Jayanth R Arnold
- Department of Cardiovascular Sciences, University of Leicester, National Institute for Health Research (NIHR) Leicester Biomedical Research Centre, Leicester, UK
| | - Jamal N Khan
- Department of Cardiovascular Sciences, University of Leicester, National Institute for Health Research (NIHR) Leicester Biomedical Research Centre, Leicester, UK
| | - Anvesha Singh
- Department of Cardiovascular Sciences, University of Leicester, National Institute for Health Research (NIHR) Leicester Biomedical Research Centre, Leicester, UK
| | - Gaurav S Gulsin
- Department of Cardiovascular Sciences, University of Leicester, National Institute for Health Research (NIHR) Leicester Biomedical Research Centre, Leicester, UK
| | - Mohamed Eltayeb
- Department of Cardiovascular Sciences, University of Leicester, National Institute for Health Research (NIHR) Leicester Biomedical Research Centre, Leicester, UK
| | - Pankaj Gupta
- Department of Cardiovascular Sciences, University of Leicester, National Institute for Health Research (NIHR) Leicester Biomedical Research Centre, Leicester, UK
| | - Iain B Squire
- Department of Cardiovascular Sciences, University of Leicester, National Institute for Health Research (NIHR) Leicester Biomedical Research Centre, Leicester, UK
| | - Gerry P McCann
- Department of Cardiovascular Sciences, University of Leicester, National Institute for Health Research (NIHR) Leicester Biomedical Research Centre, Leicester, UK
| | - Leong L Ng
- Department of Cardiovascular Sciences, University of Leicester, National Institute for Health Research (NIHR) Leicester Biomedical Research Centre, Leicester, UK
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Malahfji M, Shah DJ. Cardiac Magnetic Resonance in Valvular Heart Disease: Assessment of Severity and Myocardial Remodeling. Methodist Debakey Cardiovasc J 2020; 16:106-113. [PMID: 32670470 DOI: 10.14797/mdcj-16-2-106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Cardiac magnetic resonance (CMR) has emerged as the gold standard in assessing ventricular mass, volume, and systolic function. Due to these and other strengths, CMR has increasingly been used to study valvular heart disease (VHD) and resultant cardiac remodeling. By using CMR to assess flow, limitations in echocardiographic assessment of VHD can be overcome, particularly in regurgitant lesions. The following article reviews the current role of CMR imaging in studying disease severity and myocardial remodeling in patients with VHD.
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Affiliation(s)
- Maan Malahfji
- HOUSTON METHODIST DEBAKEY HEART & VASCULAR CENTER, HOUSTON METHODIST HOSPITAL, HOUSTON, TEXAS
| | - Dipan J Shah
- HOUSTON METHODIST DEBAKEY HEART & VASCULAR CENTER, HOUSTON METHODIST HOSPITAL, HOUSTON, TEXAS
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Kanagala P, Arnold JR, Khan JN, Singh A, Gulsin GS, Chan DCS, Cheng ASH, Yang J, Li Z, Gupta P, Squire IB, McCann GP, Ng LL. Plasma Tenascin-C: a prognostic biomarker in heart failure with preserved ejection fraction. Biomarkers 2020; 25:556-565. [PMID: 32803990 DOI: 10.1080/1354750x.2020.1810319] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Tenascin-C is a marker of interstitial fibrosis. We assessed whether plasma Tenascin-C differed between heart failure with preserved ejection fraction (HFpEF) and asymptomatic controls and related to clinical outcomes. MATERIALS AND METHODS Prospective, observational study of 172 age- and sex-matched subjects (HFpEF n = 130; controls n = 42, age 73 ± 9, males 50%) who underwent phenotyping with 20 plasma biomarkers, echocardiography, cardiac MRI and 6-minute-walk-testing. The primary endpoint was the composite of all-cause death/HF hospitalisation. RESULTS Tenascin-C was higher in HFpEF compared to controls (13.7 [10.8-17.3] vs (11.1 [8.9-12.9] ng/ml, p < 0.0001). Tenascin-C correlated positively with markers of clinical severity (NYHA, E/E', BNP) and plasma biomarkers reflecting interstitial fibrosis (ST-2, Galectin-3, GDF-15, TIMP-1, TIMP-4, MMP-2, MMP-3, MMP-7, MMP-8), cardiomyocyte stress (BNP, NTpro-ANP), inflammation (MPO, hs-CRP, TNFR-1, IL6) and renal dysfunction (urea, cystatin-C, NGAL); p < 0.05 for all. During follow-up (median 1428 days), there were 61 composite events (21 deaths, 40 HF hospitalizations). In multivariable Cox regression analysis, Tenascin-C (adjusted hazard ratio [HR] 1.755, 95% confidence interval [CI] 1.305-2.360; p < 0.0001) and indexed extracellular volume (HR 1.465, CI 1.019-2.106; p = 0.039) were independently associated with adverse outcomes. CONCLUSIONS In HFpEF, plasma Tenascin-C is higher compared to age- and sex-matched controls and a strong predictor of adverse outcomes. Trial registration: ClinicalTrials.gov: NCT03050593.
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Affiliation(s)
- Prathap Kanagala
- Department of Cardiovascular Sciences and the National Institute for Health Research (NIHR) Leicester, Biomedical Research Centre, Leicester, UK.,Department of Cardiology, Aintree University Hospital, Liverpool, UK
| | - Jayanth R Arnold
- Department of Cardiovascular Sciences and the National Institute for Health Research (NIHR) Leicester, Biomedical Research Centre, Leicester, UK
| | - Jamal N Khan
- Department of Cardiovascular Sciences and the National Institute for Health Research (NIHR) Leicester, Biomedical Research Centre, Leicester, UK
| | - Anvesha Singh
- Department of Cardiovascular Sciences and the National Institute for Health Research (NIHR) Leicester, Biomedical Research Centre, Leicester, UK
| | - Gaurav S Gulsin
- Department of Cardiovascular Sciences and the National Institute for Health Research (NIHR) Leicester, Biomedical Research Centre, Leicester, UK
| | - Daniel C S Chan
- Department of Cardiovascular Sciences and the National Institute for Health Research (NIHR) Leicester, Biomedical Research Centre, Leicester, UK
| | | | - Jing Yang
- Bristol-Myers Squibb, Princeton, NJ, USA
| | - Zhuyin Li
- Bristol-Myers Squibb, Princeton, NJ, USA
| | - Pankaj Gupta
- Department of Cardiovascular Sciences and the National Institute for Health Research (NIHR) Leicester, Biomedical Research Centre, Leicester, UK
| | - Iain B Squire
- Department of Cardiovascular Sciences and the National Institute for Health Research (NIHR) Leicester, Biomedical Research Centre, Leicester, UK
| | - Gerry P McCann
- Department of Cardiovascular Sciences and the National Institute for Health Research (NIHR) Leicester, Biomedical Research Centre, Leicester, UK
| | - Leong L Ng
- Department of Cardiovascular Sciences and the National Institute for Health Research (NIHR) Leicester, Biomedical Research Centre, Leicester, UK
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Summerhill VI, Moschetta D, Orekhov AN, Poggio P, Myasoedova VA. Sex-Specific Features of Calcific Aortic Valve Disease. Int J Mol Sci 2020; 21:ijms21165620. [PMID: 32781508 PMCID: PMC7460640 DOI: 10.3390/ijms21165620] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 07/21/2020] [Accepted: 07/31/2020] [Indexed: 01/09/2023] Open
Abstract
Calcific aortic valve disease (CAVD) is the most common valvular heart disease in developed countries predominantly affecting the elderly population therefore posing a large economic burden. It is a gradually progressive condition ranging from mild valve calcification and thickening, without the hemodynamic obstruction, to severe calcification impairing leaflet motion, known as aortic stenosis (AS). The progression of CAVD occurs over many years, and it is extremely variable among individuals. It is also associated with an increased risk of coronary events and mortality. The recent insights into the CAVD pathophysiology included an important role of sex. Accumulating evidence suggests that, in patients with CAVD, sex can determine important differences in the relationship between valvular calcification process, fibrosis, and aortic stenosis hemodynamic severity between men and women. Consequently, it has implications on the development of different valvular phenotypes, left ventricular hypertrophy, and cardiovascular outcomes in men and women. Along these lines, taking into account the sex-related differences in diagnosis, prognosis, and treatment outcomes is of profound importance. In this review, the sex-related differences in patients with CAVD, in terms of pathobiology, clinical phenotypes, and outcomes were discussed.
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Affiliation(s)
- Volha I. Summerhill
- Department of Basic Research, Institute for Atherosclerosis Research, Skolkovo Innovative Center, 121609 Moscow, Russia;
- Correspondence:
| | - Donato Moschetta
- Unit for the Study of Aortic, Valvular and Coronary Pathologies, Monzino Cardiology Center IRCCS, 20138 Milan, Italy; (D.M.); (P.P.); (V.A.M.)
- Department of Pharmacological and Biomolecular Sciences, The University of Milan, 20133 Milan, Italy
| | - Alexander N. Orekhov
- Department of Basic Research, Institute for Atherosclerosis Research, Skolkovo Innovative Center, 121609 Moscow, Russia;
- Laboratory of Angiopathology, Institute of General Pathology and Pathophysiology, Russian Academy of Medical Sciences, 125315 Moscow, Russia
| | - Paolo Poggio
- Unit for the Study of Aortic, Valvular and Coronary Pathologies, Monzino Cardiology Center IRCCS, 20138 Milan, Italy; (D.M.); (P.P.); (V.A.M.)
| | - Veronika A. Myasoedova
- Unit for the Study of Aortic, Valvular and Coronary Pathologies, Monzino Cardiology Center IRCCS, 20138 Milan, Italy; (D.M.); (P.P.); (V.A.M.)
- Laboratory of Angiopathology, Institute of General Pathology and Pathophysiology, Russian Academy of Medical Sciences, 125315 Moscow, Russia
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Kwong RY, Chandrashekhar Y. What Is of Recent Interest in CMR: Insights From the JACC Family of Journals. J Am Coll Cardiol 2020; 75:2865-2870. [PMID: 32498815 DOI: 10.1016/j.jacc.2020.04.062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Raymond Y Kwong
- Division of Cardiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Y Chandrashekhar
- Division of Cardiology, University of Minnesota/VAMC Minneapolis, Minneapolis, Minnesota.
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Saeed S, Dweck MR, Chambers J. Sex differences in aortic stenosis: from pathophysiology to treatment. Expert Rev Cardiovasc Ther 2020; 18:65-76. [PMID: 32066291 DOI: 10.1080/14779072.2020.1732209] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Introduction: In aortic stenosis (AS), there are clear sex differences in clinical presentation, left ventricular (LV) response to pressure overload, and pathophysiology of valvular calcification. These differences may affect outcome following valve intervention.Area covered: This review aims to discuss sex differences in clinical presentation, pathophysiology of aortic valve calcification, LV remodeling in view of historic and recent echocardiographic and cardiac magnetic resonance imaging studies, and outcome after valve intervention. In addition, it will also provide some brief insights on the exercise physiology in women and men with AS.Expert commentary: Women at presentation are often older, have higher prevalence of hypertension and diastolic dysfunction, while men are younger, and more often have a bicuspid aortic valve and higher atherosclerotic disease burden. Men have more valve calcification than women for a given severity of AS and develop different patterns of LV remodeling and myocardial fibrosis. Although women tend to walk shorter on treadmill and achieve lower metabolic equivalents, they achieve similar peak heart rates and blood pressure, and the frequency of revealed symptoms during exercise test is comparable in both sexes. Men are more likely to undergo a surgical AVR with better outcome, while women have generally better outcome after TAVI.
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Affiliation(s)
- Sahrai Saeed
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Marc R Dweck
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - John Chambers
- Cardiothoracic Centre, Guy's & St Thomas' Hospital, London, UK
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Kanagala P, Arnold JR, Singh A, Chan DCS, Cheng ASH, Khan JN, Gulsin GS, Yang J, Zhao L, Gupta P, Squire IB, Ng LL, McCann GP. Characterizing heart failure with preserved and reduced ejection fraction: An imaging and plasma biomarker approach. PLoS One 2020; 15:e0232280. [PMID: 32349122 PMCID: PMC7190371 DOI: 10.1371/journal.pone.0232280] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 04/10/2020] [Indexed: 02/07/2023] Open
Abstract
Introduction The pathophysiology of heart failure with preserved ejection fraction (HFpEF) remains incompletely defined. We aimed to characterize HFpEF compared to heart failure with reduced ejection fraction (HFrEF) and asymptomatic hypertensive or non-hypertensive controls. Materials and methods Prospective, observational study of 234 subjects (HFpEF n = 140; HFrEF n = 46, controls n = 48, age 73±8, males 49%) who underwent echocardiography, cardiovascular magnetic resonance imaging (CMR), plasma biomarker analysis (panel of 22) and 6-minute walk testing (6MWT). The primary end-point was the composite of all-cause mortality and/or HF hospitalization. Results Compared to controls both HF groups had lower exercise capacity, lower left ventricular (LV) EF, higher LV filling pressures (E/E’, B-type natriuretic peptide [BNP], left atrial [LA] volumes), more right ventricular (RV) systolic dysfunction, more focal and diffuse fibrosis and higher levels of all plasma markers. LV remodeling (mass/volume) was different between HFpEF (concentric, 0.68±0.16) and HFrEF (eccentric, 0.47±0.15); p<0.0001. Compared to controls, HFpEF was characterized by (mild) reductions in LVEF, more myocardial fibrosis, LA remodeling/dysfunction and RV dysfunction. HFrEF patients had lower LVEF, increased LV volumes, greater burden of focal and diffuse fibrosis, more RV remodeling, lower LAEF and higher LA volumes compared to HFpEF. Inflammatory/fibrotic/renal dysfunction plasma markers were similarly elevated in both HF groups but markers of cardiomyocyte stretch/damage (BNP, pro-BNP, N-terminal pro-atrial natriuretic peptide and troponin-I) were higher in HFrEF compared to HFpEF; p<0.0001. Focal fibrosis was associated with galectin3, GDF-15, MMP-3, MMP-7, MMP-8, BNP, pro-BNP and NTproANP; p<0.05. Diffuse fibrosis was associated with GDF-15, Tenascin-C, MMP-2, MMP-3, MMP-7, BNP, proBNP and NTproANP; p<0.05. Composite event rates (median 1446 days follow-up) did not differ between HFpEF and HFrEF (Log-Rank p = 0.784). Conclusions HFpEF is a distinct pathophysiological entity compared to age- and sex-matched HFrEF and controls. HFpEF and HFrEF are associated with similar adverse outcomes. Inflammation is common in both HF phenotypes but cardiomyocyte stretch/stress is greater in HFrEF.
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Affiliation(s)
- Prathap Kanagala
- Aintree University Hospital and Clinical Research Fellow, National Institute for Health Research (NIHR) Leicester Biomedical Research Centre, Leicester, England, United Kingdom
- * E-mail:
| | - Jayanth R. Arnold
- National Institute for Health Research (NIHR) Leicester Biomedical Research Centre, Leicester, England, United Kingdom
| | - Anvesha Singh
- National Institute for Health Research (NIHR) Leicester Biomedical Research Centre, Leicester, England, United Kingdom
| | - Daniel C. S. Chan
- National Institute for Health Research (NIHR) Leicester Biomedical Research Centre, Leicester, England, United Kingdom
| | - Adrian S. H. Cheng
- Kettering General Hospital and National Institute for Health Research (NIHR) Leicester Biomedical Research Centre, Leicester, England, United Kingdom
| | - Jamal N. Khan
- National Institute for Health Research (NIHR) Leicester Biomedical Research Centre, Leicester, England, United Kingdom
| | - Gaurav S. Gulsin
- National Institute for Health Research (NIHR) Leicester Biomedical Research Centre, Leicester, England, United Kingdom
| | - Jing Yang
- Bristol-Myers Squibb, Princeton, New Jersey, United States of America
| | - Lei Zhao
- Bristol-Myers Squibb, Princeton, New Jersey, United States of America
| | - Pankaj Gupta
- National Institute for Health Research (NIHR) Leicester Biomedical Research Centre, Leicester, England, United Kingdom
| | - Iain B. Squire
- National Institute for Health Research (NIHR) Leicester Biomedical Research Centre, Leicester, England, United Kingdom
| | - Leong L. Ng
- National Institute for Health Research (NIHR) Leicester Biomedical Research Centre, Leicester, England, United Kingdom
| | - Gerry P. McCann
- National Institute for Health Research (NIHR) Leicester Biomedical Research Centre, Leicester, England, United Kingdom
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Bhuva AN, Treibel TA, De Marvao A, Biffi C, Dawes TJW, Doumou G, Bai W, Patel K, Boubertakh R, Rueckert D, O'Regan DP, Hughes AD, Moon JC, Manisty CH. Sex and regional differences in myocardial plasticity in aortic stenosis are revealed by 3D model machine learning. Eur Heart J Cardiovasc Imaging 2020; 21:417-427. [PMID: 31280289 PMCID: PMC7100908 DOI: 10.1093/ehjci/jez166] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 06/22/2019] [Indexed: 12/12/2022] Open
Abstract
AIMS Left ventricular hypertrophy (LVH) in aortic stenosis (AS) varies widely before and after aortic valve replacement (AVR), and deeper phenotyping beyond traditional global measures may improve risk stratification. We hypothesized that machine learning derived 3D LV models may provide a more sensitive assessment of remodelling and sex-related differences in AS than conventional measurements. METHODS AND RESULTS One hundred and sixteen patients with severe, symptomatic AS (54% male, 70 ± 10 years) underwent cardiovascular magnetic resonance pre-AVR and 1 year post-AVR. Computational analysis produced co-registered 3D models of wall thickness, which were compared with 40 propensity-matched healthy controls. Preoperative regional wall thickness and post-operative percentage wall thickness regression were analysed, stratified by sex. AS hypertrophy and regression post-AVR was non-uniform-greatest in the septum with more pronounced changes in males than females (wall thickness regression: -13 ± 3.6 vs. -6 ± 1.9%, respectively, P < 0.05). Even patients without LVH (16% with normal indexed LV mass, 79% female) had greater septal and inferior wall thickness compared with controls (8.8 ± 1.6 vs. 6.6 ± 1.2 mm, P < 0.05), which regressed post-AVR. These differences were not detectable by global measures of remodelling. Changes to clinical parameters post-AVR were also greater in males: N-terminal pro-brain natriuretic peptide (NT-proBNP) [-37 (interquartile range -88 to -2) vs. -1 (-24 to 11) ng/L, P = 0.008], and systolic blood pressure (12.9 ± 23 vs. 2.1 ± 17 mmHg, P = 0.009), with changes in NT-proBNP correlating with percentage LV mass regression in males only (ß 0.32, P = 0.02). CONCLUSION In patients with severe AS, including those without overt LVH, LV remodelling is most plastic in the septum, and greater in males, both pre-AVR and post-AVR. Three-dimensional machine learning is more sensitive than conventional analysis to these changes, potentially enhancing risk stratification. CLINICAL TRIAL REGISTRATION Regression of myocardial fibrosis after aortic valve replacement (RELIEF-AS); NCT02174471. https://clinicaltrials.gov/ct2/show/NCT02174471.
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Affiliation(s)
- Anish N Bhuva
- Institute for Cardiovascular Science, University College London, Chenies Mews, London WC1E6HX, UK
- Department of Cardiovascular Imaging, Barts Heart Centre, Barts Health NHS Trust, King George V Building, West Smithfield, London EC1A 7BE, UK
| | - Thomas A Treibel
- Institute for Cardiovascular Science, University College London, Chenies Mews, London WC1E6HX, UK
- Department of Cardiovascular Imaging, Barts Heart Centre, Barts Health NHS Trust, King George V Building, West Smithfield, London EC1A 7BE, UK
| | - Antonio De Marvao
- MRC London Institute of Medical Sciences, Imperial College London, Hammersmith Hospital Campus, Du Cane Road, London W120NN, UK
| | - Carlo Biffi
- MRC London Institute of Medical Sciences, Imperial College London, Hammersmith Hospital Campus, Du Cane Road, London W120NN, UK
- Department of Computing, Imperial College London, South Kensington Campus, 180 Queen's Gate, London SW72RH, UK
| | - Timothy J W Dawes
- MRC London Institute of Medical Sciences, Imperial College London, Hammersmith Hospital Campus, Du Cane Road, London W120NN, UK
- National Heart and Lung Institute, Imperial College London, Du Cane Road, London W120NN, UK
| | - Georgia Doumou
- MRC London Institute of Medical Sciences, Imperial College London, Hammersmith Hospital Campus, Du Cane Road, London W120NN, UK
| | - Wenjia Bai
- Department of Computing, Imperial College London, South Kensington Campus, 180 Queen's Gate, London SW72RH, UK
| | - Kush Patel
- Institute for Cardiovascular Science, University College London, Chenies Mews, London WC1E6HX, UK
- Department of Cardiovascular Imaging, Barts Heart Centre, Barts Health NHS Trust, King George V Building, West Smithfield, London EC1A 7BE, UK
| | - Redha Boubertakh
- Department of Cardiovascular Imaging, Barts Heart Centre, Barts Health NHS Trust, King George V Building, West Smithfield, London EC1A 7BE, UK
| | - Daniel Rueckert
- Department of Computing, Imperial College London, South Kensington Campus, 180 Queen's Gate, London SW72RH, UK
| | - Declan P O'Regan
- MRC London Institute of Medical Sciences, Imperial College London, Hammersmith Hospital Campus, Du Cane Road, London W120NN, UK
| | - Alun D Hughes
- Institute for Cardiovascular Science, University College London, Chenies Mews, London WC1E6HX, UK
| | - James C Moon
- Institute for Cardiovascular Science, University College London, Chenies Mews, London WC1E6HX, UK
- Department of Cardiovascular Imaging, Barts Heart Centre, Barts Health NHS Trust, King George V Building, West Smithfield, London EC1A 7BE, UK
| | - Charlotte H Manisty
- Institute for Cardiovascular Science, University College London, Chenies Mews, London WC1E6HX, UK
- Department of Cardiovascular Imaging, Barts Heart Centre, Barts Health NHS Trust, King George V Building, West Smithfield, London EC1A 7BE, UK
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46
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Shan Y, Pellikka PA. Aortic stenosis in women. Heart 2020; 106:970-976. [DOI: 10.1136/heartjnl-2019-315407] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 02/25/2020] [Accepted: 02/25/2020] [Indexed: 12/17/2022] Open
Abstract
Aortic stenosis (AS) is a common valve disorder in an ageing population in western countries, and women, with longer life expectancy, comprise a substantial percentage of elderly patients with AS. Compared with men, women exhibit distinctive characteristics at the level of stenotic valve leaflets and subsequent compensatory responses of the left ventricle to chronic pressure overload, and in clinical presentation, consequences and response to intervention. Randomised controlled trials of transcatheter aortic valve implantation have yielded new evidence of sex differences in both short-term and long-term outcomes after intervention. A comprehensive knowledge of the existing evidence may inform our understanding of gender differences during assessment and treatment of patients with AS. In this paper, we review the available evidence regarding sex differences in AS in terms of symptoms, clinical presentation, anatomical differences and pathophysiological progression, management and outcomes after aortic valve replacement. Implications for further research are suggested.
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47
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Tastet L, Kwiecinski J, Pibarot P, Capoulade R, Everett RJ, Newby DE, Shen M, Guzzetti E, Arsenault M, Bédard É, Larose É, Beaudoin J, Dweck M, Clavel MA. Sex-Related Differences in the Extent of Myocardial Fibrosis in Patients With Aortic Valve Stenosis. JACC Cardiovasc Imaging 2020; 13:699-711. [PMID: 31422128 DOI: 10.1016/j.jcmg.2019.06.014] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 06/13/2019] [Accepted: 06/14/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The aim of this study was to assess the effect of sex on myocardial fibrosis as assessed by using cardiac magnetic resonance (CMR) imaging in aortic stenosis (AS). BACKGROUND Previous studies reported sex-related differences in the left ventricular (LV) remodeling response to pressure overload in AS. However, there are very few data regarding the effect of sex on myocardial fibrosis, a key marker of LV decompensation and adverse cardiac events in AS. METHODS A total of 249 patients (mean age 66 ± 13 years; 30% women) with at least mild AS were recruited from 2 prospective observational cohort studies and underwent comprehensive Doppler echocardiography and CMR examinations. On CMR, T1 mapping was used to quantify extracellular volume (ECV) fraction as a marker of diffuse fibrosis, and late gadolinium enhancement (LGE) was used to assess focal fibrosis. RESULTS There was no difference in age between women and men (age 66 ± 15 years vs 66 ± 12 years; p = 0.78). However, women presented with a better cardiovascular risk profile than men with less hypertension, dyslipidemia, diabetes, and coronary artery disease (all, p ≤ 0.10). As expected, LV mass index measured by CMR imaging was smaller in women than in men (p < 0.0001). Despite fewer comorbidities, women presented with larger ECV fraction (median: 29.0% [25th to 75th percentiles: 27.4% to 30.6%] vs. 26.8% [25th to 75th percentiles: 25.1% to 28.7%]; p < 0.0001) and similar LGE (median: 4.5% [25th-75th percentiles: 2.3% to 7.0%] vs. 2.8% [25th-75th percentiles: 0.6% to 6.8%]; p = 0.20) than men. In multivariable analysis, female sex remained an independent determinant of higher ECV fraction and LGE (all, p ≤ 0.05). CONCLUSIONS Women have greater diffuse and focal myocardial fibrosis independent of the degree of AS severity. These findings further emphasize the sex-related differences in LV remodeling response to pressure overload.
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Affiliation(s)
- Lionel Tastet
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart & Lung Institute, Laval University, Québec City, Québec, Canada
| | - Jacek Kwiecinski
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Philippe Pibarot
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart & Lung Institute, Laval University, Québec City, Québec, Canada
| | - Romain Capoulade
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart & Lung Institute, Laval University, Québec City, Québec, Canada
| | - Russell J Everett
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - David E Newby
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Mylène Shen
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart & Lung Institute, Laval University, Québec City, Québec, Canada
| | - Ezequiel Guzzetti
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart & Lung Institute, Laval University, Québec City, Québec, Canada
| | - Marie Arsenault
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart & Lung Institute, Laval University, Québec City, Québec, Canada
| | - Élisabeth Bédard
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart & Lung Institute, Laval University, Québec City, Québec, Canada
| | - Éric Larose
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart & Lung Institute, Laval University, Québec City, Québec, Canada
| | - Jonathan Beaudoin
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart & Lung Institute, Laval University, Québec City, Québec, Canada
| | - Marc Dweck
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Marie-Annick Clavel
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart & Lung Institute, Laval University, Québec City, Québec, Canada.
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48
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Pibarot P, Sengupta P, Chandrashekhar Y. Imaging Is the Cornerstone of the Management of Aortic Valve Stenosis. JACC Cardiovasc Imaging 2020; 12:220-223. [PMID: 30621995 DOI: 10.1016/j.jcmg.2018.12.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Philippe Pibarot
- Department of Cardiology, Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Partho Sengupta
- Division of Cardiology, West Virginia University Heart and Vascular Institute, West Virginia University, Morgantown, West Virginia
| | - Y Chandrashekhar
- Division of Cardiology, University of Minnesota and Veterans Affairs Medical Center, Minneapolis, Minnesota.
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Mahon C, Mohiaddin RH. The emerging applications of cardiovascular magnetic resonance imaging in transcatheter aortic valve implantation. Clin Radiol 2019; 76:73.e21-73.e37. [PMID: 31879023 DOI: 10.1016/j.crad.2019.11.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 11/13/2019] [Indexed: 12/22/2022]
Abstract
Transcatheter aortic valve implantation (TAVI) is an alternative to surgical aortic valve replacement in selected patients with severe symptomatic aortic stenosis (AS) and high surgical risk. The planning and follow-up of TAVI requires an array of imaging techniques, each has advantages and limitations. Echocardiography and multidetector computer tomography (MDCT) have established applications in patient selection and procedure guidance, but are limited in some patients. TAVI applications of cardiovascular magnetic resonance imaging (CMRI) are emerging. CMRI can provide the structural and functional imaging details required for TAVI procedure in away comparable or superior to that obtained by echocardiography and MDCT combined. In this review, we look at the continuously evolving role of CMRI as a complimentary or an alternative to more established imaging techniques and address the advantages and disadvantages of CMRI in this setting. We discuss the role of CMRI in selecting anatomically suitable patients for the TAVI procedure and in the post-TAVI follow-up with particular emphasis on its applications for assessing AS severity and haemodynamic impact, vascular imaging for TAVI access route, quantification of paravalvular leaks and LV remodelling in the post TAVI setting as well as providing imaging biomarkers tool for AS risk-stratification.
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Affiliation(s)
- C Mahon
- Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - R H Mohiaddin
- Royal Brompton and Harefield NHS Foundation Trust, London, UK; National Heart and Lung Institute, Imperial College London, London, UK.
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50
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Singh A, Musa TA, Treibel TA, Vassiliou VS, Captur G, Chin C, Dobson LE, Pica S, Loudon M, Malley T, Rigolli M, Foley JRJ, Bijsterveld P, Law GR, Dweck MR, Myerson SG, Prasad SK, Moon JC, Greenwood JP, McCann GP. Sex differences in left ventricular remodelling, myocardial fibrosis and mortality after aortic valve replacement. Heart 2019; 105:1818-1824. [PMID: 31467152 PMCID: PMC6900227 DOI: 10.1136/heartjnl-2019-314987] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 06/07/2019] [Accepted: 06/08/2019] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVES To investigate sex differences in left ventricular remodelling and outcome in patients undergoing surgical or transcatheter aortic valve replacement (SAVR/TAVR). METHODS In this multicentre, observational, outcome study with imaging core-lab analysis, patients with severe aortic stenosis (AS) listed for intervention at one of six UK centres were prospectively recruited and underwent cardiovascular magnetic resonance imaging. The primary endpoint was all-cause mortality and secondary endpoint was cardiovascular mortality. RESULTS 674 patients (425 men, 249 women, age 75±14 years) were included: 399 SAVR, 275 TAVR. Women were older, had higher surgical risk scores and underwent TAVR more frequently (53% vs 33.6%, p<0.001). More men had bicuspid aortic valves (BAVs) (26.7% vs 14.9%, p<0.001) and demonstrated more advanced remodelling than women. During a median follow-up of 3.6 years, 145 (21.5%) patients died, with no significant sex difference in all-cause mortality (23.3% vs 20.5%, p=0.114), but higher cardiovascular mortality in women (13.7% vs 8.5%, p=0.012). There were no significant sex-related differences in outcome in the SAVR or TAVR subgroups, or after excluding those with BAV. Factors independently associated with all-cause mortality were age, left ventricular ejection fraction (LVEF), BAV (better) and myocardial fibrosis detected with late gadolinium enhancement (LGE) in men, and age, LVEF and LGE in women. Age and LGE were independently associated with cardiovascular mortality in both sexes. CONCLUSIONS Men demonstrate more advanced remodelling in response to a similar severity of AS. The higher cardiovascular mortality observed in women following AVR is accounted for by women having less BAV and higher risk scores resulting in more TAVR. LGE is associated with a worse prognosis in both sexes.
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Affiliation(s)
- Anvesha Singh
- Cardiovascular Sciences, University of Leicester and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Tarique Al Musa
- Cardiovascular Sciences, Multidisciplinary Cardiovascular Research Centre and The Division of Biomedical Imaging, Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Thomas A Treibel
- Cardiovascular Sciences, Barts Health NHS Trust and University College London, London, UK
| | - Vassiliou S Vassiliou
- Cardiovascular Sciences, Imperial College London, Royal Brompton Hospital, London, UK,University of East Anglia and Norfolk and Norwich University Hospitals, Norwich, Norfolk, United Kingdom
| | - Gabriella Captur
- Cardiovascular Sciences, Barts Health NHS Trust and University College London, London, UK
| | - Calvin Chin
- Cardiovascular Medicine, National Heart Center Singapore, Singapore, Singapore
| | - Laura E Dobson
- Cardiovascular Sciences, Multidisciplinary Cardiovascular Research Centre and The Division of Biomedical Imaging, Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Silvia Pica
- Cardiovascular Sciences, Barts Health NHS Trust and University College London, London, UK
| | - Margaret Loudon
- Cardiovascular Sciences, University of Oxford Centre for Clinical Magnetic Resonance Research, Oxford, UK
| | - Tamir Malley
- Cardiovascular Sciences, Imperial College London, Royal Brompton Hospital, London, UK
| | - Marzia Rigolli
- Cardiovascular Sciences, University of Oxford Centre for Clinical Magnetic Resonance Research, Oxford, UK
| | - James Robert John Foley
- Cardiovascular Sciences, Multidisciplinary Cardiovascular Research Centre and The Division of Biomedical Imaging, Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Petra Bijsterveld
- Cardiovascular Sciences, Multidisciplinary Cardiovascular Research Centre and The Division of Biomedical Imaging, Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Graham R Law
- Medical Statistics, School of Health and Social Care, University of Lincoln and Multidisciplinary Cardiovascular Research Centre and The Division of Biomedical Imaging, Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Lincoln and Leeds, UK
| | - Marc Richard Dweck
- Cardiovascular Sciences, Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Saul G Myerson
- Cardiovascular Sciences, University of Oxford Centre for Clinical Magnetic Resonance Research, Oxford, UK
| | | | - James C Moon
- Cardiovascular Sciences, Barts Health NHS Trust and University College London, London, UK
| | - John P Greenwood
- Cardiovascular Sciences, Multidisciplinary Cardiovascular Research Centre and The Division of Biomedical Imaging, Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Gerry P McCann
- Cardiovascular Sciences, University of Leicester and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
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