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Sevilla T, Rojas G, González-Bartol E, Candela J, Gil JF, Revilla A, Aristizabal-Duque C, Gomez Salvador I, San Román Calvar JA. Magnetic resonance analysis of ventricular volumes in bicuspid and trileaflet aortic regurgitation. Heart 2023; 109:1558-1563. [PMID: 37230740 DOI: 10.1136/heartjnl-2023-322519] [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: 02/08/2023] [Accepted: 05/10/2023] [Indexed: 05/27/2023] Open
Abstract
OBJECTIVE To identify differences in left ventricular (LV) remodelling between patients with bicuspid aortic valve (BAV) and trileaflet aortic valve (TAV) with chronic aortic regurgitation (AR). METHODS Retrospective cohort study of 210 consecutive patients undergoing cardiac magnetic resonance for AR evaluation. We divided the study population according to valvular morphology. Independent predictors of LV enlargement AR were evaluated. RESULTS There were 110 patients with BAV and 100 patients with TAV. Patients with BAV were younger (mean age BAV vs TAV: 41±16 years vs 67±11 years; p<0.01), mostly male (% male BAV vs TAV: 84.5% vs 65%, p=0.01) and presented milder degrees of AR (median regurgitant fraction BAV vs TAV: 14 (6-28)% vs 22 (12-35)%, p=0.002). Both groups presented similar indexed LV volumes and ejection fraction. According to the degree of AR, at mild AR, patients with BAV presented larger LV volumes (BAV vs TAV: indexed end diastolic left ventricular volumes (iEDV): 96.5±19.7 vs 82.1±19.3 mL, p<0.01; indexed end systolic left ventricular volumes (iESV): 39.4±10.3 mL vs 33.2±10.5 mL, p=0.01). These differences disappeared at higher degrees of AR. Independent predictors of LV enlargement were regurgitant fraction (EDV: OR 1.118 (1.081-1.156), p<0.001; ESV: OR 1.067 (1.042-1.092), p<0.001), age (EDV: OR 0.940 (0.917-0.964), p<0.001, ESV: OR 0.962 (0.945-0.979), p<0.001) and weight (EDV: OR 1.054 (1.025-1.083), p<0.001). CONCLUSIONS In chronic AR, LV enlargement is an early finding. LV volumes display a direct correlation with regurgitant fraction and an inverse association with age. Patients with BAV present larger ventricular volumes, especially at mild AR. However, these differences are attributable to demographic disparities; valve type is not independently associated with LV size.
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Affiliation(s)
- Teresa Sevilla
- Department of Cardiology, Hospital Clinico Universitario de Valladolid, Valladolid, Castilla y León, Spain
- Centro de Investigación Biomédica en Red, CIBERCV, Madrid, Comunidad de Madrid, Spain
| | - Gino Rojas
- Department of Cardiology, Hospital Clinico Universitario de Valladolid, Valladolid, Castilla y León, Spain
| | - Esther González-Bartol
- Department of Cardiology, Hospital Clinico Universitario de Valladolid, Valladolid, Castilla y León, Spain
| | - Jordi Candela
- Department of Cardiology, Hospital Clinico Universitario de Valladolid, Valladolid, Castilla y León, Spain
| | - José Francisco Gil
- Department of Cardiology, Hospital Clinico Universitario de Valladolid, Valladolid, Castilla y León, Spain
| | - Ana Revilla
- Department of Cardiology, Hospital Clinico Universitario de Valladolid, Valladolid, Castilla y León, Spain
- Centro de Investigación Biomédica en Red, CIBERCV, Madrid, Comunidad de Madrid, Spain
| | | | - Itziar Gomez Salvador
- Department of Cardiology, Hospital Clinico Universitario de Valladolid, Valladolid, Castilla y León, Spain
- Centro de Investigación Biomédica en Red, CIBERCV, Madrid, Comunidad de Madrid, Spain
| | - José Alberto San Román Calvar
- Department of Cardiology, Hospital Clinico Universitario de Valladolid, Valladolid, Castilla y León, Spain
- Centro de Investigación Biomédica en Red, CIBERCV, Madrid, Comunidad de Madrid, Spain
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Peigh G, Puthumana JJ, Bonow RO. Aortic Regurgitation and Heart Failure: Advances in Diagnosis, Management, and Interventions. Heart Fail Clin 2023; 19:285-296. [PMID: 37230644 DOI: 10.1016/j.hfc.2023.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
This review discusses the contemporary clinical evaluation and management of patients with comorbid aortic regurgitation (AR) and heart failure (HF) (AR-HF). Importantly, as clinical HF exists along the spectrum of AR severity, the present review also details novel strategies to detect early signs of HF before the clinical syndrome ensues. Indeed, there may be a vulnerable cohort of AR patients who benefit from early detection and management of HF. Additionally, while the mainstay of operative management for AR has historically been surgical aortic valve replacement, this review discusses alternate procedures that may be beneficial in high-risk cohorts.
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Affiliation(s)
- Graham Peigh
- Division of Cardiology, Northwestern University, Feinberg School of Medicine, 676 North St. Clair Suite 600, Chicago, IL 60611, USA.
| | - Jyothy J Puthumana
- Division of Cardiology, Northwestern University, Feinberg School of Medicine, 676 North St. Clair Suite 600, Chicago, IL 60611, USA
| | - Robert O Bonow
- Division of Cardiology, Northwestern University, Feinberg School of Medicine, 676 North St. Clair Suite 600, Chicago, IL 60611, USA
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Tower-Rader A, Mathias IS, Obuchowski NA, Kocyigit D, Kumar Y, Donnellan E, Bolen M, Phelan D, Flamm S, Griffin B, Cho L, Svensson LG, Pettersson G, Popovic Z, Kwon D. Sex-based differences in left ventricular remodeling in patients with chronic aortic regurgitation: a multi-modality study. J Cardiovasc Magn Reson 2022; 24:12. [PMID: 35193584 PMCID: PMC8862390 DOI: 10.1186/s12968-022-00845-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 01/16/2022] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Significant aortic regurgitation (AR) leads to left ventricular (LV) remodeling; however, little data exist regarding sex-based differences in LV remodeling in this setting. We sought to compare LV remodeling and AR severity, assessed by echocardiography and cardiovascular magnetic resonance (CMR), to discern sex-based differences. METHODS Patients with ≥ moderate chronic AR by echocardiography who underwent CMR within 90 days between December 2005 and October 2015 were included. Nonlinear regression models were built to assess the effect of AR regurgitant fraction (RF) on LV remodeling. A generalized linear model and Bland Altman analyses were constructed to evaluate differences between CMR and echocardiography. Referral for surgical intervention based on symptoms and LV remodeling was evaluated. RESULTS Of the 243 patients (48.3 ± 16.6 years, 58 (24%) female), 119 (49%) underwent surgical intervention with a primary indication of severe AR, 97 (82%) men, 22 (18%) women. Significant sex differences in LV remodeling emerged on CMR. Women demonstrated significantly smaller LV end-diastolic volume index (LVEDVI) (96.8 ml/m2 vs 125.6 ml/m2, p < 0.001), LV end-systolic volume index (LVESVI) (41.1 vs 54.5 ml/m2, p < 0.001), blunted LV dilation in the setting of increasing AR severity (LVEDVI p value < 0.001, LVESVI p value 0.011), and LV length indexed (8.32 vs 9.69 cm, p < 0.001). On Bland Altman analysis, a significant interaction with sex and LV diameters was evident, demonstrating a significant increase in the difference between CMR and echocardiography measurements as the LV enlarged in women: LVEDVI (p = 0.006), LVESVI (p < 0.001), such that echocardiographic measurements increasingly underestimated LV diameters in women as the LV enlarged. LV length was higher for males with a linear effect from RF (p < 0.001), with LV length increasing at a higher rate with increasing RF for males compared to females (two-way interaction with sex p = 0.005). Sphericity volume index was higher for men after adjusting for a relative wall thickness (p = 0.033). CONCLUSIONS CMR assessment of chronic AR revealed significant sex differences in LV remodeling and significant echocardiographic underestimation of LV dilation, particularly in women. Defining optimal sex-based CMR thresholds for surgical referral should be further developed. TRIAL REGISTRATION NA.
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Affiliation(s)
- Albree Tower-Rader
- Department of Cardiology, Harvard Medical School, Massachusetts General Hospital, 55 Fruit St, Yawkey 5B, Boston, MA, 02114, USA
| | - Isadora Sande Mathias
- Department of Cardiology, Houston Methodist Hospital, Weill Cornell Medical College, 6565 Fannin St., Houston, TX, 77030, USA
| | - Nancy A Obuchowski
- Quantitative Health Sciences, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
| | - Duygu Kocyigit
- Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
| | - Yash Kumar
- Case Western University, 10900 Euclid Ave, Cleveland, OH, 44106-7017, USA
| | - Eoin Donnellan
- Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
| | - Michael Bolen
- Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
| | - Dermot Phelan
- Sanger Heart & Vascular Institute, Atrium Health, 1237 Harding Place, MOB1 Suite 5000, Charlotte, NC, 28204, USA
| | - Scott Flamm
- Imaging Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
| | - Brian Griffin
- Imaging Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
| | - Leslie Cho
- Imaging Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
| | - Lars G Svensson
- Imaging Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
| | - Gosta Pettersson
- Imaging Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
| | - Zoran Popovic
- Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
- Imaging Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
| | - Deborah Kwon
- Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA.
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Reid A, Blanke P, Bax JJ, Leipsic J. Multimodality imaging in valvular heart disease: how to use state-of-the-art technology in daily practice. Eur Heart J 2021; 42:1912-1925. [PMID: 33186469 DOI: 10.1093/eurheartj/ehaa768] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 06/15/2020] [Accepted: 09/08/2020] [Indexed: 12/16/2022] Open
Abstract
Our understanding of the complexities of valvular heart disease (VHD) has evolved in recent years, primarily because of the increased use of multimodality imaging (MMI). Whilst echocardiography remains the primary imaging technique, the contemporary evaluation of patients with VHD requires comprehensive analysis of the mechanism of valvular dysfunction, accurate quantification of severity, and active exclusion extravalvular consequences. Furthermore, advances in surgical and percutaneous therapies have driven the need for meticulous multimodality imaging to aid in patient and procedural selection. Fundamental decision-making regarding whom, when, and how to treat patients with VHD has become more complex. There has been rapid technological advancement in MMI; many techniques are now available in routine clinical practice, and their integration into has the potential to truly individualize management strategies. This review provides an overview of the current evidence for the use of MMI in VHD, and how various techniques within each modality can be used practically to answer clinical conundrums.
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Affiliation(s)
- Anna Reid
- Department of Radiology and Cardiology, Center for Heart Lung Innovation, St. Paul's Hospital, University of British Columbia, 1081 Burrard Street, Vancouver V6Z1Y6, BC, Canada
| | - Philipp Blanke
- Department of Radiology and Cardiology, Center for Heart Lung Innovation, St. Paul's Hospital, University of British Columbia, 1081 Burrard Street, Vancouver V6Z1Y6, BC, Canada
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, Netherlands
| | - Jonathon Leipsic
- Department of Radiology and Cardiology, Center for Heart Lung Innovation, St. Paul's Hospital, University of British Columbia, 1081 Burrard Street, Vancouver V6Z1Y6, BC, Canada
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5
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Zheng Y, Yang K, Chen X, Li R, Su G, Yin G, Wang K, Lu M, Zhao S. Prognostic significance of myocardial fibrosis and CMR characteristics in bicuspid aortic valve with moderate and severe aortic insufficiency. Eur Radiol 2021; 31:7262-7272. [PMID: 33860827 DOI: 10.1007/s00330-021-07823-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 02/03/2021] [Accepted: 02/19/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES This study attempted to evaluate the characteristics and prognostic value of myocardial fibrosis (MF) in aortic insufficiency (AI) patients with bicuspid aortic valve (BAV) or tricuspid aortic valve (TAV) by cardiac magnetic resonance (CMR). METHODS A total of 314 adults with CMR-diagnosed AI were retrospectively retrieved. Of them, 166 patients with moderate or severe AI were included and divided into two groups: BAV group (N = 46) and a TAV group (N = 120). The presence and characteristics of MF were assessed with CMR. The patients were followed for adverse clinical events. The prognostic capability of the parameters was assessed using Cox regression model. RESULTS LV fibrosis was more common in the BAV group than in the TAV group (65.2% vs. 45.0%; p = 0.020). There was a strong association between BAV and MF even after adjusting for clinical and imaging variables (odds ratio: 3.57; p = 0.031). Kaplan-Meier analysis showed a higher rate of clinical adverse events in AI+BAV patients with MF during a median follow-up of 4.7 years. Multivariate Cox regression analysis showed that late gadolinium enhancement (LGE) was an independent predictor of clinical adverse outcome. CONCLUSION MF is more common in AI with BAV than with TAV and is a predictor of clinical adverse events. KEY POINTS • The presence and extent of late gadolinium enhancement of left ventricular were more common and severer in the bicuspid aortic valve group than in the tricuspid aortic valve group in aortic insufficiency patients. • Bicuspid aortic valve was an independent factor for myocardial fibrosis in aortic insufficiency patients. • Late gadolinium enhancement could be used as an independent predictor of adverse clinical events in this population.
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Affiliation(s)
- Yucong Zheng
- MR Center, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases of China, Chinese Academy of Medical Sciences and Peking Union Medical College, Beilishi Road No 167, Xicheng District, 100037, Beijing, China.,Department of Radiology, Shanxi Bethune Hospital, Shanxi Medical University, Shanxi Academy of Medical Sciences, Taiyuan, 030032, China
| | - Kai Yang
- MR Center, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases of China, Chinese Academy of Medical Sciences and Peking Union Medical College, Beilishi Road No 167, Xicheng District, 100037, Beijing, China
| | - Xiuyu Chen
- MR Center, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases of China, Chinese Academy of Medical Sciences and Peking Union Medical College, Beilishi Road No 167, Xicheng District, 100037, Beijing, China
| | - Rui Li
- Sichuan Key Laboratory of Medical Imaging, Affiliated Hospital of North Sichuan Medical College, 63# Wenhua Rd, Shunqing District, Nanchong, 637000, Sichuan, China
| | - Guohai Su
- Department of Cardiology, Jinan Central Hospital, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, 250013, Shandong, China
| | - Gang Yin
- MR Center, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases of China, Chinese Academy of Medical Sciences and Peking Union Medical College, Beilishi Road No 167, Xicheng District, 100037, Beijing, China
| | - Kai Wang
- Department of Radiology, Shanxi Bethune Hospital, Shanxi Medical University, Shanxi Academy of Medical Sciences, Taiyuan, 030032, China
| | - Minjie Lu
- Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Key Laboratory of Cardiovascular Imaging (Cultivation), Beijing, China.
| | - Shihua Zhao
- MR Center, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases of China, Chinese Academy of Medical Sciences and Peking Union Medical College, Beilishi Road No 167, Xicheng District, 100037, Beijing, China.
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6
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Butcher SC, Fortuni F, Kong W, Vollema EM, Prevedello F, Perry R, Ng ACT, Poh KK, Almeida AG, González-Gómez A, Shen M, Yeo TC, Shanks M, Popescu BA, Galian-Gay L, Fijalkowski M, Liang M, Tay E, Ajmone Marsan N, Selvanayagam JB, Pinto FJ, Zamorano J, Pibarot P, Evangelista A, Bax JJ, Delgado V. Prognostic implications of left atrial dilation in aortic regurgitation due to bicuspid aortic valve. Heart 2021; 108:137-144. [PMID: 33833069 DOI: 10.1136/heartjnl-2020-318907] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 03/08/2021] [Accepted: 03/09/2021] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To investigate the prognostic value of left atrial volume index (LAVI) in patients with moderate to severe aortic regurgitation (AR) and bicuspid aortic valve (BAV). METHODS 554 individuals (45 (IQR 33-57) years, 80% male) with BAV and moderate or severe AR were selected from an international, multicentre registry. The association between LAVI and the combined endpoint of all-cause mortality or aortic valve surgery was investigated with Cox proportional hazard regression analyses. RESULTS Dilated LAVI was observed in 181 (32.7%) patients. The mean indexed aortic annulus, sinus of Valsalva, sinotubular junction and ascending aorta diameters were 13.0±2.0 mm/m2, 19.4±3.7 mm/m2, 16.5±3.8 mm/m2 and 20.4±4.5 mm/m2, respectively. After a median follow-up of 23 (4-82) months, 272 patients underwent aortic valve surgery (89%) or died (11%). When compared with patients with normal LAVI (<35 mL/m2), those with a dilated LAVI (≥35 mL/m2) had significantly higher rates of aortic valve surgery or mortality (43% and 60% vs 23% and 36%, at 1 and 5 years of follow-up, respectively, p<0.001). Dilated LAVI was independently associated with reduced event-free survival (HR=1.450, 95% CI 1.085 to 1.938, p=0.012) after adjustment for LV ejection fraction, aortic root diameter, LV end-diastolic diameter and LV end-systolic diameter. CONCLUSIONS In this large, multicentre registry of patients with BAV and moderate to severe AR, left atrial dilation was independently associated with reduced event-free survival. The role of this parameter for the risk stratification of individuals with significant AR merits further investigation.
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Affiliation(s)
- Steele C Butcher
- Department of Cardiology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands.,Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Federico Fortuni
- Department of Cardiology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands.,Department of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - William Kong
- Department of Cardiology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands.,Department of Cardiology, National University Heart Centre Singapore, National University Health System, Singapore
| | - E Mara Vollema
- Department of Cardiology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Francesca Prevedello
- Department of Cardiology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands.,Division of Cardiology, West Vicenza General Hospitals, Arzignano (Vicenza), Italy
| | - Rebecca Perry
- Department of Cardiovascular Medicine, Flinders University, Flinders Medical Centre, Bedford Park, Adelaide, Australia.,University of South Australia, Allied Health and Human Performance, Adelaide, South Australia, Australia
| | - Arnold Chin Tse Ng
- Department of Cardiology, Princess Alexandra Hospital, The University of Queensland, Brisbane, Queensland, Australia
| | - Kian Keong Poh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Ana G Almeida
- Department of Cardiology, Centro Hospitalar Universitário Lisboa Norte (CHULN), CCUL, Universidade de Lisboa, Lisboa, Portugal
| | | | - Mylène Shen
- Department of Cardiology, Québec Heart and Lung Institute, Laval University, Québec, Quebec, Canada
| | - Tiong-Cheng Yeo
- Department of Cardiology, National University Heart Centre Singapore, National University Health System, Singapore
| | - Miriam Shanks
- Division of Cardiology, University of Alberta, Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Bogdan A Popescu
- University of Medicine and Pharmacy "Carol Davila" - Euroecolab, Institute of Cardiovascular Diseases "Prof. Dr. C. C. Iliescu", Bucharest, Romania
| | - Laura Galian-Gay
- Department of Cardiology, Hospital Universitari Vall d'Hebro'n, Barcelona, Spain
| | - Marcin Fijalkowski
- First Department of Cardiology, Medical University of Gdansk, Gdansk, Poland
| | - Michael Liang
- Department of Cardiology, National University Heart Centre Singapore, National University Health System, Singapore.,Department of Cardiology, Khoo Teck Puat Hospital, Singapore
| | - Edgar Tay
- Department of Cardiology, National University Heart Centre Singapore, National University Health System, Singapore
| | - Nina Ajmone Marsan
- Department of Cardiology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Joseph B Selvanayagam
- Department of Cardiovascular Medicine, Flinders University, Flinders Medical Centre, Bedford Park, Adelaide, Australia
| | - Fausto J Pinto
- Department of Cardiology, Centro Hospitalar Universitário Lisboa Norte (CHULN), CCUL, Universidade de Lisboa, Lisboa, Portugal
| | - José Zamorano
- Department of Cardiology, Hospital Universitario Ramo'n y Cajal, Madrid, Spain
| | - Philippe Pibarot
- Department of Cardiology, Québec Heart and Lung Institute, Laval University, Québec, Quebec, Canada
| | - Arturo Evangelista
- Department of Cardiology, Hospital Universitari Vall d'Hebro'n, Barcelona, Spain
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands.,Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland; Heart Center, Turku University Hospital, Turku, Finland, Turku, Finland
| | - Victoria Delgado
- Department of Cardiology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
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7
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Yang LT, Anand V, Zambito EI, Pellikka PA, Scott CG, Thapa P, Padang R, Takeuchi M, Nishimura RA, Enriquez-Sarano M, Michelena HI. Association of Echocardiographic Left Ventricular End-Systolic Volume and Volume-Derived Ejection Fraction With Outcome in Asymptomatic Chronic Aortic Regurgitation. JAMA Cardiol 2021; 6:189-198. [PMID: 33146680 DOI: 10.1001/jamacardio.2020.5268] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Volumetric measurements by transthoracic echocardiogram may better reflect left ventricular (LV) remodeling than conventional linear LV dimensions. However, the association of LV volumes with mortality in patients with chronic hemodynamically significant aortic regurgitation (AR) is unknown. Objective To assess whether LV volumes and volume-derived LV ejection fraction (Vol-LVEF) are determinants of mortality in AR. Design, Setting, and Participants This cohort study included consecutive asymptomatic patients with chronic moderately severe to severe AR from a tertiary referral center (January 2004 through April 2019). Exposures Clinical and echocardiographic data were analyzed retrospectively. Aortic regurgitation severity was graded by comprehensive integrated approach. De novo disk-summation method was used to derive LV volumes and Vol-LVEF. Main Outcome and Measures Associations between all-cause mortality under medical surveillance and the following LV indexes: linear LV end-systolic dimension index (LVESDi), linear LVEF, LV end-systolic volume index (LVESVi), and Vol-LVEF. Results Of 492 asymptomatic patients (mean [SD] age, 60 [17] years; 425 men [86%]), ischemic heart disease prevalence was low (41 [9%]), and 453 (92.1%) had preserved linear LVEF (≥50%) with mean (SD) LVESVi of 41 (15) mL/m2. At a median (interquartile range) of 5.4 (2.5-10.1) years, 66 patients (13.4%) died under medical surveillance; overall survival was not different than the age- and sex-matched general population (P = .55). Separate multivariate models, adjusted for age, sex, Charlson Comorbidity Index, and AR severity, demonstrated that in addition to linear LVEF and LVESDi, LVESVi and Vol-LVEF were independently associated with mortality under surveillance (all P < .046) with similar C statistics (range, 0.83-0.84). Spline curves showed that continuous risks of death started to rise for both linear LVEF and Vol-LVEF less than 60%, LVESVi more than 40 to 45 mL/m2, and LVESDi above 21 to 22 mm/m2. As dichotomized variables, patients with LVESVi more than 45 mL/m2 exhibited increased relative death risk (hazard ratio, 1.93; 95% CI, 1.10-3.38; P = .02) while LVESDi more than 20 mm/m2 did not (P = .32). LVESVi more than 45 mL/m2 showed a decreased survival trend compared with expected population survival. Conclusions and Relevance In this large asymptomatic cohort of patients with hemodynamically significant AR, LVESVi and Vol-LVEF worked equally as well as LVESDi and linear LVEF in risk discriminating patients with excess mortality. A LVESVi threshold of 45 mL/m2 or greater was significantly associated with an increased mortality risk.
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Affiliation(s)
- Li-Tan Yang
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.,Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Vidhu Anand
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Elena I Zambito
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Christopher G Scott
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Prabin Thapa
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Ratnasari Padang
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Masaaki Takeuchi
- Department of Laboratory and Transfusion Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Rick A Nishimura
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Hector I Michelena
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
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8
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Abstract
PURPOSE OF REVIEW Cardiac involvement in patients with ankylosing spondylitis (AS) generally manifests itself as aortic insufficiency, aortitis, disturbance in cardiac conduction, and myocardial dysfunction. We have used a case-based approach to review the current state of the art knowledge regarding the diagnosis and management of aortic valve disease and aortitis in patients with AS. RECENT FINDINGS The risk for aortic valve disease and aortic valve replacement or repair is significantly higher than in people without AS, and this risk increases with age. Echocardiography, cardiac MRI, and CT can serve as effective tools for screening and follow-up. Surgical repair/replacement remains the mainstay of therapy for aortic insufficiency and aortic dilation, whereas transcatheter-based techniques may be favorable in the setting of aortic stenosis. Aortic valve and atrioventricular conduction abnormalities contribute to overall cardiovascular burden in AS. Optimal timing and therapeutic technique are dependent on assessment of overall risk and serial follow-up.
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9
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Cavarretta E, Frati G, Sciarra L, Peruzzi M. Aortic regurgitation in athletes: Pieces of the puzzle we have so far omitted. Eur J Prev Cardiol 2019; 27:1549-1551. [PMID: 31847562 DOI: 10.1177/2047487319897343] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
- E Cavarretta
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy.,Mediterranea Cardiocentro, Naples, Italy
| | - G Frati
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy.,Department of Angiocardioneurology, IRCCS Neuromed, Pozzilli (IS), Italy
| | - L Sciarra
- Division of Cardiology, Policlinico Casilino, Rome, Italy
| | - M Peruzzi
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy.,Mediterranea Cardiocentro, Naples, Italy
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10
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Aortic regurgitation assessment by cardiovascular magnetic resonance imaging and transthoracic echocardiography: intermodality disagreement impacting on prediction of post-surgical left ventricular remodeling. Int J Cardiovasc Imaging 2019; 36:91-100. [PMID: 31414256 DOI: 10.1007/s10554-019-01682-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 07/31/2019] [Indexed: 12/17/2022]
Abstract
Transthoracic echocardiography (TTE) is the primary clinical imaging modality for the assessment of patients with isolated aortic regurgitation (AR) in whom TTE's linear left ventricular (LV) dimension is used to assess disease severity to guide aortic valve replacement (AVR), yet TTE is relatively limited with regards to its integrated semi-quantitative/qualitative approach. We therefore compared TTE and cardiovascular magnetic resonance (CMR) assessment of isolated AR and investigated each modality's ability to predict LV remodeling after AVR. AR severity grading by CMR and TTE were compared in 101 consecutive patients referred for CMR assessment of chronic AR. LV end-diastolic diameter and end-systolic diameter measurements by both modalities were compared. Twenty-four patients subsequently had isolated AVR. The pre-AVR estimates of regurgitation severity by CMR and TTE were correlated with favorable post-AVR LV remodeling. AR severity grade agreement between CMR and TTE was moderate (ρ = 0.317, P = 0.001). TTE underestimated CMR LV end-diastolic and LV end-systolic diameter by 6.6 mm (P < 0.001, CI 5.8-7.7) and 5.9 mm (P < 0.001, CI 4.1-7.6), respectively. The correlation of post-AVR LV remodeling with CMR AR grade (ρ = 0.578, P = 0.004) and AR volumes (R = 0.664, P < 0.001) was stronger in comparison to TTE (ρ = 0.511, P = 0.011; R = 0.318, P = 0.2). In chronic AR, CMR provides more prognostic relevant information than TTE in assessing AR severity. CMR should be considered in the management of chronic AR patients being considered for AVR.
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11
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Yang LT, Michelena HI, Maleszewski JJ, Schaff HV, Pellikka PA. Contemporary Etiologies, Mechanisms, and Surgical Approaches in Pure Native Aortic Regurgitation. Mayo Clin Proc 2019; 94:1158-1170. [PMID: 31272566 DOI: 10.1016/j.mayocp.2018.11.034] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Revised: 11/12/2018] [Accepted: 11/19/2018] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To study contemporary etiologies, mechanisms, and corresponding surgical approaches in isolated aortic regurgitation (AR). PATIENTS AND METHODS Consecutive patients undergoing surgery for moderately severe and severe AR were retrospectively identified from January 1, 2006, through October 20, 2017. Intraoperative echocardiograms, surgical reports, and pathology reports were reviewed. RESULTS Of 382 patients (54±16 years, 82% men), there were 207 (54%) tricuspid (TAV), 167 (44%) bicuspid (BAV), 5 quadricuspid, and 3 unicuspid aortic valves. Isolated AR mechanisms (n=116, 30%) included cusp prolapse (n=44, 11%), restriction/retraction (n=33, 9%), aortic root dilatation (n=33, 9%), perforation (n=5, 1%), and fenestration (<1%); mixed mechanisms were present in 266 (70%). The most common mixed mechanism was root dilatation and prolapse (27% BAV vs 16% TAV, P=.01). Valve repair (AVr) was performed in 31% BAV and 23% TAV (P=.06). Aortic surgery was more common in BAV (37% vs 27%, P<.001). Overall, root dilatation was associated with AVr. In TAV, cusp prolapse and restriction/retraction were associated with replacement; in BAV, prolapse was associated with AVr. AR etiology was idiopathic in 43% TAV patients, 47% of whom had root dilatation. CONCLUSIONS BAV accounted for 44% of surgical referrals for AR and, compared with TAV, was more often associated with prolapse, root dilatation, and mixed mechanisms of AR. Because mechanisms affected the choice of AVr differently in BAV and TAV, comprehensive mechanistic description of surgical AR is critical.
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Affiliation(s)
- Li-Tan Yang
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
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