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Demirel C, Winter MP, Nitsche C, Koschatko S, Jantsch C, Mascherbauer K, Halavina K, Heitzinger G, Dona C, Dannenberg V, Spinka G, Koschutnik M, Andreas M, Hengstenberg C, Bartko PE. Mixed aortic valve disease: association with paravalvular leak and reduced survival after transcatheter aortic valve replacement. Eur Heart J Cardiovasc Imaging 2024; 25:718-726. [PMID: 38236149 DOI: 10.1093/ehjci/jeae005] [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: 12/26/2023] [Accepted: 12/29/2023] [Indexed: 01/19/2024] Open
Abstract
AIMS Transcatheter aortic valve replacement (TAVR) revolutionized the therapy of severe aortic stenosis (AS) with rising numbers. Mixed aortic valve disease (MAVD) treated by TAVR is gaining more interest, as those patients represent a more complex cohort as compared with isolated AS. However, concerning long-term outcome for this cohort only, limited data are available. The aim of the study is to assess the prevalence of MAVD in TAVR patients, investigate its association with paravalvular regurgitation (PVR), and analyse its impact on long-term mortality after TAVR. METHODS AND RESULTS We conducted a registry-based cohort study using the Vienna TAVR registry, enrolling patients who underwent TAVR at Medical University of Vienna between January 2007 and May 2020 with available transthoracic echocardiography before and after TAVR (n = 880). Data analysis included PVR incidence and long-term survival outcomes. A total of 647 (73.52%) out of 880 patients had ≥ mild aortic regurgitation next to severe AS. MAVD was associated with PVR compared with isolated AS with an odds ratio of 2.06, 95% confidence interval (CI): 1.51-2.81 (P = <0.001). More than mild PVR after TAVR (n = 168 out of 880: 19.09%) was related to higher mortality compared with the absence of PVR with a hazard ratio (HR) of 1.33, 95% CI: 1.05- 1.67 (P = 0.016). MAVD patients developing ≥ mild PVR after TAVR were also associated with higher mortality compared with the absence of PVR with an HR of 1.30 and 95% CI: 1.04-1.62 (P = 0.022). CONCLUSION MAVD is prevalent among TAVR patients and presents unique challenges, with increased PVR risk and worse outcomes compared with isolated AS. Long-term survival for MAVD patients, not limited to those developing PVR post-TAVR, is compromised. Earlier intervention before the occurrence of structural myocardial damage or surgical valve replacement might be a potential workaround to improve outcomes.
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Affiliation(s)
- Caglayan Demirel
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20A, 1090 Vienna, Austria
| | - Max Paul Winter
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20A, 1090 Vienna, Austria
| | - Christian Nitsche
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20A, 1090 Vienna, Austria
| | - Sophia Koschatko
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20A, 1090 Vienna, Austria
| | - Charlotte Jantsch
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20A, 1090 Vienna, Austria
| | - Katharina Mascherbauer
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20A, 1090 Vienna, Austria
| | - Kseniya Halavina
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20A, 1090 Vienna, Austria
| | - Gregor Heitzinger
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20A, 1090 Vienna, Austria
| | - Carolina Dona
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20A, 1090 Vienna, Austria
| | - Varius Dannenberg
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20A, 1090 Vienna, Austria
| | - Georg Spinka
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20A, 1090 Vienna, Austria
| | - Matthias Koschutnik
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20A, 1090 Vienna, Austria
| | - Martin Andreas
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Christian Hengstenberg
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20A, 1090 Vienna, Austria
| | - Philipp E Bartko
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20A, 1090 Vienna, Austria
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Saijo Y, Kusunose K, Takahashi T, Yamada H, Sata M, Sato K, Albakaa N, Ishizu T, Seo Y. Impact of Transcatheter Aortic Valve Replacement on Cardiac Reverse Remodeling and Prognosis in Mixed Aortic Valve Disease. J Am Heart Assoc 2024; 13:e033289. [PMID: 38362873 PMCID: PMC11010113 DOI: 10.1161/jaha.123.033289] [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: 11/24/2023] [Accepted: 01/23/2024] [Indexed: 02/17/2024]
Abstract
BACKGROUND The management of mixed aortic valve disease (MAVD), defined as the concomitant presence of aortic stenosis (AS) and aortic regurgitation, remains a clinical challenging. The present study assessed the impact of transcatheter aortic valve replacement (TAVR) on cardiac geometry and prognosis in patients with MAVD. METHODS AND RESULTS A retrospective multicenter TAVR registry was conducted, including patients who underwent TAVR for severe symptomatic AS between January 2015 and March 2019. Patients were subdivided into 2 groups according to concomitant presence of moderate or more severe aortic regurgitation as the MAVD group, and with mild or less severe aortic regurgitation as the isolated AS group. The primary outcome was a composite of cardiovascular death and rehospitalization due to cardiovascular causes. A total of 1742 patients (isolated AS, 1522 patients; MAVD, 220 patients) were included (84.0±5.2 years). Although MAVD exhibited significantly larger left ventricular volumes and higher left ventricular mass index at the TAVR procedure than isolated AS (respectively, P<0.001), MAVD showed a greater improvement of left ventricular volumes and left ventricular mass index after TAVR (respectively, P≤0.001). During a median follow-up of 747 days, 301 patients achieved the primary event. The prognosis post-TAVR was comparable between the 2 groups (log-rank P=0.65). Even after adjustment using propensity score matching to reduce the potential bias between the 2 groups, similar results were obtained for the entire cohort. CONCLUSIONS Despite more advanced cardiac remodeling in MAVD at the time of TAVR compared with isolated AS, a greater improvement of cardiac reverse remodeling was found in MAVD, and the prognosis following TAVR was comparable between the 2 groups.
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Affiliation(s)
- Yoshihito Saijo
- Cardiovascular Department Tokushima University Hospital Tokushima Japan
| | - Kenya Kusunose
- Department of Cardiovascular Medicine, Nephrology and Neurology University of the Ryukyus Okinawa Japan
| | | | - Hirotsugu Yamada
- Cardiovascular Department Tokushima University Hospital Tokushima Japan
| | - Masataka Sata
- Cardiovascular Department Tokushima University Hospital Tokushima Japan
| | - Kimi Sato
- Department of Cardiology, Faculty of Medicine University of Tsukuba Japan
| | - Noor Albakaa
- Department of Cardiology, Faculty of Medicine University of Tsukuba Japan
| | - Tomoko Ishizu
- Department of Cardiology, Faculty of Medicine University of Tsukuba Japan
| | - Yoshihiro Seo
- Department of Cardiology Nagoya City University Graduate School of Medical Sciences Nagoya Japan
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Liao H, Yang S, Yu S, Hu X, Meng X, Wu K. Prognostic Value of Left Ventricular Global Longitudinal Strain for Major Adverse Cardiovascular Events in Patients with Aortic Valve Disease: A Meta-Analysis. Cardiology 2024; 149:277-285. [PMID: 38301616 DOI: 10.1159/000536331] [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: 09/14/2023] [Accepted: 01/08/2024] [Indexed: 02/03/2024]
Abstract
INTRODUCTION Valvular heart disease is one of the most common heart diseases. It is characterized by abnormal function or structure of the heart valves. There may be no clinical symptoms in the early stages. Clinical symptoms of arrhythmia, heart failure, or thromboembolic events may occur in the late stages of the disease, such as palpitation after activities, breathing difficulties, fatigue, and so on. Aortic valve disease is a major part of valvular heart disease. The main treatment for aortic valve disease is valve replacement or repair surgery, but it is extremely risky. Therefore, a rigorous prognostic assessment is extremely important for patients with aortic valve disease. The global longitudinal strain is an index that describes the deformation capacity of myocardium. There is evidence that it provides a test for systolic dysfunction other than LVEF (left ventricular ejection fraction) and provides additional prognostic information. METHOD Search literature published between 2010 and 2023 on relevant platforms and contain the following keywords: "Aortic valve disease," "Aortic stenosis," "Aortic regurgitation," and "longitudinal strain" or "strain." The data is then extracted and collated for analysis. RESULTS A total of 15 articles were included. The total population involved in this study was 3,678 individuals. The absolute value of LVGLS was higher in the no-MACE group than in the MACE group in patients with aortic stenosis (Z = 8.10, p < 0.00001), and impaired LVGLS was a risk factor for MACE in patients with aortic stenosis (HR = 1.14, p < 0.00001, 95% CI: 1.08-1.20). There was also a correlation between impaired LVGLS and aortic valve surgery in patients with aortic valve disease (HR = 1.16, p < 0.0001, 95% CI: 1.08-1.25) or patients with aortic valve regurgitation (HR = 1.21, p = 0.0004, 95% CI: 1.09-1.34). We also found that impaired LVGLS had no significant association between LVGLS and mortality during the period of follow-up in patients with aortic valve stenosis (HR = 1.08, 95% CI: 0.94-1.25, p = 0.28), but it was associated with mortality in studies of prospective analyses (HR = 1.34, 95% CI: 1.02-1.75, p = 0.04). CONCLUSIONS Impaired LVGLS correlates with major adverse cardiovascular events in patients with aortic valve disease, and it has predictive value for the prognosis of patients with aortic valve disease.
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Affiliation(s)
- Hongsheng Liao
- Graduate School, Guizhou Medical University, Guiyang, China,
| | - Siyuan Yang
- Department of Cardiovascular Surgery, Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Shaomei Yu
- Ultrasound Center, Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Xuanyi Hu
- Department of Cardiovascular Surgery, Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - XiongWei Meng
- Department of Cardiovascular Surgery, Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Kui Wu
- Department of Cardiovascular Surgery, Affiliated Hospital of Guizhou Medical University, Guiyang, China
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Liu Q, Hu Y, Chen W, Yao T, Li W, Xiao Z, Liu J, Xiao Y. Evaluation of right ventricular longitudinal strain in pediatric patients with pulmonary hypertension by two-dimensional speckle-tracking echocardiography. Front Pediatr 2023; 11:1189373. [PMID: 37780047 PMCID: PMC10540637 DOI: 10.3389/fped.2023.1189373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 08/30/2023] [Indexed: 10/03/2023] Open
Abstract
Objectives We aimed to investigate the association between right ventricular longitudinal strain measured by two-dimensional speckle-tracking echocardiography (2D-STE) and right heart catheterization data in pediatric patients with pulmonary hypertension (PH). Methods Two groups were evaluated, each consisting of 58 patients. Group 1, patients with PH; Group 2, normal matched controls. Data were collected from 58 patients with PH who underwent invasive hemodynamic evaluation. Standard transthoracic echocardiographic assessment was performed in all patients under the same circumstances. All patients underwent 2D-STE, and off-line analysis generated right ventricle longitudinal strain (RVLS) and right ventricular free wall strain (RVFW) and collected echocardiographic conventional parameters of right ventricular function, including the control group. The relationship between invasive characteristics and right ventricular function parameters was analyzed. Results In all, 58 PH patients were included in our study. The mean pulmonary artery pressure (mPAP) and pulmonary vascular resistance (PVR) were strongly correlated with right ventricular free wall strain (RVFW) and right ventricular longitudinal strain (RVLS), moderately correlated with the right ventricle myocardial performance index (Tei index), weakly correlated with the transverse diameter of the right ventricle (RV) and the transverse diameter of the right atrium (RA), and moderately negatively correlated with right ventricular fractional area change (RVFAC). In terms of segments of the right ventricular free wall, the basal segment had the highest correlation coefficient with mPAP and PVR (r = 0.413, 0.523, 0.578, r = 0.421, 0.533, 0.575, p < 0.05, respectively). Tricuspid annular plane systolic excursion (TAPSE), main pulmonary artery diameter (MPA), peak systolic velocity of the right ventricle (RV-S'), and RA area parameters were not associated with mPAP and PVR (p > 0.05). Conclusions Right ventricular longitudinal strain is a reliable indicator to evaluate right ventricular function in pediatric patients with PH. It can provide valuable reference information for the clinical judgment of the status and severity of the disease in children.
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Affiliation(s)
- Qianjun Liu
- Department of Ultrasound, Hunan Children’s Hospital, Changsha, China
| | - Yuan Hu
- Department of Ultrasound, Hunan Children’s Hospital, Changsha, China
| | - Wenjuan Chen
- Department of Ultrasound, Hunan Children’s Hospital, Changsha, China
| | - Taoyue Yao
- Department of Ultrasound, Hunan Children’s Hospital, Changsha, China
| | - Wenfeng Li
- Department of Ultrasound, Hunan Children’s Hospital, Changsha, China
| | - Zhenghui Xiao
- Intensive Care Unit, Hunan Children’s Hospital, Changsha, China
| | - Jinqiao Liu
- Department of Ultrasound, Hunan Children’s Hospital, Changsha, China
| | - Yunbin Xiao
- Department of Cardiology, Hunan Children’s Hospital, Changsha, China
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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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Onishi H, Izumo M, Ouchi T, Yuki H, Naganuma T, Nakao T, Nakamura S. Clinical impact of aortic valve replacement in patients with moderate mixed aortic valve disease. Front Cardiovasc Med 2023; 10:1259188. [PMID: 37692041 PMCID: PMC10484795 DOI: 10.3389/fcvm.2023.1259188] [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: 07/15/2023] [Accepted: 08/07/2023] [Indexed: 09/12/2023] Open
Abstract
Background Information is scarce regarding the clinical implications of aortic valve replacement (AVR) for patients suffering from moderate mixed aortic valve disease (MAVD), characterized by a combination of moderate aortic stenosis (AS) and regurgitation (AR). The objective of this retrospective study was to explore the clinical effects of AVR in individuals with moderate MAVD. Methods We examined the clinical data from patients with moderate MAVD and preserved left ventricular ejection fraction, who had undergone echocardiography in the period spanning from 2010 to 2018. Moderate AS was defined as aortic valve area index of 0.60-0.85 cm2/m2 and peak velocity of 3.0-4.0 m/s. Moderate AR was defined as a vena contracta width of 3.0-6.0 mm. The primary endpoint was a composite of all-cause death and heart failure hospitalization. Results Among 88 patients (mean age, 74.4 ± 6.8 years; 48.9%, men), 44 (50.0%) required AVR during a median follow-up period of 3.3 years (interquartile range, 0.5-4.9). Mean values of specific aortic valve variables are as follows: aortic valve area index, 0.64 ± 0.04 cm2/m2; peak velocity, 3.40 ± 0.30 m/s; and vena contracta width, 4.1 ± 0.7 mm. The primary endpoint occurred in 32 (36.4%) patients during a median follow-up duration of 5.3 years (interquartile range, 3.2-8.0). Multivariable analysis revealed that AVR was significantly associated with the endpoint (hazard ratio, 0.248; 95% confidence interval, 0.107-0.579; p = 0.001) after adjusting for age, B-type natriuretic peptide, and the Charlson comorbidity index. Patients who underwent AVR during follow-up had significantly lower incidence rates of the endpoint than those managed with medical treatment (10.2% vs. 44.1% at 5 years; p < 0.001). Conclusions Approximately half of the patients diagnosed with moderate MAVD eventually necessitated AVR throughout the period of observation, leading to positive clinical results. Vigilant tracking of these patients and watchful monitoring for signs requiring AVR during this time frame are essential.
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Affiliation(s)
- Hirokazu Onishi
- Department of Cardiology, New Tokyo Hospital, Chiba, Japan
- Department of Cardiology, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Masaki Izumo
- Department of Cardiology, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Toru Ouchi
- Department of Cardiology, New Tokyo Hospital, Chiba, Japan
| | - Haruhito Yuki
- Department of Cardiology, New Tokyo Hospital, Chiba, Japan
| | - Toru Naganuma
- Department of Cardiology, New Tokyo Hospital, Chiba, Japan
| | - Tatsuya Nakao
- Department of Cardiovascular Surgery, New Tokyo Hospital, Chiba, Japan
| | - Sunao Nakamura
- Department of Cardiology, New Tokyo Hospital, Chiba, Japan
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Saijo Y, Wang TKM, Isaza N, Conic JZ, Johnston D, Roselli EE, Desai MY, Grimm RA, Svensson LG, Kapadia SR, Griffin BP, Popović ZB. Prognostic impact of left ventricular systolic dysfunction in patients with mixed aortic valve disease undergoing aortic valve replacement. Echocardiography 2023; 40:318-326. [PMID: 36859633 DOI: 10.1111/echo.15544] [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: 05/09/2022] [Revised: 01/19/2023] [Accepted: 02/06/2023] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND The implications of left ventricular remodeling and dysfunction before and after aortic valve replacement (AVR) for mixed aortic valve disease (MAVD) are not well understood. This study aims to evaluate the impact of AVR on left ventricular (LV) systolic function in MAVD, and determine the prognostic value of postoperative LV global longitudinal strain (LV-GLS) and LV ejection fraction (LVEF). METHODS We retrospectively assessed 489 consecutive patients with MAVD (defined as at least moderate aortic stenosis and at least moderate aortic regurgitation) and baseline LVEF ≥50%, who underwent AVR between February 2003 and August 2018. All patients had baseline echocardiography, whereas 192 patients underwent postoperative echocardiography between 3 and 18 months after AVR. The primary endpoint was all-cause mortality. RESULTS Mean age was 65 ± 15 years, and 65% were male. AVR in MAVD patients has a neutral effect on LV systolic function quantitated by LVEF and LV-GLS. During a median follow-up period of 5.8 years, 65 patients (34%) of 192 patients with follow-up echocardiography died. The patients with postoperative LVEF ≥50% had better survival than those with postoperative LVEF <50% (P < .001). Furthermore, among patients with postoperative LVEF ≥50%, mortality differed between patients with postoperative LV-GLS worse than -15% and those with postoperative LV-GLS better than -15% (P < .001). CONCLUSIONS In patients with MAVD who underwent AVR, the mean postoperative LV-GLS and LVEF remain at a similar value to baseline. However, worse postoperative LV-GLS and LVEF were both independently associated with higher mortality in this population.
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Affiliation(s)
- Yoshihito Saijo
- Department of Cardiovascular Medicine, Heart, Thoracic and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Tom Kai Ming Wang
- Department of Cardiovascular Medicine, Heart, Thoracic and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Nicolas Isaza
- Department of Cardiovascular Medicine, Heart, Thoracic and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Julijana Z Conic
- Department of Cardiovascular Medicine, Heart, Thoracic and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Douglas Johnston
- Department of Thoracic and Cardiovascular Surgery, Heart, Thoracic and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Heart, Thoracic and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Milind Y Desai
- Department of Cardiovascular Medicine, Heart, Thoracic and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Richard A Grimm
- Department of Cardiovascular Medicine, Heart, Thoracic and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Lars G Svensson
- Department of Thoracic and Cardiovascular Surgery, Heart, Thoracic and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Samir R Kapadia
- Department of Cardiovascular Medicine, Heart, Thoracic and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Brian P Griffin
- Department of Cardiovascular Medicine, Heart, Thoracic and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Zoran B Popović
- Department of Cardiovascular Medicine, Heart, Thoracic and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Nedadur R, Belzile D, Farrell A, Tsang W. Mixed aortic stenosis and regurgitation: a clinical conundrum. Heart 2023; 109:264-275. [PMID: 35609962 DOI: 10.1136/heartjnl-2021-320501] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 03/10/2022] [Indexed: 02/01/2023] Open
Abstract
Mixed aortic stenosis (AS) and aortic regurgitation (AR) is the most frequent concomitant valve disease worldwide and represents a heterogeneous population ranging from mild AS with severe AR to mild AR with severe AS. About 6.8% of patients with at least moderate AS will also have moderate or greater AR, and 17.9% of patients with at least moderate AR will suffer from moderate or greater AS. Interest in mixed AS/AR has increased, with studies demonstrating that patients with moderate mixed AS/AR have similar outcomes to those with isolated severe AS. The diagnosis and quantification of mixed AS/AR severity are predominantly echocardiography-based, but the combined lesions lead to significant limitations in the assessment. Aortic valve peak velocity is the best parameter to evaluate the combined haemodynamic impact of both lesions, with a peak velocity greater than 4.0 m/s suggesting severe mixed AS/AR. Moreover, symptoms, increased left ventricular wall thickness and filling pressures, and abnormal left ventricular global longitudinal strain likely identify high-risk patients who may benefit from closer follow-up. Although guidelines recommend interventions based on the predominant lesion, some patients could potentially benefit from earlier intervention. Once a patient is deemed to require intervention, for patients receiving transcatheter valves, the presence of mixed AS/AR could confer benefit to those at high risk of paravalvular leak. Overall, the current approach of managing patients based on the dominant lesion might be too reductionist and a more holistic approach including biomarkers and multimodality imaging cardiac remodelling and inflammation data might be more appropriate.
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Affiliation(s)
- Rashmi Nedadur
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - David Belzile
- Division of Cardiology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Ashley Farrell
- Library and Information Services, University Health Network, Toronto, Ontario, Canada
| | - Wendy Tsang
- Division of Cardiology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
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Stassen J, Ewe SH, Pio SM, Pibarot P, Redfors B, Leipsic J, Genereux P, Van Mieghem NM, Kuneman JH, Makkar R, Hahn RT, Playford D, Marsan NA, Delgado V, Ben-Yehuda O, Leon MB, Bax JJ. Managing Patients With Moderate Aortic Stenosis. JACC Cardiovasc Imaging 2023:S1936-878X(22)00741-0. [PMID: 36881428 DOI: 10.1016/j.jcmg.2022.12.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 11/02/2022] [Accepted: 12/02/2022] [Indexed: 02/10/2023]
Abstract
Current guidelines recommend that clinical surveillance for patients with moderate aortic stenosis (AS) and aortic valve replacement (AVR) may be considered if there is an indication for coronary revascularization. Recent observational studies, however, have shown that moderate AS is associated with an increased risk of cardiovascular events and mortality. Whether the increased risk of adverse events is caused by associated comorbidities, or to the underlying moderate AS itself, is incompletely understood. Similarly, which patients with moderate AS need close follow-up or could potentially benefit from early AVR is also unknown. In this review, the authors provide a comprehensive overview of the current literature on moderate AS. They first provide an algorithm that helps to diagnose moderate AS correctly, especially when discordant grading is observed. Although the traditional focus of AS assessment has been on the valve, it is increasingly acknowledged that AS is not only a disease of the aortic valve but also of the ventricle. The authors therefore discuss how multimodality imaging can help to evaluate the left ventricular remodeling response and improve risk stratification in patients with moderate AS. Finally, they summarize current evidence on the management of moderate AS and highlight ongoing trials on AVR in moderate AS.
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Affiliation(s)
- Jan Stassen
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands; Department of Cardiology, Jessa Hospital, Hasselt, Belgium
| | - See Hooi Ewe
- Department of Cardiology, National Heart Centre Singapore, Singapore
| | - Stephan M Pio
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Philippe Pibarot
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Université Laval, Québec City, Québec, Canada
| | - Bjorn Redfors
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jonathon Leipsic
- Departments of Medicine and Radiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Philippe Genereux
- Department of Cardiology, Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, New Jersey, USA
| | - Nicolas M Van Mieghem
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Jurrien H Kuneman
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Raj Makkar
- Department of Cardiology, Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | - Rebecca T Hahn
- Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York, USA
| | - David Playford
- Department of Cardiology, University of Notre Dame, Fremantle, Western Australia, Australia
| | - Nina Ajmone Marsan
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Victoria Delgado
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Ori Ben-Yehuda
- Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York, USA
| | - Martin B Leon
- Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York, USA
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands; Turku Heart Center, University of Turku and Turku University Hospital, Turku, Finland.
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10
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Harris AW, Bach DS. Mixed Aortic Valve Disease and Strain: Unraveling the Myocardial Response. JACC Cardiovasc Imaging 2021; 14:1335-1337. [PMID: 33865765 DOI: 10.1016/j.jcmg.2021.02.007] [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] [Received: 02/08/2021] [Accepted: 02/09/2021] [Indexed: 11/17/2022]
Affiliation(s)
- Andrew W Harris
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - David S Bach
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA.
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