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Nguyen LA, Gencer U, Goudot G, Craiem D, Casciaro ME, Cheng C, Messas E, Mousseaux E, Soulat G. Flow quantification within the aortic ejection tract using 4D flow cardiac MRI in patients with bicuspid aortic valve: Implications for the assessment of aortic regurgitation. Diagn Interv Imaging 2024:S2211-5684(24)00194-3. [PMID: 39271367 DOI: 10.1016/j.diii.2024.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 08/05/2024] [Accepted: 09/03/2024] [Indexed: 09/15/2024]
Abstract
PURPOSE The purpose of this study was to evaluate the performance of four-dimensional (4D) flow cardiac MRI in quantifying aortic flow in patients with bicuspid aortic valve (BAV). MATERIALS AND METHODS Patients with BAV who underwent transthoracic echocardiography (TTE) and 4D flow cardiac MRI were prospectively included. Aortic flow was quantified using two-dimensional phase contrast velocimetry at the sinotubular junction and in the ascending aorta and using 4D flow in the regurgitant jet, in the left ventricular outflow tract, at the aortic annulus, the sinotubular junction, and the ascending aorta, with or without anatomical tracking. Flow quantification was compared with ventricular volumes, pulmonary flow using Pearson correlation test, bias and limits of agreement (LOA) using Bland Altman method, and with multiparametric transthoracic echocardiography quantification using weighted kappa test. RESULTS Eighty-eight patients (63 men, 25 women) with a mean age of 50.5 ± 14.8 (standard deviation) years (age range: 20.8-78.3) were included. Changes in flow with or without tracking were modest (< 5 mL). The best correlation was obtained at the aortic annulus for forward volume (r = 0.84; LOA [-28.4; 25.3] mL) and at the regurgitant jet and sinotubular junction for regurgitant volume (r = 0.68; LOA [-27.8; 33.8] and r = 0.69; LOA [-28.6; 24.2] mL). A combined approach for regurgitant fraction and net volume calculations using forward volume measured at ANN and regurgitant volume at sinotubular junction performed better than each level taken separately (r = 0.90; LOA [-20.7; 10.0] mL and r = 0.48, LOA [-33.8; 33.4] %). The agreement between transthoracic echocardiography and 4D flow cardiac MRI for aortic regurgitation grading was poor (kappa, 0.13 to 0.42). CONCLUSION In patients with BAV, aortic flow quantification by 4D flow cardiac MRI is the most accurate at the annulus for the forward volume, and at the sinotubular junction or directly in the jet for the regurgitant volume.
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Affiliation(s)
- Lan-Anh Nguyen
- Université Paris Cité, INSERM, PARCC, Paris 75015, France; Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, 75015 Paris, France
| | - Umit Gencer
- Université Paris Cité, INSERM, PARCC, Paris 75015, France; Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, 75015 Paris, France
| | - Guillaume Goudot
- Université Paris Cité, INSERM, PARCC, Paris 75015, France; Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, 75015 Paris, France
| | - Damian Craiem
- Instituto de Medicina Traslacional, Trasplante y Bioingeniería (IMeTTyB), Universidad Favaloro-CONICET, CP 1078 Buenos Aires, Argentina
| | - Mariano E Casciaro
- Instituto de Medicina Traslacional, Trasplante y Bioingeniería (IMeTTyB), Universidad Favaloro-CONICET, CP 1078 Buenos Aires, Argentina
| | - Charles Cheng
- Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, 75015 Paris, France
| | - Emmanuel Messas
- Université Paris Cité, INSERM, PARCC, Paris 75015, France; Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, 75015 Paris, France
| | - Elie Mousseaux
- Université Paris Cité, INSERM, PARCC, Paris 75015, France; Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, 75015 Paris, France
| | - Gilles Soulat
- Université Paris Cité, INSERM, PARCC, Paris 75015, France; Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, 75015 Paris, France.
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Arnold Z, Elnekheli A, Geisler D, Aschacher T, Lenz V, Winkler B, Moidl R, Grabenwöger M. Left Ventricular Reverse Remodeling after Surgical Aortic Valve Replacement for Aortic Regurgitation-An Explorative Study. Diseases 2024; 12:191. [PMID: 39195190 DOI: 10.3390/diseases12080191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2024] [Revised: 08/11/2024] [Accepted: 08/20/2024] [Indexed: 08/29/2024] Open
Abstract
BACKGROUND The timing of treatment for chronic aortic valve regurgitation (AR), especially in asymptomatic patients, is gaining attention since less invasive strategies have become available. The aim of the present study was to evaluate left ventricular reverse remodeling after aortic valve replacement (AVR) for severe AR. METHODS Patients (n = 25) who underwent surgical AVR for severe AR with left ventricular ejection fraction (LVEF) less than 55% were included in this study. Preprocedural and follow-up clinical and echocardiographic measurements of LVEF and left ventricular (LV) diameters were retrospectively analyzed. RESULTS Mean LVEF increased significantly following surgical AVR (p < 0.0001). LV diameters showed a clear regression (p = 0.0088). Younger patients and those receiving a mechanical valve tended to have less improved LVEF on follow-up than patients over 60 years or the ones who were implanted with a biological prosthesis (p = 0.0239 and p = 0.069, respectively). Gender had no effect on the degree of LVEF improvement (p = 0.4908). CONCLUSIONS We demonstrated significant LV reverse remodeling following AVR for AR. However, more data are needed on LV functional and geometrical improvement comparing the different types of valve prostheses to provide an optimal treatment strategy.
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Affiliation(s)
- Zsuzsanna Arnold
- Department of Cardiovascular Surgery, Clinic Floridsdorf, 1210 Vienna, Austria
- Institute of Cardiovascular Research, Karl Landsteiner Society, 1210 Vienna, Austria
| | | | - Daniela Geisler
- Department of Cardiovascular Surgery, Clinic Floridsdorf, 1210 Vienna, Austria
- Institute of Cardiovascular Research, Karl Landsteiner Society, 1210 Vienna, Austria
| | - Thomas Aschacher
- Department of Cardiovascular Surgery, Clinic Floridsdorf, 1210 Vienna, Austria
- Institute of Cardiovascular Research, Karl Landsteiner Society, 1210 Vienna, Austria
| | - Verena Lenz
- Department of Cardiovascular Surgery, Clinic Floridsdorf, 1210 Vienna, Austria
- Institute of Cardiovascular Research, Karl Landsteiner Society, 1210 Vienna, Austria
| | - Bernhard Winkler
- Department of Cardiovascular Surgery, Clinic Floridsdorf, 1210 Vienna, Austria
- Institute of Cardiovascular Research, Karl Landsteiner Society, 1210 Vienna, Austria
- Medical Faculty, Sigmund Freud University, 1020 Vienna, Austria
| | - Reinhard Moidl
- Department of Cardiovascular Surgery, Clinic Floridsdorf, 1210 Vienna, Austria
- Institute of Cardiovascular Research, Karl Landsteiner Society, 1210 Vienna, Austria
| | - Martin Grabenwöger
- Department of Cardiovascular Surgery, Clinic Floridsdorf, 1210 Vienna, Austria
- Institute of Cardiovascular Research, Karl Landsteiner Society, 1210 Vienna, Austria
- Medical Faculty, Sigmund Freud University, 1020 Vienna, Austria
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Still SA, Ryan M, Gunnarsson C, Heidrich N, Davies JE. Economic Benefits of Surgical Aortic Valve Replacement on Patients With Symptomatic Aortic Valve Regurgitation. J Am Heart Assoc 2024; 13:e9983. [PMID: 39158572 DOI: 10.1161/jaha.124.035278] [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: 02/29/2024] [Accepted: 07/11/2024] [Indexed: 08/20/2024]
Abstract
BACKGROUND Aortic regurgitation is distinguished by the backflow of blood from the aorta into the left ventricle. American College of Cardiology/American Heart Association guidelines recommend surgical aortic valve replacement (SAVR) for patients with symptomatic aortic regurgitation (sAR). This study estimates the difference in mortality, health care use, and costs between patients with sAR who receive SAVR within 12 months of diagnosis versus those who do not. METHODS AND RESULTS We used the Optum United Healthcare database to identify 132 317 patients diagnosed with sAR from 2016 to 2021 who had at least 6 months of enrollment before sAR and 12 months of enrollment after. Criteria were no history of aortic stenosis or transcatheter aortic valve replacement and ≥2 visits for heart failure, angina, dyspnea, or syncope. Outcomes were all-cause mortality, health care use, and annualized cost. Baseline differences in demographics and comorbidities were adjusted with inverse propensity score weighting. We modeled survival and estimated health care use and costs using Cox proportional hazards and general linear models, respectively. Of the 132 317 patients, 400 underwent SAVR within 12 months of diagnosis. They were on average younger, more often men, and with a slightly higher Elixhauser Comorbidity Index score. After inverse propensity score weighting, patients with sAR who had SAVR had lower mortality, fewer inpatient and emergency department visits, fewer hospital days, and lower annualized cost. CONCLUSIONS SAVR performed within 12 months of an sAR diagnosis is associated with improved mortality and lower annualized health care use and costs. These clinical and economic benefits should be considered when managing patients with sAR.
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Lee SH, Yoon SJ, Sun BJ, Kim HM, Kim HY, Lee S, Shim CY, Kim EK, Cho DH, Park JB, Seo JS, Son JW, Kim IC, Lee SH, Heo R, Lee HJ, Park JH, Song JM, Lee SC, Kim H, Kang DH, Ha JW, Kim KH. 2023 Korean Society of Echocardiography position paper for diagnosis and management of valvular heart disease, part I: aortic valve disease. J Cardiovasc Imaging 2024; 32:11. [PMID: 39061115 PMCID: PMC11282617 DOI: 10.1186/s44348-024-00019-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 11/24/2023] [Indexed: 07/28/2024] Open
Abstract
This manuscript represents the official position of the Korean Society of Echocardiography on valvular heart diseases. This position paper focuses on the clinical management of valvular heart diseases with reference to the guidelines recently published by the American College of Cardiology/American Heart Association and the European Society of Cardiology. The committee tried to reflect the recently published results on the topic of valvular heart diseases and Korean data by a systematic literature search based on validity and relevance. In part I of this article, we will review and discuss the current position of aortic valve disease in Korea.
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Affiliation(s)
- Sun Hwa Lee
- Division of Cardiology, Department of Internal Medicine, Jeonbuk National University Medical School, Jeonbuk National University Hospital, Jeonju, Republic of Korea
| | - Se-Jung Yoon
- Division of Cardiology, National Health Insurance Service Ilsan Hospital, Goyang, Republic of Korea
| | - Byung Joo Sun
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hyue Mee Kim
- Division of Cardiology, Department of Internal Medicine, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Republic of Korea
| | - Hyung Yoon Kim
- Department of Cardiovascular Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Sahmin Lee
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Chi Young Shim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Eun Kyoung Kim
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Heart Vascular Stroke Institute, Samsung Medical Center, Seoul, Republic of Korea
| | - Dong-Hyuk Cho
- Division of Cardiology, Department of Internal Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Jun-Bean Park
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jeong-Sook Seo
- Division of Cardiology, Department of Internal Medicine, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Jung-Woo Son
- Division of Cardiology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - In-Cheol Kim
- Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
| | - Sang-Hyun Lee
- Division of Cardiology, Pusan National Yangsan Hospital, Pusan National University School of Medicine, Busan, Republic of Korea
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National Yangsan Hospital, Busan, Republic of Korea
| | - Ran Heo
- Division of Cardiology, Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Hyun-Jung Lee
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jae-Hyeong Park
- Division of Cardiology, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Republic of Korea
- Regional Cardiocerebrovascular Center, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Jong-Min Song
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang-Chol Lee
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Heart Vascular Stroke Institute, Samsung Medical Center, Seoul, Republic of Korea
| | - Hyungseop Kim
- Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
| | - Duk-Hyun Kang
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jong-Won Ha
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kye Hun Kim
- Department of Cardiovascular Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea.
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Xiao W, Yuan JL, Chen Y, Ma G, Zhang C, Sun L, Hong C, Ye T. Development and validation of a prediction model for heart failure in patients with heart valvular regurgitation. ESC Heart Fail 2024. [PMID: 38923827 DOI: 10.1002/ehf2.14899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 05/06/2024] [Accepted: 05/24/2024] [Indexed: 06/28/2024] Open
Abstract
AIMS Patients with heart valvular regurgitation is increasing; early screening of potential patients developing heart failure (HF) is crucial. METHODS From 1 November 2019 to 31 October 2023, a total of 509 patients with heart valvular regurgitation hospitalized in the Department of Cardiovascular Disease of the First Affiliated Hospital of Guangzhou University of Traditional Medicine were enrolled. Three hundred fifty-six cases were selected as the training set for modelling, and 153 cases were selected as the validation set for the internal validation of the model. RESULTS A predictive model of heart failure with the following nine risk factors was developed: atrial fibrillation (AF), pulmonary infection (PI), coronary artery disease (CAD), creatinine (CREA), low-density lipoprotein cholesterol (LDL-C), d-dimer (DDi), left ventricular end-diastolic diameter (LVEDd), mitral regurgitation (MR) and aortic regurgitation (AR). The model was evaluated by the C-index [the training set: area under curve (AUC) 0.937, 95% confidence interval (CI) 0.911-0.963; the validation set: AUC 0.928, 95% CI 0.890-0.967]. Hosmer-Lemeshow test (the training set: χ2 10.908, P = 0.207; the validation set: χ2 4.896, P = 0.769) revealed that both the training and validation sets performed well in terms of model differentiation and calibration. Decision curve analysis showed that both the training and validation sets have higher net benefits, indicating that the model has good utility. Ten-fold cross-validation showed that the training set has high similarities with the validation set, which means that the model has good stability. CONCLUSIONS The occurrence of heart failure in patients with valvular regurgitation has a significant correlation with AF, PI, CAD, CREA, LDL-C, DDi, LVEDd, MR and AR. Based on these risk factors, a prediction model for heart failure was developed and validated, which showed good differentiation and utility, high accuracy and stability, providing a method for predicting heart failure.
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Affiliation(s)
- WenKang Xiao
- Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Jia-Lin Yuan
- Guangzhou University of Chinese Medicine, Guangzhou, China
| | - YunYi Chen
- Guangzhou University of Chinese Medicine, Guangzhou, China
| | - GuiPing Ma
- Department of Cardiovascular Disease, Beijing University of Chinese Medicine Shenzhen Hospital, Shenzhen, China
| | | | - Le Sun
- Department of Rheumatology, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China
| | - ChuangXiong Hong
- The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Taochun Ye
- The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
- Guangdong Clinical Research Academy of Chinese Medicine, Guangzhou, China
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Hisatomi K, Miura T. The Importance of Left Ventricular End-Systolic Diameter for Aortic Valve Replacement in Japanese Asymptomatic Patients With Chronic Severe Aortic Regurgitation. Circ J 2024:CJ-24-0342. [PMID: 38825488 DOI: 10.1253/circj.cj-24-0342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/04/2024]
Affiliation(s)
- Kazuki Hisatomi
- Department of Cardiovascular Surgery, Nagasaki University Hospital
| | - Takashi Miura
- Department of Cardiovascular Surgery, Nagasaki University Hospital
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Marigliano AN, Ortiz JT, Casas J, Evangelista A. Aortic Regurgitation: From Valvular to Myocardial Dysfunction. J Clin Med 2024; 13:2929. [PMID: 38792470 PMCID: PMC11122337 DOI: 10.3390/jcm13102929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 04/30/2024] [Accepted: 05/02/2024] [Indexed: 05/26/2024] Open
Abstract
Chronic aortic regurgitation (AR) leads to volume overload in the left ventricle (LV), which is well tolerated for years. In this condition, the LV usually dilates with minimal reduction in the ejection fraction (EF), even in the absence of symptoms. Echocardiography is the primary imaging test used to quantify AR. However, no single assessment of Doppler measures is accurate and precise in individual patients; therefore, the integration of multiple parameters is necessary. Recent guidelines recommend surgical treatment for severe AR in patients who are symptomatic or have an LVEF < 55% and an end-systolic diameter > 50 mm. Nevertheless, advances in imaging technology have improved the quantification of AR and the assessment of LV subclinical dysfunction. It is widely recognized that patients who undergo aortic valve replacement/repair (AVR) due to symptoms or a low LVEF experience worse outcomes than those undergoing AVR for non-Class I indications. In fact, subclinical irreversible myocardial damage may occur in clinically well-compensated and closely monitored patients while awaiting formal surgical indications. This condition could be prevented by the use of multimodal imaging parameters, in particular longitudinal LV strain and magnetic resonance imaging. In addition, better cut-off values for mortality predictors should be established. This review aims to identify simple models that integrate several echocardiographic and cardiac magnetic resonance-derived parameters to predict the optimal timing of surgical treatment in asymptomatic patients with chronic severe AR.
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Affiliation(s)
- Alba-Nidia Marigliano
- Heart Institute, Teknon Medical Center, 08022 Barcelona, Spain; (A.-N.M.); (J.-T.O.)
| | - José-Tomas Ortiz
- Heart Institute, Teknon Medical Center, 08022 Barcelona, Spain; (A.-N.M.); (J.-T.O.)
| | - Jorge Casas
- Instituto Cedic, Bahía Blanca B8000, Argentina;
| | - Arturo Evangelista
- Heart Institute, Teknon Medical Center, 08022 Barcelona, Spain; (A.-N.M.); (J.-T.O.)
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Jasinski MJ, Nienaber CA. Paradigm shift to earlier surgery for aortic regurgitation: What should be done? J Thorac Cardiovasc Surg 2024; 167:e159-e160. [PMID: 37921734 DOI: 10.1016/j.jtcvs.2023.09.075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 09/30/2023] [Indexed: 11/04/2023]
Affiliation(s)
- Marek J Jasinski
- Department of Cardiac Surgery, Wroclaw Medical University, Wroclaw, Poland; Royal Brompton Hospital, London, United Kingdom
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Kočková R, Vojáček J, Bedáňová H, Fila P, Skalský I, Žáková D, Klán M, Míková B, Mědílek K, Tuna M, Fialová M, Dvořáková R, Hlubocká Z, Panovský R, Slabý K, Kelen de Oliveira E, Casselman F, Pěnička M. Rationale and design of the ELEANOR trial early aortic valve surgery versus watchful waiting strategy in severe asymptomatic aortic regurgitation, ACRONYM: ELEANOR. Heliyon 2024; 10:e29470. [PMID: 38638969 PMCID: PMC11024602 DOI: 10.1016/j.heliyon.2024.e29470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 03/17/2024] [Accepted: 04/08/2024] [Indexed: 04/20/2024] Open
Abstract
Background The optimal treatment of patients with severe symptomatic aortic regurgitation (AR) is state-of-the-art surgery. Asymptomatic patients with advanced left ventricular (LV) dilatation and/or impaired ejection fraction should undergo surgical treatment, but there is no guidelines consensus on cut-off values for this recommendation. Multimodality imaging has brought new tools for the accurate selection of asymptomatic patients at risk of early clinical deterioration, however, prospective and randomized data are pending. Cardiac magnetic resonance (CMR)-derived AR quantification along with LV remodeling assessment appears to be the most accurate tool for a selection of such patients at risk. Trial design The objective of our prospective and multicenter study is to determine whether patients at risk of early clinical deterioration as per CMR assessment will benefit from early surgical treatment. The study is designed as a superiority trial to demonstrate that early surgical treatment is safe and more effective than the standard treatment. A total of 217 asymptomatic patients with severe AR, but without current guidelines-based surgical indication, will be enrolled across all centers. We expect 24 % of patients identified as high clinical risk and therefore eligible for 1:1 randomization to early surgical treatment within 3 months or a watchful waiting strategy. Follow-up will be annual. We expect a complete restoration of LV size and function along with improved quality of life and physical performance in a short-term follow-up of 12 months. The primary endpoint will be a composite safety and efficacy with all criteria mandatory: 15 % or larger reduction of baseline CMR-derived LV end-diastolic volume index, LV ejection fraction >50 %, and no major adverse cardiovascular events. The annual follow-up will continue for a minimum of 4 years until the required number of endpoints is achieved to show a statistically significant difference in cardiovascular morbidity and mortality in early surgically treated patients. Conclusion The ELEANOR trial is the first multicenter randomized controlled study to compare early surgical treatment with a watchful waiting strategy in asymptomatic patients with chronic severe AR at high risk of early clinical deterioration as per CMR assessment but without guidelines-based indications for surgical treatment.
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Affiliation(s)
- Radka Kočková
- Na Homolce Hospital, Prague, Czech Republic
- Charles University, Faculty of Medicine in Hradec Králové, Hradec Králové, Czech Republic
| | - Jan Vojáček
- Charles University, Faculty of Medicine in Hradec Králové, Hradec Králové, Czech Republic
- University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Helena Bedáňová
- Centre of Cardiovascular Surgery and Transplantation, Brno, Czech Republic
| | - Petr Fila
- Centre of Cardiovascular Surgery and Transplantation, Brno, Czech Republic
- Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | | | - Daniela Žáková
- Centre of Cardiovascular Surgery and Transplantation, Brno, Czech Republic
| | | | | | - Karel Mědílek
- Charles University, Faculty of Medicine in Hradec Králové, Hradec Králové, Czech Republic
- University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Martin Tuna
- Charles University, Faculty of Medicine in Hradec Králové, Hradec Králové, Czech Republic
- University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Monika Fialová
- University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Radka Dvořáková
- University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Zuzana Hlubocká
- 2nd Department of Internal Cardiovascular Medicine, General University Hospital in Prague, First Faculty of Medicine, Charles University, Czech Republic
| | - Roman Panovský
- International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czech Republic
- 1st Department of Internal, Brno, Czech Republic Medicine/Cardioangiology at St. Anne's University Hospital, Brno, Czech Republic
| | - Kryštof Slabý
- Department of Rehabilitation and Sports Medicine, Second Faculty of Medicine, Charles University in Prague, Czech Republic
| | - Elayne Kelen de Oliveira
- CardioPaTh PhD Program, Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
- Cardiovascular Center OLV Clinic Aalst, Belgium
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Jneid H, Chikwe J, Arnold SV, Bonow RO, Bradley SM, Chen EP, Diekemper RL, Fugar S, Johnston DR, Kumbhani DJ, Mehran R, Misra A, Patel MR, Sweis RN, Szerlip M. 2024 ACC/AHA Clinical Performance and Quality Measures for Adults With Valvular and Structural Heart Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Performance Measures. J Am Coll Cardiol 2024; 83:1579-1613. [PMID: 38493389 DOI: 10.1016/j.jacc.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/18/2024]
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11
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Jneid H, Chikwe J, Arnold SV, Bonow RO, Bradley SM, Chen EP, Diekemper RL, Fugar S, Johnston DR, Kumbhani DJ, Mehran R, Misra A, Patel MR, Sweis RN, Szerlip M. 2024 ACC/AHA Clinical Performance and Quality Measures for Adults With Valvular and Structural Heart Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Performance Measures. Circ Cardiovasc Qual Outcomes 2024; 17:e000129. [PMID: 38484039 DOI: 10.1161/hcq.0000000000000129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/18/2024]
Affiliation(s)
- Hani Jneid
- ACC/AHA Joint Committee on Clinical Data Standards liaison
- Society for Cardiovascular Angiography and Interventions representative
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Sanz J, Nelson KF. Prognosis in Chronic Aortic Regurgitation: Does Pulmonary Hypertension Play a Role? JACC. ADVANCES 2024; 3:100831. [PMID: 38938821 PMCID: PMC11198267 DOI: 10.1016/j.jacadv.2024.100831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/29/2024]
Affiliation(s)
- Javier Sanz
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Health System, New York, New York, USA
| | - Kyle F. Nelson
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Health System, New York, New York, USA
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Tsampasian V, Victor K, Bhattacharyya S, Oxborough D, Ring L. Echocardiographic assessment of aortic regurgitation: a narrative review. Echo Res Pract 2024; 11:1. [PMID: 38167345 PMCID: PMC10762934 DOI: 10.1186/s44156-023-00036-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 11/08/2023] [Indexed: 01/05/2024] Open
Abstract
Aortic regurgitation (AR) is the third most frequently encountered valve lesion and may be caused by abnormalities of the valve cusps or the aorta. Echocardiography is instrumental in the assessment of AR as it enables the delineation of valvular morphology, the mechanism of the lesion and the grading of severity. Severe AR has a major impact on the myocardium and carries a significant risk of morbidity and mortality if left untreated. Established and novel echocardiographic methods, such as global longitudinal strain and three-dimensional echocardiography, allow an estimation of this risk and provide invaluable information for patient management and prognosis. This narrative review summarises the epidemiology of AR, reviews current practices and recommendations with regards to the echocardiographic assessment of AR and outlines novel echocardiographic tools that may prove beneficial in patient assessment and management.
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Affiliation(s)
| | | | | | - David Oxborough
- Research Institute of Sports and Exercise Science and Liverpool Centre for Cardiovascular Science, Liverpool John Moores University, Liverpool, UK
| | - Liam Ring
- West Suffolk Hospital NHS Foundation Trust, Bury St Edmunds, UK
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14
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Ranard LS, Bonow RO, Nishimura R, Mack MJ, Thourani VH, Bavaria J, O'Gara PT, Bax JJ, Blanke P, Delgado V, Leipsic J, Lang RM, Michelena HI, Cavalcante JL, Vahl TP, Leon MB, Rigolin VH. Imaging Methods for Evaluation of Chronic Aortic Regurgitation in Adults: JACC State-of-the-Art Review. J Am Coll Cardiol 2023; 82:1953-1966. [PMID: 37940233 DOI: 10.1016/j.jacc.2023.08.051] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 08/21/2023] [Indexed: 11/10/2023]
Abstract
A global multidisciplinary workshop was convened to discuss the multimodality diagnostic evaluation of aortic regurgitation (AR). Specifically, the focus was on assessment tools for AR severity and analyzing evolving data on the optimal timing of aortic valve intervention. The key concepts from this expert panel are summarized as: 1) echocardiography is the primary imaging modality for assessment of AR severity; however, when data is incongruent or incomplete, cardiac magnetic resonance may be helpful; 2) assessment of left ventricular size and function is crucial in determining the timing of intervention; 3) recent evidence suggests current cutpoints for intervention in asymptomatic severe AR patients requires further scrutiny; 4) left ventricular end-systolic volume index has emerged as an additional parameter that has promise in guiding timing of intervention; and 5) the role of additional factors (including global longitudinal strain, regurgitant fraction, and myocardial extracellular volume) is worthy of future investigation.
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Affiliation(s)
- Lauren S Ranard
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Robert O Bonow
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Northwestern Memorial Hospital, Chicago, Illinois, USA
| | - Rick Nishimura
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael J Mack
- Division of Cardiothoracic Surgery, Heart Hospital Baylor Plano, Baylor Healthcare System, Plano, Texas, USA
| | - Vinod H Thourani
- Department of Cardiovascular Surgery, Marcus Valve Center, Piedmont Heart Institute, Atlanta, Georgia, USA
| | - Joseph Bavaria
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Patrick T O'Gara
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Philipp Blanke
- Department of Radiology, St Paul's Hospital & University of British Columbia, Vancouver, British Columbia, Canada
| | - Victoria Delgado
- Department of Cardiology, Hospital University Germans Trias i Pujol, Badalona, Spain
| | - Jonathon Leipsic
- Department of Radiology, St Paul's Hospital & University of British Columbia, Vancouver, British Columbia, Canada
| | - Roberto M Lang
- Section of Cardiology, Heart and Vascular Center, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Hector I Michelena
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - João L Cavalcante
- Division of Cardiology, Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Torsten P Vahl
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Martin B Leon
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Vera H Rigolin
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Northwestern Memorial Hospital, Chicago, Illinois, USA.
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15
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Malahfji M, Saeed M, Zoghbi WA. Aortic Regurgitation: Review of the Diagnostic Criteria and the Management Guidelines. Curr Cardiol Rep 2023; 25:1373-1380. [PMID: 37715804 DOI: 10.1007/s11886-023-01955-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/28/2023] [Indexed: 09/18/2023]
Abstract
PURPOSE OF REVIEW The evaluation of aortic regurgitation (AR) has advanced from physical examination and angiography towards evidence based non-invasive quantitative methods, primarily with echocardiography and more recently with cardiac magnetic resonance (CMR). This review highlights the guidelines and recent evidence in the diagnosis and management of AR; and outlines future areas of research. RECENT FINDINGS Contemporary large cohorts of AR patients studied with echocardiography and CMR suggest that the left ventricular remodeling and systolic function triggers for intervention may be lower than previously recommended in the guidelines and emphasize the importance of LV volumes in risk stratification. Important gaps of knowledge in the quantitation of AR severity and patient risk stratification were fulfilled recently. Potential thresholds for intervention using ventricular volumes and CMR quantitative findings were recently described. The criteria for what constitutes hemodynamically significant AR and the optimal timing of intervention AR deserve further study.
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Affiliation(s)
- Maan Malahfji
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA.
| | - Mujtaba Saeed
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA
| | - William A Zoghbi
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA
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16
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Barradas‐Pires A, Merás P, Constantine A, Costola G, de la Cal TS, Rafiq I, Kempny A, Li W, Babu‐Narayan SV, Hoschtitzky JA, Gatzoulis MA, Rubio AM, Dimopoulos K. Repair of Aortic Regurgitation in Young Adults: Sooner Rather Than Later. J Am Heart Assoc 2023; 12:e029251. [PMID: 37721152 PMCID: PMC10547301 DOI: 10.1161/jaha.122.029251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 07/31/2023] [Indexed: 09/19/2023]
Abstract
Background Establishing surgical criteria for aortic valve replacement (AVR) in severe aortic regurgitation in young adults is challenging due to the lack of evidence-based recommendations. We studied indications for AVR in young adults with severe aortic regurgitation and their outcomes, as well as the relationship between presurgical echocardiographic parameters and postoperative left ventricular (LV) size, function, clinical events, and valve-related complications. Methods and Results Data were collected retrospectively on 172 consecutive adult patients who underwent AVR or repair for severe aortic regurgitation between 2005 and 2019 in a tertiary cardiac center (age at surgery 29 [22-41] years, 81% male). One-third underwent surgery before meeting guideline indications. Postsurgery, 65% achieved LV size and function normalization. LV ejection fraction showed no significant change from baseline. A higher presurgical LV end-systolic diameter correlated with a lack of LV normalization (odds ratio per 1-cm increase 2.81, P<0.01). The baseline LV end-systolic diameter cut-off for predicting lack of LV normalization was 43 mm. Pre- and postoperative LV dimensions and postoperative LV ejection fraction predicted clinical events during follow-up. Prosthetic valve-related complications occurred in 20.3% during an average 5.6-year follow-up. Freedom from aortic reintervention was 98%, 96.5%, and 85.4% at 1, 5, and 10 years, respectively. Conclusions Young adult patients with increased baseline LV end-systolic diameter or prior cardiac surgery are less likely to achieve LV normalization after AVR. Clinicians should carefully balance the long-term benefits of AVR against procedural risks and future interventions, especially in younger patients. Evidence-based criteria for AVR in severe aortic regurgitation in young adults are crucial to improve outcomes.
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Affiliation(s)
- Ana Barradas‐Pires
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Cardiology Department, Royal Brompton HospitalGuy’s and St Thomas’ NHS Foundation TrustLondonUnited Kingdom
- Department of MedicineAutonomous University of BarcelonaBarcelonaSpain
| | - Pablo Merás
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Cardiology Department, Royal Brompton HospitalGuy’s and St Thomas’ NHS Foundation TrustLondonUnited Kingdom
- Cardiology DepartmentUniversity Hospital La PazMadridSpain
| | - Andrew Constantine
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Cardiology Department, Royal Brompton HospitalGuy’s and St Thomas’ NHS Foundation TrustLondonUnited Kingdom
- National Heart and Lung InstituteImperial College LondonLondonUnited Kingdom
| | - Giulia Costola
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Cardiology Department, Royal Brompton HospitalGuy’s and St Thomas’ NHS Foundation TrustLondonUnited Kingdom
| | - Teresa Segura de la Cal
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Cardiology Department, Royal Brompton HospitalGuy’s and St Thomas’ NHS Foundation TrustLondonUnited Kingdom
- Cardiology DepartmentUniversity Hospital 12 de OctubreMadridSpain
| | - Isma Rafiq
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Cardiology Department, Royal Brompton HospitalGuy’s and St Thomas’ NHS Foundation TrustLondonUnited Kingdom
| | - Aleksander Kempny
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Cardiology Department, Royal Brompton HospitalGuy’s and St Thomas’ NHS Foundation TrustLondonUnited Kingdom
- National Heart and Lung InstituteImperial College LondonLondonUnited Kingdom
| | - Wei Li
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Cardiology Department, Royal Brompton HospitalGuy’s and St Thomas’ NHS Foundation TrustLondonUnited Kingdom
- National Heart and Lung InstituteImperial College LondonLondonUnited Kingdom
| | - Sonya V. Babu‐Narayan
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Cardiology Department, Royal Brompton HospitalGuy’s and St Thomas’ NHS Foundation TrustLondonUnited Kingdom
- National Heart and Lung InstituteImperial College LondonLondonUnited Kingdom
| | - J. Andreas Hoschtitzky
- National Heart and Lung InstituteImperial College LondonLondonUnited Kingdom
- Cardiothoracic and Congenital Heart Surgery, The Royal Brompton HospitalGuy’s and St Thomas’ NHS Foundation TrustLondonUnited Kingdom
| | - Michael A. Gatzoulis
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Cardiology Department, Royal Brompton HospitalGuy’s and St Thomas’ NHS Foundation TrustLondonUnited Kingdom
- National Heart and Lung InstituteImperial College LondonLondonUnited Kingdom
| | - Antonio Martinez Rubio
- Department of MedicineAutonomous University of BarcelonaBarcelonaSpain
- Cardiology DepartmentUniversity Hospital Parc TauliSabadellSpain
| | - Konstantinos Dimopoulos
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Cardiology Department, Royal Brompton HospitalGuy’s and St Thomas’ NHS Foundation TrustLondonUnited Kingdom
- National Heart and Lung InstituteImperial College LondonLondonUnited Kingdom
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17
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Lebehn M, Vahl T, Kampaktsis P, Hahn RT. Contemporary Evaluation and Clinical Treatment Options for Aortic Regurgitation. J Cardiovasc Dev Dis 2023; 10:364. [PMID: 37754793 PMCID: PMC10532324 DOI: 10.3390/jcdd10090364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 08/21/2023] [Accepted: 08/22/2023] [Indexed: 09/28/2023] Open
Abstract
Aortic regurgitation (AR) is the third most frequent form of valvular disease and has increasing prevalence with age. This will be of increasing clinical importance with the advancing age of populations around the globe. An understanding of the various etiologies and mechanisms leading to AR requires a detailed understanding of the structure of the aortic valve and aortic root. While acute and chronic AR may share a similar etiology, their hemodynamic impact on the left ventricle (LV) and management are very different. Recent studies suggest current guideline recommendations for chronic disease may result in late intervention and suboptimal outcomes. Accurate quantitation of ventricular size and function, as well as grading of the severity of regurgitation, requires a multiparametric and multimodality imaging approach with an understanding of the strengths and weaknesses of each metric. Echocardiography remains the primary imaging modality for diagnosis with supplemental information provided by computed tomography (CT) and cardiac magnetic resonance imaging (CMR). Emerging transcatheter therapies may allow the treatment of patients at high risk for surgery, although novel methods to assess AR severity and its impact on LV size and function may improve the timing and outcomes of surgical intervention.
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Affiliation(s)
- Mark Lebehn
- Department of Medicine, Columbia University Irving Medical Center, New York, NY 10032, USA
| | - Torsten Vahl
- Department of Medicine, Columbia University Irving Medical Center, New York, NY 10032, USA
- Cardiovascular Research Foundation, New York, NY 10019, USA
| | - Polydoros Kampaktsis
- Department of Medicine, Columbia University Irving Medical Center, New York, NY 10032, USA
| | - Rebecca T. Hahn
- Department of Medicine, Columbia University Irving Medical Center, New York, NY 10032, USA
- Cardiovascular Research Foundation, New York, NY 10019, USA
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18
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Hanet V, Schäfers HJ, Lansac E, de Kerchove L, El Hamansy I, Vojácek J, Contino M, Pouleur AC, Beauloye C, Pasquet A, Vanoverschelde JL, Vancraeynest D, Gerber BL. Impact of early versus class I-triggered surgery on postoperative survival in severe aortic regurgitation: An observational study from the Aortic Valve Insufficiency and Ascending Aorta Aneurysm International Registry. J Thorac Cardiovasc Surg 2023:S0022-5223(23)00545-7. [PMID: 37422134 DOI: 10.1016/j.jtcvs.2023.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 06/07/2023] [Accepted: 06/25/2023] [Indexed: 07/10/2023]
Abstract
OBJECTIVES Class I triggers for severe and chronic aortic regurgitation surgery mainly rely on symptoms or systolic dysfunction, resulting in a negative outcome despite surgical correction. Therefore, US and European guidelines now advocate for earlier surgery. We sought to determine whether earlier surgery leads to improved postoperative survival. METHODS We evaluated the postoperative survival of patients who underwent surgery for severe aortic regurgitation in the international multicenter registry for aortic valve surgery, Aortic Valve Insufficiency and Ascending Aorta Aneurysm International Registry, over a median follow-up of 37 months. RESULTS Among 1899 patients (aged 49 ± 15 years, 85% were male), 83% and 84% had class I indication according to the American Heart Association and European Society of Cardiology, respectively, and most were offered repair surgery (92%). Twelve patients (0.6%) died after surgery, and 68 patients died within 10 years after the procedure. Heart failure symptoms (hazard ratio, 2.60 [1.20-5.66], P = .016) and either left ventricular end-systolic diameter greater than 50 mm or left ventricular end-systolic diameter index greater than 25 mm/m2 (hazard ratio, 1.64 [1.05-2.55], P = .030) predicted survival independently over and above age, gender, and bicuspid phenotype. Therefore, patients who underwent surgery based on any class I trigger had worse adjusted survival. However, patients who underwent surgery while meeting early imaging triggers (left ventricular end-systolic diameter index 20-25 mm/m2 or left ventricular ejection fraction 50% to 55%) had no significant outcome penalty. CONCLUSIONS In this international registry of severe aortic regurgitation, surgery when meeting class I triggers led to postoperative outcome penalty compared with earlier triggers (left ventricular end-systolic diameter index 20-25 mm/m2 or ventricular ejection fraction 50%-55%). This observation, which applies to expert centers where aortic valve repair is feasible, should encourage the global use of repair techniques and the conduction of randomized trials.
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Affiliation(s)
- Vincent Hanet
- Department of Cardiovascular Diseases, Cliniques Universitaires St Luc, Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique IREC UCLouvain, Brussels, Belgium
| | | | - Emmanuel Lansac
- Surgery Department, Institut Mutualiste Montsouris, Paris, France
| | - Laurent de Kerchove
- Department of Cardiovascular Diseases, Cliniques Universitaires St Luc, Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique IREC UCLouvain, Brussels, Belgium
| | | | - Jan Vojácek
- Surgery Department, Charles University Hospital, Hradec Kralove, Czech Republic
| | - Monica Contino
- Surgery Department, Socio Sanitaria Territoriale Università degli Studi di Milano, Milano, Italy
| | - Anne-Catherine Pouleur
- Department of Cardiovascular Diseases, Cliniques Universitaires St Luc, Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique IREC UCLouvain, Brussels, Belgium
| | - Christophe Beauloye
- Department of Cardiovascular Diseases, Cliniques Universitaires St Luc, Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique IREC UCLouvain, Brussels, Belgium
| | - Agnès Pasquet
- Department of Cardiovascular Diseases, Cliniques Universitaires St Luc, Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique IREC UCLouvain, Brussels, Belgium
| | - Jean-Louis Vanoverschelde
- Department of Cardiovascular Diseases, Cliniques Universitaires St Luc, Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique IREC UCLouvain, Brussels, Belgium
| | - David Vancraeynest
- Department of Cardiovascular Diseases, Cliniques Universitaires St Luc, Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique IREC UCLouvain, Brussels, Belgium
| | - Bernhard L Gerber
- Department of Cardiovascular Diseases, Cliniques Universitaires St Luc, Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique IREC UCLouvain, Brussels, Belgium.
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19
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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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20
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Malahfji M, Crudo V, Kaolawanich Y, Nguyen DT, Telmesani A, Saeed M, Reardon MJ, Zoghbi WA, Polsani V, Elliott M, Bonow RO, Graviss EA, Kim R, Shah DJ. Influence of Cardiac Remodeling on Clinical Outcomes in Patients With Aortic Regurgitation. J Am Coll Cardiol 2023; 81:1885-1898. [PMID: 36882135 DOI: 10.1016/j.jacc.2023.03.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 03/02/2023] [Indexed: 03/07/2023]
Abstract
BACKGROUND Quantitative cardiac magnetic resonance (CMR) outcome studies in aortic regurgitation (AR) are few. It is unclear if volume measurements are beneficial over diameters. OBJECTIVES This study sought to evaluate the association of CMR quantitative thresholds and outcomes in AR patients. METHODS In a multicenter study, asymptomatic patients with moderate or severe AR on CMR with preserved left ventricular ejection fraction (LVEF) were evaluated. Primary outcome was development of symptoms or decrease in LVEF to <50%, development of guideline indications for surgery based on LV dimensions, or death under medical management. Secondary outcome was the same as the primary outcome, excluding surgery for remodeling indications. We excluded patients who underwent surgery within 30 days of CMR. Receiver-operating characteristic analyses for the association with outcomes were performed. RESULTS We studied 458 patients (median age: 60 years; IQR: 46-70 years). During a median follow-up of 2.4 years (IQR: 0.9-5.3 years), 133 events occurred. Optimal thresholds were regurgitant volume of 47 mL and regurgitant fraction of 43%, indexed LV end-systolic (iLVES) volume of 43 mL/m2, indexed LV end-diastolic volume of 109 mL/m2, and iLVES diameter of 2 cm/m2. In multivariable regression analysis, iLVES volume of ≥43 mL/m2 (HR: 2.53; 95% CI: 1.75-3.66; P < 0.001) and indexed LV end-diastolic volume of ≥109 mL/m2 were independently associated with the outcomes and provided additional discrimination improvement over iLVES diameter, whereas iLVES diameter was independently associated with the primary outcome but not the secondary outcome. CONCLUSIONS In asymptomatic AR patients with preserved LVEF, CMR findings can be used to guide management. CMR-based LVES volume assessment performed favorably compared to LV diameters.
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Affiliation(s)
- Maan Malahfji
- Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas, USA
| | - Valentina Crudo
- Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas, USA
| | - Yodying Kaolawanich
- Division of Cardiology, Department of Internal Medicine, Duke University, Durham, North Carolina, USA
| | - Duc T Nguyen
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital Research Institute, Houston, Texas, USA
| | - Amr Telmesani
- Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas, USA
| | - Mujtaba Saeed
- Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas, USA
| | - Michael J Reardon
- Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas, USA
| | - William A Zoghbi
- Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas, USA
| | | | - Michael Elliott
- Sanger Heart & Vascular Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Robert O Bonow
- Division of Cardiology, Department of Internal Medicine, Northwestern University, Chicago, Illinois, USA
| | - Edward A Graviss
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital Research Institute, Houston, Texas, USA
| | - Raymond Kim
- Division of Cardiology, Department of Internal Medicine, Duke University, Durham, North Carolina, USA
| | - Dipan J Shah
- Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas, USA.
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21
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Anand V, Hu H, Weston AD, Scott CG, Michelena HI, Pislaru SV, Carter RE, Pellikka PA. Machine learning-based risk stratification for mortality in patients with severe aortic regurgitation. EUROPEAN HEART JOURNAL. DIGITAL HEALTH 2023; 4:188-195. [PMID: 37265866 PMCID: PMC10232267 DOI: 10.1093/ehjdh/ztad006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 12/06/2022] [Indexed: 06/03/2023]
Abstract
Aims The current guidelines recommend aortic valve intervention in patients with severe aortic regurgitation (AR) with the onset of symptoms, left ventricular enlargement, or systolic dysfunction. Recent studies have suggested that we might be missing the window of early intervention in a significant number of patients by following the guidelines. Methods and results The overarching goal was to determine if machine learning (ML)-based algorithms could be trained to identify patients at risk for death from AR independent of aortic valve replacement (AVR). Models were trained with five-fold cross-validation on a dataset of 1035 patients, and performance was reported on an independent dataset of 207 patients. Optimal predictive performance was observed with a conditional random survival forest model. A subset of 19/41 variables was selected for inclusion in the final model. Variable selection was performed with 10-fold cross-validation using random survival forest model. The top variables included were age, body surface area, body mass index, diastolic blood pressure, New York Heart Association class, AVR, comorbidities, ejection fraction, end-diastolic volume, and end-systolic dimension, and the relative variable importance averaged across five splits of cross-validation in each repeat were evaluated. The concordance index for predicting survival of the best-performing model was 0.84 at 1 year, 0.86 at 2 years, and 0.87 overall, respectively. Conclusion Using common echocardiographic parameters and patient characteristics, we successfully trained multiple ML models to predict survival in patients with severe AR. This technique could be applied to identify high-risk patients who would benefit from early intervention, thereby improving patient outcomes.
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Affiliation(s)
- Vidhu Anand
- Corresponding author. Tel: +507 284 4441, Fax: +507 266 0228,
| | - Hanwen Hu
- Department of Quantitative Health Sciences Research, Mayo Clinic, Jacksonville, FL 32202, USA
| | - Alexander D Weston
- Department of Quantitative Health Sciences Research, Mayo Clinic, Jacksonville, FL 32202, USA
| | - Christopher G Scott
- Department of Quantitative Health Science, Mayo Clinic, Rochester, MN 55905, USA
| | - Hector I Michelena
- Department of Cardiovascular Medicine, Mayo Clinic Rochester Minnesota, 200 First Street SW, Rochester, MN 55905, USA
| | - Sorin V Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic Rochester Minnesota, 200 First Street SW, Rochester, MN 55905, USA
| | - Rickey E Carter
- Department of Quantitative Health Sciences Research, Mayo Clinic, Jacksonville, FL 32202, USA
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22
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Inanc IH, Cilingiroglu M, Iliescu C, NInios V, Matar F, Ates I, Toutouzas K, Hermiller J, Marmagkiolis K. Comparison of American and European Guidelines for the Management of Patients With Valvular Heart Disease. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 47:76-85. [PMID: 36270966 DOI: 10.1016/j.carrev.2022.10.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 10/11/2022] [Accepted: 10/12/2022] [Indexed: 01/25/2023]
Abstract
This review compares the recommendations of the recent 2020 American College of Cardiology (ACC)/American Heart Association (AHA) and 2021 European Society of Cardiology (ESC)/European Association for Cardio-Thoracic Surgery (EACTS) guidelines on the management of patients with valvular heart disease (VHD). ACC/AHA and ESC/EACTS guidelines are both the updated versions of previous 2017 documents. Both guidelines fundamentally agree on the extended indications of percutaneous valve interventions, the optimal use of imaging modalities other than 2D echocardiography, the importance of a multidisciplinary Heart Team as well as active patient participation in clinical decision making, more widespread use of NOACs and earlier intervention with lower left ventricular dilatation thresholds to decrease long-term mortality. The differences between the guidelines are mainly related to the classification of the severity of valve pathologies and frequency of follow-up, level of recommendations of valve intervention indications in special patient groups such as frail patients and the left ventricular diameter and ejection fraction thresholds for intervention.
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Affiliation(s)
- Ibrahim Halil Inanc
- Kırıkkale Yuksek Ihtisas Hospital, Department of Cardiology, Kırıkkale, Turkey.
| | - Mehmet Cilingiroglu
- University of Texas in Houston, MD Anderson Cancer Center, Houston, TX, United States of America
| | - Cezar Iliescu
- University of Texas in Houston, MD Anderson Cancer Center, Houston, TX, United States of America.
| | - Vlasis NInios
- Department of Cardiology, Interbalkan European Medical Center, Thessaloniki, Greece
| | - Fadi Matar
- Department of Cardiology, University of South Florida, Tampa, FL, United States of America.
| | - Ismail Ates
- Department of Cardiology, Sisli Kolan International Hospital, Istanbul, Turkey
| | - Konstantinos Toutouzas
- Hippocrateion Athens General Hospital, Athens Medical School, National and Kapodistrian University of Athens, Athens, Greece.
| | - James Hermiller
- Department of Cardiology, St Vincent Heart Center, Indianapolis, IN, United States of America
| | - Kostas Marmagkiolis
- University of Texas in Houston, MD Anderson Cancer Center, Houston, TX, United States of America; Department of Cardiology, University of South Florida, Tampa, FL, United States of America
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23
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Long-term outcomes after aortic valve surgery in patients with aortic regurgitation with preserved ejection fraction and left ventricular dilation. Gen Thorac Cardiovasc Surg 2023; 71:51-58. [PMID: 35852755 DOI: 10.1007/s11748-022-01849-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 06/22/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVES This study aims to assess the long-term outcomes and prognostic predictors of asymptomatic patients with severe aortic regurgitation (AR) accompanied by left ventricular ejection fraction (LVEF) ≥ 55% and left ventricular end-diastolic diameter (LVEDD) > 65 mm undergoing aortic valve replacement (AVR). METHODS We retrospectively studied 291 consecutive asymptomatic patients with severe AR accompanied by LVEF ≥ 55% and LVEDD > 65 mm undergoing AVR from January 2000 to December 2013. The long-term outcomes and prognostic predictors were evaluated. RESULTS There were 2 (0.7%) in-hospital deaths caused by multiple organ failure. The overall survival rate was 95.2% at 5 years, 89.9% at 10 years, 85.9% at 15 years, and 85.9% at 20 years. The left ventricular end-systolic volume index (LVESVi) was an independent predictor of overall mortality, with 59 ml/m2 being the best cut-off value. The left ventricular (LV) dimension decreased within 1 year after surgery and sustained thereafter. There were 15.5% of patients had incomplete LV reverse remodeling. LVESVi was an independent predictor of incomplete LV reverse remodeling, with 56 ml/m2 being the best cut-off value. CONCLUSIONS AVR can be performed with an acceptable outcome in patients with severe AR accompanied by LVEF ≥ 55% and LVEDD > 65 mm. The LVESVi has the best predictive value for prognosis and the cut-off value is 59 ml/m2, and has the best predictive value for incomplete LV reverse remodeling and the cut-off value is 56 ml/m2.
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24
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Ajmone Marsan N, Delgado V, Shah DJ, Pellikka P, Bax JJ, Treibel T, Cavalcante JL. Valvular heart disease: shifting the focus to the myocardium. Eur Heart J 2023; 44:28-40. [PMID: 36167923 PMCID: PMC9805407 DOI: 10.1093/eurheartj/ehac504] [Citation(s) in RCA: 28] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 07/12/2022] [Accepted: 08/26/2022] [Indexed: 01/05/2023] Open
Abstract
Adverse cardiac remodelling is the main determinant of patient prognosis in degenerative valvular heart disease (VHD). However, to give an indication for valvular intervention, current guidelines include parameters of cardiac chamber dilatation or function which are subject to variability, do not directly reflect myocardial structural changes, and, more importantly, seem to be not sensitive enough in depicting early signs of myocardial dysfunction before irreversible myocardial damage has occurred. To avoid irreversible myocardial dysfunction, novel biomarkers are advocated to help refining indications for intervention and risk stratification. Advanced echocardiographic modalities, including strain analysis, and magnetic resonance imaging have shown to be promising in providing new tools to depict the important switch from adaptive to maladaptive myocardial changes in response to severe VHD. This review, therefore, summarizes the current available evidence on the role of these new imaging biomarkers in degenerative VHD, aiming at shifting the clinical perspective from a valve-centred to a myocardium-focused approach for patient management and therapeutic decision-making.
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Affiliation(s)
- Nina Ajmone Marsan
- Department of Cardiology, Leiden Univesity Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - Victoria Delgado
- Department of Cardiology, Leiden Univesity Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
- Department of Cardiology, Germans Trias i Pujol Hospital, Carretera de Canyet s/n. 08916 Badalona, Barcelona, Spain
| | - Dipan J Shah
- Division of Cardiovascular Imaging, Weill Cornell Medical College, Houston Methodist DeBakey Heart & Vascular Center, 6565 Fannin St, Houston, TX 77030, USA
| | - Patricia Pellikka
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA
| | - Jeroen J Bax
- Department of Cardiology, Leiden Univesity Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - Thomas Treibel
- Department of Cardiology, Barts Heart Centre and University College London, West Smithfield, London EC1A 7BE, UK
| | - João L Cavalcante
- Department of Cardiology, Minneapolis Heart Institute at Abbott Northwestern Hospital, 800 E 28th St, Minneapolis, MN 55407, USA
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25
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Fontana M, Ioannou A. Optimizing the Timing of Aortic Valve Surgery: A Multiparametric Approach. Circ Cardiovasc Imaging 2022; 15:e015004. [PMID: 36538595 DOI: 10.1161/circimaging.122.015004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Marianna Fontana
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - Adam Ioannou
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
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26
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Kočková R, Línková H, Hlubocká Z, Mědílek K, Tuna M, Vojáček J, Skalský I, Černý Š, Malý J, Hlubocký J, Mizukami T, De Colle C, Pěnička M. Multiparametric Strategy to Predict Early Disease Decompensation in Asymptomatic Severe Aortic Regurgitation. Circ Cardiovasc Imaging 2022; 15:e014901. [PMID: 36538596 DOI: 10.1161/circimaging.122.014901] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Use of the current echocardiography-based indications for aortic regurgitation (AR) surgery might result in late valve replacement at the stage of irreversible myocardial damage. Therefore, we aimed to identify simple models combining multiple echocardiography or magnetic resonance imaging (MRI)-derived indices and natriuretic peptides (BNP [brain natriuretic peptide] or NT-proBNP [N-terminnal pro-B type natriuretic peptide]) to predict early disease decompensation in asymptomatic severe AR. METHODS This prospective and multicenter study included asymptomatic patients with severe AR, preserved left ventricular ejection fraction (>50%), and sinus rhythm. The echocardiography and MRI images were analyzed centrally in the CoreLab. The study end point was the onset of indication for aortic valve surgery as per current guidelines. RESULTS The derivative cohort consisted of 127 asymptomatic patients (age 45±14 years, 84% males) with 41 (32%) end points during a median follow-up of 1375 (interquartile range, 1041-1783) days. In multivariable Cox regression analysis, age, BNP, 3-dimensional vena contracta area, MRI left ventricular end-diastolic volume index, regurgitant volume, and a fraction were identified as independent predictors of end point (all P<0.05). However, a combined model including one parameter of AR assessment (MRI regurgitant volume or regurgitant fraction or 3-dimensional vena contracta area), 1 parameter of left ventricular remodeling (MRI left ventricular end-diastolic volume index or echocardiography 2-dimensional global longitudinal strain or E wave), and BNP showed significantly higher predictive accuracy (area under the curve, 0.74-0.81) than any parameter alone (area under the curve, 0.61-0.72). These findings were confirmed in the validation cohort (n=100 patients, 38 end points). CONCLUSIONS In asymptomatic severe AR, multimodality and multiparametric model combining 2 imaging indices with natriuretic peptides, showed high accuracy to identify early disease decompensation. Further prospective studies are warranted to explore the clinical benefit of implementing these models to guide patient management. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT02910349.
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Affiliation(s)
- Radka Kočková
- Cardiothoracic Surgery Department, Na Homolce Hospital, Czech Republic (R.K., I.S., S.C.)
| | - Hana Línková
- Department of Cardiology, Royal Vinohrady University Hospital, Czech Republic (H.L.)
| | - Zuzana Hlubocká
- Department of Cardiology (Z.H.), General University Hospital, Prague, Czech Republic
| | - Karel Mědílek
- 1st Department Medicine - Cardioangiology, University Hospital Hradec Králové, Sokolská Czech Republic (K.M.)
| | - Martin Tuna
- Department of Cardiac Surgery, University Hospital Hradec Králové, Hradec Králové, Czech Republic (M.T., J.V.)
| | - Jan Vojáček
- Department of Cardiac Surgery, University Hospital Hradec Králové, Hradec Králové, Czech Republic (M.T., J.V.)
| | - Ivo Skalský
- Cardiothoracic Surgery Department, Na Homolce Hospital, Czech Republic (R.K., I.S., S.C.)
| | - Štěpán Černý
- Cardiothoracic Surgery Department, Na Homolce Hospital, Czech Republic (R.K., I.S., S.C.)
| | - Jiří Malý
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.M.)
| | - Jaroslav Hlubocký
- Department of Cardiovascular Surgery (J.H.), General University Hospital, Prague, Czech Republic
| | - Takuya Mizukami
- Cardiovascular Center Aalst, Belgium (T.M., C.D.C., M.P.).,Division of Clinical Pharmacology, Department of Pharmacology, Showa University, Tokyo, Japan (T.M.)
| | - Cristina De Colle
- Cardiovascular Center Aalst, Belgium (T.M., C.D.C., M.P.).,Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy (C.D.C.)
| | - Martin Pěnička
- Cardiovascular Center Aalst, Belgium (T.M., C.D.C., M.P.)
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27
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Dumpies O, Pausch J, Reichenspurner H, Thiele H. Frühe Herzklappentherapie bei asymptomatischen Patienten – was gilt schon jetzt? AKTUELLE KARDIOLOGIE 2022. [DOI: 10.1055/a-1842-4283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
ZusammenfassungBei einer asymptomatischen hochgradigen Aortenklappenstenose (AS) mit normaler linksventrikulärer Funktion sollte eine „Watchful-Waiting“-Strategie verfolgt werden. Asymptomatische
Patienten mit Risikofaktoren, wie sehr schwere AS, schwere kalzifizierter AS oder 3-fach erhöhtem proBNP-Level, können bei niedrigem operativem Risiko eine Intervention erhalten. Erste
randomisierte Studien weisen auf einen Vorteil des frühzeitigen Aortenklappenersatzes bei niedrigem OP-Risiko hin.Für Patienten mit einer asymptomatischen hochgradigen Aortenklappeninsuffizienz sollte bei niedrigem operativem Risiko bereits frühzeitig eine OP erwogen werden, wenn sich Zeichen der
linksventrikulären Schädigung zeigen.Bei asymptomatischer primärer Mitralklappeninsuffizienz (MI) kann die chirurgische Mitralklappenrekonstruktion bereits vor dem Auftreten einer linksventrikulären Dilatation oder
anderweitigen Folgeschäden erwogen werden, falls mit einer hohen Rekonstruktionswahrscheinlichkeit zu rechnen ist.
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Affiliation(s)
- Oliver Dumpies
- Klinik für Innere Medizin/Kardiologie, Herzzentrum Leipzig – Universität Leipzig, Leipzig, Deutschland
| | - Jonas Pausch
- Klinik für Herz- und Gefäßchirurgie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Hermann Reichenspurner
- Klinik für Herz- und Gefäßchirurgie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Holger Thiele
- Klinik für Innere Medizin/Kardiologie, Herzzentrum Leipzig – Universität Leipzig, Leipzig, Deutschland
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28
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Hecht S, Butcher SC, Pio SM, Kong WKF, Singh GK, Ng ACT, Perry R, Poh KK, Almeida AG, González A, Shen M, Yeo TC, Shanks M, Popescu BA, Gay LG, Fijałkowski M, Liang M, Tay E, Marsan NA, Selvanayagam J, Pinto F, Zamorano JL, Evangelista A, Delgado V, Bax JJ, Pibarot P. Impact of Left Ventricular Ejection Fraction on Clinical Outcomes in Bicuspid Aortic Valve Disease. J Am Coll Cardiol 2022; 80:1071-1084. [PMID: 36075677 DOI: 10.1016/j.jacc.2022.06.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 06/13/2022] [Accepted: 06/21/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND The prognostic impact of left ventricular ejection fraction (LVEF) in patients with bicuspid aortic valve (BAV) disease has not been previously studied. OBJECTIVES The purpose of this study was to determine the prognostic impact of LVEF in BAV patients according to the type of aortic valve dysfunction. METHODS We retrospectively analyzed the data collected in 2,672 patients included in an international registry of patients with BAV. Patients were classified according to the type of aortic valve dysfunction: isolated aortic stenosis (AS) (n = 749), isolated aortic regurgitation (AR) (n = 554), mixed aortic valve disease (MAVD) (n = 190), or no significant aortic valve dysfunction (n = 1,179; excluded from this analysis). The study population was divided according to LVEF strata to investigate its impact on clinical outcomes. RESULTS The risk of all-cause mortality and the composite endpoint of aortic valve replacement or repair (AVR) and all-cause mortality increased when LVEF was <60% in the whole cohort as well as in the AS and AR groups, and when LVEF was <55% in MAVD group. In multivariable analysis, LVEF strata were significantly associated with increased rate of mortality (LVEF 50%-59%: HR: 1.83 [95% CI: 1.09-3.07]; P = 0.022; LVEF 30%-49%: HR: 1.97 [95% CI: 1.13-3.41]; P = 0.016; LVEF <30%: HR: 4.20 [95% CI: 2.01-8.75]; P < 0.001; vs LVEF 60%-70%, reference group). CONCLUSIONS In BAV patients, the risk of adverse clinical outcomes increases significantly when the LVEF is <60%. These findings suggest that LVEF cutoff values proposed in the guidelines to indicate intervention should be raised from 50% to 60% in AS or AR and 55% in MAVD.
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Affiliation(s)
- Sébastien Hecht
- Quebec Heart and Lung Institute, Laval University, Quebec, Quebec, Canada
| | - Steele C Butcher
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands; Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Stephan M Pio
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - William K F Kong
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands; Department of Cardiology, National University Heart Centre, National University Health System, Singapore, Singapore
| | - Gurpreet K Singh
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Arnold C T Ng
- Department of Cardiology, Princess Alexandra Hospital, The University of Queensland, Brisbane, Queensland, Australia
| | - Rebecca Perry
- Department of Cardiovascular Medicine, Flinders Medical Centre, Bedford Park, Adelaide, South Australia, Australia
| | - Kian Keong Poh
- Department of Cardiology, National University Heart Centre, National University Health System, Singapore, Singapore
| | - Ana G Almeida
- Cardiology Department, Santa Maria University Hospital (CHLN), CAML, CCUL, Lisbon School of Medicine of the Universidade de Lisboa, Lisbon, Portugal
| | - Ariana González
- Department of Cardiology, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - Mylène Shen
- Quebec Heart and Lung Institute, Laval University, Quebec, Quebec, Canada
| | - Tiong Cheng Yeo
- Department of Cardiology, National University Heart Centre, National University Health System, Singapore, Singapore
| | - Miriam Shanks
- Division of Cardiology, University of Alberta, Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Bogdan A Popescu
- University of Medicine and Pharmacy "Carol Davila"-Euroecolab, Institute of Cardiovascular Diseases "Prof. Dr C. C. Iliescu," Bucharest, Romania
| | - Laura Galian Gay
- Department of Cardiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Marcin Fijałkowski
- First Department of Cardiology, Medical University of Gdansk, Gdansk, Poland
| | - Michael Liang
- Department of Cardiology, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Edgar Tay
- Department of Cardiology, National University Heart Centre, National University Health System, Singapore, Singapore
| | - Nina Ajmone Marsan
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Joseph Selvanayagam
- Department of Cardiovascular Medicine, Flinders Medical Centre, Bedford Park, Adelaide, South Australia, Australia
| | - Fausto Pinto
- Cardiology Department, Santa Maria University Hospital (CHLN), CAML, CCUL, Lisbon School of Medicine of the Universidade de Lisboa, Lisbon, Portugal
| | - Jose L Zamorano
- Department of Cardiology, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - Arturo Evangelista
- Department of Cardiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Victoria Delgado
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands; Heart Center, University of Turku and Turku University Hospital, Turku, Finland.
| | - Philippe Pibarot
- Quebec Heart and Lung Institute, Laval University, Quebec, Quebec, Canada.
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29
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Transcatheter Aortic Valve Implantation for Pure Native Aortic Regurgitation: The Last Frontier. J Clin Med 2022; 11:jcm11175181. [PMID: 36079111 PMCID: PMC9457283 DOI: 10.3390/jcm11175181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 08/29/2022] [Accepted: 08/29/2022] [Indexed: 11/17/2022] Open
Abstract
Transcatheter aortic valve implantation (TAVI) to treat patients with severe symptomatic aortic stenosis is a well-established procedure. Even though cases series have reported TAVI use in high-risk patients with pure native aortic regurgitation, this is still considered an off-label intervention, especially when the aortic annulus dimensions are beyond the recommended by prosthesis manufacturers. Herein, we provide an updated review regarding the transcatheter treatment of pure native aortic regurgitation and illustrate this issue by presenting a clinical case of a patient with pure aortic regurgitation and a large aortic annulus who received a self-expanding non-dedicated transcatheter heart valve.
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30
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Kassier A. Guidelines for Aortic Regurgitation and Thoracic Aortic Aneurysms in Asian Population: Need a Second Look? JACC. ASIA 2022; 2:487-489. [PMID: 36339360 PMCID: PMC9627914 DOI: 10.1016/j.jacasi.2022.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Adnan Kassier
- Interventional Cardiology–Structural Heart Disease, Ascension Borgess Hospital–Michigan State University, Kalamazoo, Michigan, USA
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31
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Patrick WL, Rosen JL, Bavaria JE, Ahmed S, Freas A, Yarlagadda S, Cannon B, Iyengar A, Kelly JJ, Zhao Y, Grimm JC, Szeto WY, Desai ND. Valve-sparing Root Reimplantation In Patients With Left Ventricular Dilation. Eur J Cardiothorac Surg 2022; 62:6647842. [PMID: 35861386 DOI: 10.1093/ejcts/ezac393] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 06/29/2022] [Accepted: 07/19/2022] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The purpose of this study was to evaluate the association between left ventricular (LV) dilation and outcomes following valve-sparing root reimplantation. METHODS Patients with an indexed left ventricular internal diameter during systole (iLVIDS) of ≥ 2.0 cm/m2 were categorized as having LV dilation. Outcomes were post-operative aortic insufficiency (AI), re-intervention, and all-cause mortality. The cumulative incidence of each outcome was computed using the Kaplan-Meier estimator. Adjusted comparisons between strata were performed for each outcome using a Cox proportional-hazards model. Where possible, the competing risk of death was accounted for. Multilevel mixed-effects ordered logistic regression was performed for AI grade at follow-up. RESULTS There were 295 patients of whom 52 had LV dilation. Operative outcomes were excellent; there were no significant differences between groups. Patients with LV dilation demonstrated significant improvement in iLVIDS overtime. There was no association between LV dilation and post-operative AI grade >2 (HR 0.88, 95% CI 0.21 to 3.67, p = 0.89) or odds of increased AI grade overtime (OR = 0.76, 95% CI 0.30 to 1.93, p = 0.57). There were no re-interventions among those with LV dilation. Adjusted mortality was significantly higher among those with LV dilation (HR 5.56, 95% CI 1.56 to 19.9), however, deaths were unrelated to aortic valve dilation. CONCLUSIONS Left ventricular dilation is not associated with poorer operative outcomes, post-operative AI, or re-intervention. It is associated with increased risk of mortality, though not from valvular dysfunction. LV dilation should not deter VSRR when otherwise indicated.
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Affiliation(s)
- William L Patrick
- Division of Cardiovascular Surgery, University of Pennsylvania.,Leonard Davis Institute, University of Pennsylvania, Philadelphia, Pennsylvania.,Penn Cardiovascular Outcomes, Quality, & Evaluative Research Center, Philadelphia, Pennsylvania
| | - Jake L Rosen
- Division of Cardiovascular Surgery, University of Pennsylvania
| | | | - Sania Ahmed
- Division of Cardiovascular Surgery, University of Pennsylvania
| | - Andrew Freas
- Division of Cardiovascular Surgery, University of Pennsylvania
| | | | - Brittany Cannon
- Division of Cardiovascular Surgery, University of Pennsylvania
| | - Amit Iyengar
- Division of Cardiovascular Surgery, University of Pennsylvania
| | - John J Kelly
- Division of Cardiovascular Surgery, University of Pennsylvania
| | - Yu Zhao
- Division of Cardiovascular Surgery, University of Pennsylvania.,Leonard Davis Institute, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joshua C Grimm
- Division of Cardiovascular Surgery, University of Pennsylvania
| | - Wilson Y Szeto
- Division of Cardiovascular Surgery, University of Pennsylvania
| | - Nimesh D Desai
- Division of Cardiovascular Surgery, University of Pennsylvania.,Leonard Davis Institute, University of Pennsylvania, Philadelphia, Pennsylvania.,Penn Cardiovascular Outcomes, Quality, & Evaluative Research Center, Philadelphia, Pennsylvania
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32
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Hashimoto G, Enriquez-Sarano M, Stanberry LI, Oh F, Wang M, Acosta K, Sato H, Lopes BBC, Fukui M, Garcia S, Goessl M, Sorajja P, Bapat VN, Lesser J, Cavalcante JL. Association of Left Ventricular Remodeling Assessment by Cardiac Magnetic Resonance With Outcomes in Patients With Chronic Aortic Regurgitation. JAMA Cardiol 2022; 7:924-933. [PMID: 35857306 DOI: 10.1001/jamacardio.2022.2108] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Importance Chronic aortic regurgitation (AR) causes left ventricular (LV) volume overload, which results in progressive LV remodeling negatively affecting outcomes. Whether cardiac magnetic resonance (CMR) volumetric quantification can provide incremental risk stratification over standard clinical and echocardiographic evaluation in patients with chronic moderate or severe AR is unknown. Objective To compare LV remodeling measurements by CMR and echocardiography between patients with and without heart failure symptoms and to verify the association of remodeling measurements of patients with chronic moderate or severe AR but no or minimal symptoms with clinical outcomes receiving medical management. Design, Setting, and Participants This multicenter retrospective cohort study included consecutive patients with at least moderate chronic native AR evaluated by 2-dimensional transthoracic echocardiography and CMR examination within 90 days from each other between January 2012 and February 2020 at Allina Health System. Data were analyzed from June 2021 to January 2022. Exposures Clinical evaluation and risk stratification by CMR. Main Outcomes and Measures The end point was a composite of death, heart failure hospitalization, or progression of New York Heart Association functional class while receiving medical management, censoring patients at the time of aortic valve replacement (when performed) or at the end of follow-up. Results Of the 178 included patients, 119 (66.9%) were male, 158 (88.8%) presented with no or minimal symptoms (New York Heart Association class I or II), and the median (IQR) age was 58 (44-69) years. Compared with patients with no or minimal symptoms, symptomatic patients had greater LV end-systolic volume index (LVESVi) by CMR (median [IQR], 66 [46-85] mL/m2 vs 42 [30-58] mL/m2; P < .001), while there were no significant differences by echocardiography (LVESVi: median [IQR], 38 [30-58] mL/m2 vs 27 [20-42] mL/m2; P = .07; LV end-systolic diameter index: median [IQR], 21 [17-25] mm/m2 vs 18 [15-22] mm/m2; P = .17). During the median (IQR) follow-up of 3.3 (1.6-5.8) years, 50 patients with no or minimal symptoms receiving medical management developed the composite end point, which, in multivariate analysis adjusted for age and EuroSCORE II, was independently associated with LVESVi of 45 mL/m2 or greater and aortic regurgitant fraction of 32% or greater, the latter adding incremental prognostic value to CMR volumetric assessment. Conclusions and Relevance In patients with chronic moderate or severe AR, patients presenting with heart failure symptoms have greater LVESVi by CMR than those with no or minimal symptoms. In patients with no or minimal symptoms, CMR quantification of LVESVi and AR severity may identify those at risk of death or incident heart failure and therefore should be considered in the clinical evaluation and decision-making of these patients.
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Affiliation(s)
- Go Hashimoto
- Cardiovascular Imaging Research Center and Core Lab, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Maurice Enriquez-Sarano
- Valve Science Center, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota.,Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Larissa I Stanberry
- Cardiovascular Imaging Research Center and Core Lab, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Felix Oh
- Cardiovascular Imaging Research Center and Core Lab, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Matthew Wang
- Cardiovascular Imaging Research Center and Core Lab, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Keith Acosta
- Cardiovascular Imaging Research Center and Core Lab, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Hirotomo Sato
- Cardiovascular Imaging Research Center and Core Lab, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Bernardo B C Lopes
- Cardiovascular Imaging Research Center and Core Lab, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Miho Fukui
- Cardiovascular Imaging Research Center and Core Lab, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Santiago Garcia
- Valve Science Center, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota.,Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Mario Goessl
- Valve Science Center, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota.,Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Paul Sorajja
- Valve Science Center, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota.,Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Vinayak N Bapat
- Valve Science Center, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota.,Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - John Lesser
- Valve Science Center, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota.,Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - João L Cavalcante
- Cardiovascular Imaging Research Center and Core Lab, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota.,Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
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33
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Bonow RO, O'Gara PT. Left Ventricular Volume and Outcomes in Patients With Chronic Aortic Regurgitation. JAMA Cardiol 2022; 7:885-886. [PMID: 35857309 DOI: 10.1001/jamacardio.2022.2152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Robert O Bonow
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois.,Editor, JAMA Cardiology
| | - Patrick T O'Gara
- Division of Cardiovascular Disease, Brigham and Women's Hospital, Boston, Massachusetts.,Deputy Editor, JAMA Cardiology
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34
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Vejpongsa P, Xu J, Quinones MA, Shah DJ, Zoghbi WA. Differences in Cardiac Remodeling in Left-Sided Valvular Regurgitation: Implications for Optimal Definition of Significant Aortic Regurgitation. JACC. CARDIOVASCULAR IMAGING 2022; 15:1730-1741. [PMID: 35842362 DOI: 10.1016/j.jcmg.2022.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 04/20/2022] [Accepted: 05/19/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND Grading of aortic regurgitation (AR) and mitral regurgitation (MR) is similar in the cardiology guidelines despite distinct differences in left ventricular (LV) adaptive pathophysiology. OBJECTIVES This study compared differences in LV remodeling in patients with similar degrees of AR and MR severity and evaluated optimal cutoffs for significant AR in relation to the outcome of aortic valve replacement or repair (AVR) during follow-up. METHODS From 2008 to 2018, consecutive patients with isolated AR or MR who had cardiovascular magnetic resonance (CMR) were identified and CMR parameters were compared. Patients with left ventricular ejection fraction (LVEF) <50%, ischemic scar >5%, valve stenosis, or concomitant regurgitation were excluded. Patients were followed longitudinally for AVR. RESULTS Baseline characteristics of isolated AR (n = 418) and isolated MR (n = 1,073) were comparable except for higher male proportion and hypertension in AR, while heart failure was more prevalent in MR. Indexed LV end-diastolic and end-systolic volumes and mass were higher in AR compared with MR at the same level of regurgitant fraction. During follow-up (mean 2.1 years), 18.7% of AR patients underwent AVR based on symptoms or LV remodeling. Interestingly, 38.0% of patients that underwent AVR within 3 months after CMR did not meet severe AVR by current guidelines of AR severity. AR regurgitant fraction>35% had high sensitivity (86%) and specificity (88%) for identifying patients who underwent AVR. CONCLUSIONS For similar regurgitation severity, LV remodeling is different in AR compared with MR. Cardiac symptoms and significant LV remodeling in AR requiring AVR occur frequently in patients with less severity than currently proposed. The study findings suggest that the optimal threshold for severe AR with CMR is different than MR and is lower than currently stated in the guidelines.
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Affiliation(s)
- Pimprapa Vejpongsa
- Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
| | - Jiaqiong Xu
- Center for Outcomes Research, Houston Methodist Research Institute, Houston, Texas, USA
| | - Miguel A Quinones
- Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
| | - Dipan J Shah
- Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
| | - William A Zoghbi
- Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA.
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35
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Staging cardiac damage in patients with aortic regurgitation. Int J Cardiovasc Imaging 2022; 38:2645-2653. [DOI: 10.1007/s10554-022-02673-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 06/07/2022] [Indexed: 11/26/2022]
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36
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Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Rafael Sádaba J, Tribouilloy C, Wojakowski W. Guía ESC/EACTS 2021 sobre el diagnóstico y tratamiento de las valvulopatías. Rev Esp Cardiol 2022. [DOI: 10.1016/j.recesp.2021.11.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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37
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Svensson LG, Rosinski BF, Tucker NJ, Gillinov AM, Rajeswaran J, Roselli EE, Johnston DR, Desai MY, Griffin BP, Blackstone EH. Comparison of Outcomes of Patients Undergoing Reimplantation versus Bentall Root Procedure. AORTA 2022; 10:57-68. [PMID: 35933986 PMCID: PMC9357471 DOI: 10.1055/s-0042-1744135] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Background
A bioprosthesis- or mechanical-prosthesis–containing polyester graft (composite graft) is standard surgical management for aortic root aneurysms (Bentall procedure), but particularly in the young patient in whom a bioprosthesis is likely to deteriorate and a mechanical prosthesis mandates life-long anticoagulation, valve-sparing procedures have been devised. One such procedure involves reimplantation of the native aortic valve in the polyester graft. With focus on selecting the optimum procedure for young relatively asymptomatic patients, we compared outcomes of reimplantation of the aortic valve versus the Bentall procedure and identified factors influencing outcomes.
Methods
From January 2000 to January 2017, 643 adults age ≤ 70 with tricuspid aortic valves underwent elective aortic root replacement with either reimplantation (
n
= 448/70%) or a composite valve graft (Bentall) procedure (
n
= 195/30%). Outcomes were compared in 100 propensity-matched pairs.
Results
Patients with fewer symptoms, less aortic regurgitation (AR), higher left ventricular ejection fraction, and smaller cross-sectional aortic area/height ratio had a higher likelihood of valve repair with reimplantation (all
p
< 0.02) versus receiving a Bentall procedure. Operative mortality was 0.16% (reimplantation, 1/448, 0.22%; Bentall 0/195, 0%). After reimplantation, 8-year freedom from severe AR was 95% and 10-year freedom from reintervention was 98%. Ten-year survival was 95%. Higher preoperative AR grade (
p
< 0.0001) but not larger root diameter (
p
= 0.3) was associated with higher grade of late regurgitation after a reimplantation procedure. Among propensity-matched patients, reimplantation compared with a Bentall was associated with similar 10-year survival (89% vs. 94%), but more late AR (8-year freedom from severe AR: 93% vs. 99.9%) and greater early reduction in, but similar late, left ventricular mass (104 vs. 105 g•m
–2
at 8 years).
Conclusion
Excellent aortic valve reimplantation results versus Bentall lead us to recommend reimplantation more often in patients who present with even moderately severe or severe AR and significantly enlarged aortic roots.
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Affiliation(s)
- Lars G. Svensson
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
- The Aorta Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Brad F. Rosinski
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Nicholas J. Tucker
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - A. Marc Gillinov
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jeevanantham Rajeswaran
- Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eric E. Roselli
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
- The Aorta Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Douglas R. Johnston
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
- The Aorta Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Milind Y. Desai
- The Aorta Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Brian P. Griffin
- The Aorta Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eugene H. Blackstone
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
- The Aorta Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
- Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
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38
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Yang LT, Takeuchi M, Scott CG, Thapa P, Wang TD, Villarraga HR, Padang R, Enriquez-Sarano M, Michelena HI. Automated Global Longitudinal Strain Exhibits a Robust Association with Death in Asymptomatic Chronic Aortic Regurgitation. J Am Soc Echocardiogr 2022; 35:692-702.e8. [PMID: 35341954 DOI: 10.1016/j.echo.2021.10.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 09/13/2021] [Accepted: 10/31/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Whether automated left ventricular global longitudinal strain (LVGLS) is associated with outcomes in asymptomatic aortic regurgitation (AR) is unknown. OBJECTIVE To explore the impact of automated LVGLS on survival and compare it with conventional LV parameters in chronic asymptomatic AR. METHODS LVGLS (presented as absolute value) was measured using fully-automated two-dimensional strain software in consecutive patients with isolated chronic ≥moderate-severe AR between 2004 and 2020; incremental value of LVGLS was assessed. Limited correction of endocardial border tracking was performed if needed. RESULTS Of 550 asymptomatic patients (age 60±17 years; 86% men), average LVGLS was 17±3% (1st and 2nd tertile, 15.8% and 18.5%). In 16% cases, tracking border was partially corrected; average time for analysis was 25±5 seconds. At a median (interquartile range) of 4.8(1.5-9.9) years, 87 patients had died (19 died after aortic-valve surgery [AVS]). Separate multivariable models adjusted for age, sex, Charlson index, AR severity and time-dependent AVS demonstrated that LVEF(hazard ratio[HR] per 10%: 0.9), LV end-systolic volume index(LVESVi; HR per 5ml/m2: 1.08) and LVGLS(HR per unit: 0.87) were independently associated with death(all p≤0.018); however, LVGLS remained statistically significant (HR: 0.86-0.9; P≤0.007) as compared head-to-head to LVEF, LVESVi and LV end-systolic dimension index(LVESDi). The association of LVGLS and mortality was consistent across all subgroups (P for interaction all≥0.08). Spline curves showed that continuous risk of death rose at LVGLS <15%. Those with LVGLS <15% had 2.6-fold risk of death [95% CI 1.54-4.23] while those with LVGLS <15% plus LVESVi≥45ml/m2 had 3.96-fold risk[95% CI 1.94-8.03]. CONCLUSION In this large cohort of asymptomatic patients with ≥moderate-severe AR, automated LVGLS was feasible, efficient, and independently associated with death on head-to-head comparison with conventional LVEF, LVESDi, and LVESVi. The automated-LVGLS threshold of <15% alone or combined with LVESVi≥45ml/m2, was significantly associated with increased mortality risk and may be considered in early surgery decision-making.
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Affiliation(s)
- Li-Tan Yang
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester Minnesota; Cardiovascular Center and Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.
| | - Masaaki Takeuchi
- Department of Laboratory and Transfusion Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Christopher G Scott
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester Minnesota
| | - Prabin Thapa
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester Minnesota
| | - Tzung-Dau Wang
- Cardiovascular Center and Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | | | - Ratnasari Padang
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester Minnesota
| | | | - Hector I Michelena
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester Minnesota.
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39
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Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W. 2021 ESC/EACTS Guidelines for the management of valvular heart disease. EUROINTERVENTION 2022; 17:e1126-e1196. [PMID: 34931612 PMCID: PMC9725093 DOI: 10.4244/eij-e-21-00009] [Citation(s) in RCA: 146] [Impact Index Per Article: 73.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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40
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Latifi AN, Ortiz J, Cunningham JW, McGregor PC, Aragam J. Early Identification of Decompensated Aortic Regurgitation With Stress Echocardiography. CASE (PHILADELPHIA, PA.) 2021; 5:403-407. [PMID: 34993372 PMCID: PMC8712953 DOI: 10.1016/j.case.2021.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
•Chronic severe AR progresses slowly with a long asymptomatic compensated phase.•Stress echocardiography (SE) has the ability to uncover subclinical LV dysfunction.•SE can identify patients with severe AR who may benefit from earlier intervention.
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Affiliation(s)
- Ahmad N. Latifi
- Cardiovascular Division, Boston Medical Center, Boston, Massachusetts
- Department of Cardiology, Boston Veterans Affairs Healthcare System, West Roxbury, Massachusetts
| | - Jake Ortiz
- Department of Cardiology, Boston Veterans Affairs Healthcare System, West Roxbury, Massachusetts
| | - Jonathan W. Cunningham
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Pei-Chun McGregor
- Department of Cardiology, Boston Veterans Affairs Healthcare System, West Roxbury, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Jayashri Aragam
- Department of Cardiology, Boston Veterans Affairs Healthcare System, West Roxbury, Massachusetts
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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41
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Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W. 2021 ESC/EACTS Guidelines for the management of valvular heart disease. Eur J Cardiothorac Surg 2021; 60:727-800. [PMID: 34453161 DOI: 10.1093/ejcts/ezab389] [Citation(s) in RCA: 314] [Impact Index Per Article: 104.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
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42
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[ESC/EACTS guidelines 2021 on the management of valvular heart diseases : What are the most important innovations?]. Herz 2021; 47:19-30. [PMID: 34609559 DOI: 10.1007/s00059-021-05068-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/09/2021] [Indexed: 10/20/2022]
Abstract
In August 2021 the European Society for Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) updated their guidelines on the management of valvular heart disease. Since the publication of the previous version in 2017 new evidence regarding epidemiology, diagnosis and treatment of valvular heart diseases has been accumulating, which led to reassessment of several recommendations. Most importantly, the critical role of the heart team in treatment decision-making was reemphasized, the criteria for choosing the mode of aortic valve interventions were clarified, the definition of severe secondary mitral regurgitation was revised and the recommendation for transcatheter edge-to-edge mitral valve repair in patients with this condition was upgraded. Additionally, antithrombotic therapeutic regimens in patients with native valvular heart diseases and bioprostheses were reappraised, the indications for early surgery in selected asymptomatic patient groups were expanded and the potential of transcatheter tricuspid valve interventions in inoperable and high-risk patients was acknowledged, although the latter needs to be further evaluated. This review article summarizes the most important recommendations of the new guidelines.
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43
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Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W. 2021 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J 2021; 43:561-632. [PMID: 34453165 DOI: 10.1093/eurheartj/ehab395] [Citation(s) in RCA: 2252] [Impact Index Per Article: 750.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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44
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Amano M, Izumi C. Optimal Management of Chronic Severe Aortic Regurgitation - How to Determine Cutoff Values for Surgical Intervention? Circ J 2021; 86:1691-1698. [PMID: 34456205 DOI: 10.1253/circj.cj-21-0652] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Aortic regurgitation (AR) is a common valvular heart disease, but the optimal timing of surgical intervention remains controversial. In the natural history of chronic severe AR, sudden death is rare, and the annual mortality rate is comparatively low. Considering the hemodynamic features of combined volume and pressure overload and long-term compensation in patients with chronic AR, symptoms related to AR do not frequently occur. Therefore, the progression of left ventricular (LV) dysfunction is a key factor in determining the timing of surgical intervention in patients with severe chronic AR. In addition to symptoms, an ejection fraction <50% and an LV endsystolic diameter (LVESD) >45 mm are appropriate cutoff values for surgical intervention in Japanese patients, whereas LV end-diastolic diameter is not a good indicator. An LVESD index of 25 mm/m2is controversial, because adjusting for body size may cause overcorrection in Japanese patients who have a small body size compared with Westerners. Accumulation of data from the Japanese population is indispensable for establishing guidelines on optimal management of patients with chronic AR.
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Affiliation(s)
- Masashi Amano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Chisato Izumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
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45
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Abstract
Purpose of Review Preservation or repair of the aortic valve has evolved dynamically in the past 20 years. It leads to a high freedom from valve-related complications if an adequate valve durability can be achieved; it may possibly also improve survival. To date, little structured information is available about which valves can be repaired and which should better be replaced. Recent Findings For surgical decision-making, the size of the aortic root is important and the anatomy of the aortic valve must be considered. In the presence of root aneurysm, most tricuspid and bicuspid aortic valves can be preserved. In aortic regurgitation and normal aortic dimensions, the majority of tricuspid and bicuspid aortic valves can be repaired with good long-term durability. In bicuspid aortic valves, the morphologic characteristics must be taken into consideration. Unicuspid and quadricuspid aortic valves can be repaired in selected cases. Generally, cusp calcification is a sign of a poor substrate for repair; the same is true for cusp retraction and cusp destruction due to active endocarditis. They are associated with limited valve durability. Summary Using current concepts, many non-calcified aortic valves can be repaired. Modern imaging, in particular three-dimensional transesophageal echocardiography (TEE), should be able to define repairable aortic valves with a high probability.
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46
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Cormican DS, McHugh S, Sypert M, Shoubaki A, Boisen M, Ramakrishna H. Intervention for Asymptomatic Valvular Heart Disease: Analysis of Recent Data and Implications for the Perioperative Echocardiographer. J Cardiothorac Vasc Anesth 2021; 36:2196-2206. [PMID: 34247925 DOI: 10.1053/j.jvca.2021.05.054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 05/28/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Daniel S Cormican
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Allegheny Health Network, Pittsburgh, PA; Division of Critical Care Medicine, Department of Anesthesiology, Allegheny Health Network, Pittsburgh, PA
| | - Stephen McHugh
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center Shadyside, Pittsburgh, PA
| | - Michael Sypert
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Allegheny Health Network, Pittsburgh, PA
| | - Ahmad Shoubaki
- Department of Anesthesiology, Allegheny Health Network, Pittsburgh, PA
| | - Michael Boisen
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center Shadyside, Pittsburgh, PA
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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47
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Halliday BP, Senior R, Pennell DJ. Assessing left ventricular systolic function: from ejection fraction to strain analysis. Eur Heart J 2021; 42:789-797. [PMID: 32974648 DOI: 10.1093/eurheartj/ehaa587] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 05/04/2020] [Accepted: 07/02/2020] [Indexed: 12/22/2022] Open
Abstract
The measurement of left ventricular ejection fraction (LVEF) is a ubiquitous component of imaging studies used to evaluate patients with cardiac conditions and acts as an arbiter for many management decisions. This follows early trials investigating heart failure therapies which used a binary LVEF cut-off to select patients with the worst prognosis, who may gain the most benefit. Forty years on, the cardiac disease landscape has changed. Left ventricular ejection fraction is now a poor indicator of prognosis for many heart failure patients; specifically, for the half of patients with heart failure and truly preserved ejection fraction (HF-PEF). It is also recognized that LVEF may remain normal amongst patients with valvular heart disease who have significant myocardial dysfunction. This emphasizes the importance of the interaction between LVEF and left ventricular geometry. Guidelines based on LVEF may therefore miss a proportion of patients who would benefit from early intervention to prevent further myocardial decompensation and future adverse outcomes. The assessment of myocardial strain, or intrinsic deformation, holds promise to improve these issues. The measurement of global longitudinal strain (GLS) has consistently been shown to improve the risk stratification of patients with heart failure and identify patients with valvular heart disease who have myocardial decompensation despite preserved LVEF and an increased risk of adverse outcomes. To complete the integration of GLS into routine clinical practice, further studies are required to confirm that such approaches improve therapy selection and accordingly, the outcome for patients.
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Affiliation(s)
- Brian P Halliday
- National Heart Lung Institute, Imperial College, Dovehouse St, London SW3 6NP, UK.,Cardiovascular Magnetic Resonance Unit, Royal Brompton and Harefield NHS Foundation Trust, Sydney St, London SW3 6NP, UK
| | - Roxy Senior
- National Heart Lung Institute, Imperial College, Dovehouse St, London SW3 6NP, UK.,Department of Echocardiography, Royal Brompton and Harefield NHS Foundation Trust, Sydney St, London SW3 6NP, UK
| | - Dudley J Pennell
- National Heart Lung Institute, Imperial College, Dovehouse St, London SW3 6NP, UK.,Cardiovascular Magnetic Resonance Unit, Royal Brompton and Harefield NHS Foundation Trust, Sydney St, London SW3 6NP, UK
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48
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Jamart L, Ducharme A, Garceau P, Basmadjian A, Dorval JF, Bouchard D, Pellerin M, Asgar AW. Optimizing Timing of Valve Intervention in Patients With Asymptomatic Severe Valvular Heart Disease. Can J Cardiol 2021; 37:1041-1053. [PMID: 33989710 DOI: 10.1016/j.cjca.2021.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 05/03/2021] [Accepted: 05/03/2021] [Indexed: 12/12/2022] Open
Abstract
The management of valvular heart disease has changed dramatically over the past decade with advances in cardiac imaging, the use of novel biomarkers, and the development of transcatheter valve repair and replacement technology. International society guidelines have kept pace to provide recommendations for diagnosis, follow-up, and timing of intervention. The most challenging patient cohort for clinicians are patients with asymptomatic severe disease in whom the optimal timing of intervention can be ill-defined. It is a fine balance between the risks of early intervention on asymptomatic patients and improving patient outcomes by preventing long-term cardiac complications. The key in optimal patient management is gathering the necessary information on patient risk and combining that with the risk, efficacy, and durability of valve interventions to arrive at the appropriate timing for intervention. This group of patients will be the focus of this review as we delve into the natural history, recommended follow-up, and indications for intervention in patients with degenerative aortic and mitral valve disease.
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Affiliation(s)
- Laurent Jamart
- Department of Cardiology, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Anique Ducharme
- Department of Cardiology, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Patrick Garceau
- Department of Cardiology, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Arsène Basmadjian
- Department of Cardiology, Montreal Heart Institute, Montreal, Quebec, Canada
| | | | - Denis Bouchard
- Department of Cardiac Surgery, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Michel Pellerin
- Department of Cardiac Surgery, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Anita W Asgar
- Department of Cardiology, Montreal Heart Institute, Montreal, Quebec, Canada.
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49
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2020 ACC/AHA guideline for the management of patients with valvular heart disease: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Thorac Cardiovasc Surg 2021; 162:e183-e353. [PMID: 33972115 DOI: 10.1016/j.jtcvs.2021.04.002] [Citation(s) in RCA: 90] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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50
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Jenner J, Ilami A, Petrini J, Eriksson P, Franco-Cereceda A, Eriksson MJ, Caidahl K. Pre- and postoperative left atrial and ventricular volumetric and deformation analyses in severe aortic regurgitation. Cardiovasc Ultrasound 2021; 19:14. [PMID: 33583414 PMCID: PMC7883437 DOI: 10.1186/s12947-021-00243-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 01/31/2021] [Indexed: 11/10/2022] Open
Abstract
Background The impact of volume overload due to aortic regurgitation (AR) on systolic and diastolic left ventricular (LV) indices and left atrial remodeling is unclear. We assessed the structural and functional effects of severe AR on LV and left atrium before and after aortic valve replacement. Methods Patients with severe AR scheduled for aortic valve replacement (n = 65) underwent two- and three-dimensional echocardiography, including left atrial strain imaging, before and 1 year after surgery. A control group was selected, and comprised patients undergoing surgery for thoracic aortic aneurysm without aortic valve replacement (n = 20). Logistic regression analysis was used to assess predictors of impaired left ventricular functional and structural recovery, defined as a composite variable of diastolic dysfunction grade ≥ 2, EF < 50%, or left ventricular end-diastolic volume index above the gender-specific normal range. Results Diastolic dysfunction was present in 32% of patients with AR at baseline. Diastolic LV function indices and left atrial strain improved, and both left atrial and LV volumes decreased in the AR group following aortic valve replacement. Preoperative left atrial strain during the conduit phase added to left ventricular end-systolic volume index for the prediction of impaired LV functional and structural recovery after aortic valve replacement (model p < 0.001, accuracy 70%; addition of left atrial strain during the conduit phase to end-systolic volume index p = 0.006). Conclusions One-third of patients with severe AR had signs of diastolic dysfunction. Aortic valve surgery reduced LV and left atrial volumes and improved diastolic indices. Left atrial strain during the conduit phase added to the well-established left ventricular end-diastolic dimension for the prediction of impaired left ventricular functional and structural recovery at follow-up. However, long-term follow-up studies with hard endpoints are needed to assess the value of left atrial strain as predictor of myocardial recovery in aortic regurgitation.
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Affiliation(s)
- Jonas Jenner
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden. .,Department of Clinical Physiology, Södersjukhuset, Stockholm, Sweden. .,Department of Clinical Physiology, Karolinska University Hospital, 171 76, Stockholm, Sweden.
| | - Ali Ilami
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Physiology, Karolinska University Hospital, 171 76, Stockholm, Sweden
| | - Johan Petrini
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Physiology, Södersjukhuset, Stockholm, Sweden
| | - Per Eriksson
- Division of Cardiovascular Medicine, Department of Medicine Solna, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Anders Franco-Cereceda
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Unit of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Maria J Eriksson
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Physiology, Karolinska University Hospital, 171 76, Stockholm, Sweden
| | - Kenneth Caidahl
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Departments of Molecular and Clinical Medicine, Gothenburg University, and Clinical Physiology, Sahlgrenska University Hospital, Gothenburg, Sweden
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