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Bain ER, George B, Jafri SH, Rao RA, Sinha AK, Guglin ME. Outcomes in patients with aortic stenosis and severely reduced ejection fraction following surgical aortic valve replacement and transcatheter aortic valve replacement. J Cardiothorac Surg 2024; 19:258. [PMID: 38643131 PMCID: PMC11031863 DOI: 10.1186/s13019-024-02724-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 03/29/2024] [Indexed: 04/22/2024] Open
Abstract
BACKGROUND Patients with severe aortic stenosis (AS) and left ventricular (LV) dysfunction demonstrate improvement in left ventricular injection fraction (LVEF) after aortic valve replacement (AVR). The timing and magnitude of recovery in patients with very low LVEF (≤ 25%) in surgical or transcatheter AVR is not well studied. OBJECTIVE Determine clinical outcomes following transcatheter aortic valve replacement (TAVR) and surgical aortic valve repair (SAVR) in the subset of patients with severely reduced EF ≤ 25%. METHODS Single-center, retrospective study with primary endpoint of LVEF 1-week following either procedure. Secondary outcomes included 30-day mortality and delayed postprocedural LVEF. T-test was used to compare variables and linear regression was used to adjust differences among baseline variables. RESULTS 83 patients were enrolled (TAVR = 56 and SAVR = 27). TAVR patients were older at the time of procedure (TAVR 77.29 ± 8.69 vs. SAVR 65.41 ± 10.05, p < 0.001). One week post procedure, all patients had improved LVEF after both procedures (p < 0.001). There was no significant difference in LVEF between either group (TAVR 33.5 ± 11.77 vs. SAVR 35.3 ± 13.57, p = 0.60). Average LVEF continued to rise and increased by 101% at final follow-up (41.26 ± 13.70). 30-day mortality rates in SAVR and TAVR were similar (7.4% vs. 7.1%, p = 0.91). CONCLUSION Patients with severe AS and LVEF ≤ 25% have a significant recovery in post-procedural EF following AVR regardless of method. LVEF doubled at two years post-procedure. There was no significant difference in 30-day mortality or mean EF recovery between TAVR and SAVR. TRIAL REGISTRATION Indiana University institutional review board granted approval for above study numbered 15,322.
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Affiliation(s)
- Eric R Bain
- Department of Internal Medicine, Indiana University School of Medicine, 635 Barnhill Drive Van Nuys Medical Science Building 116, Indianapolis, IN, 46202, USA.
| | - Bistees George
- Department of Internal Medicine, Indiana University School of Medicine, 635 Barnhill Drive Van Nuys Medical Science Building 116, Indianapolis, IN, 46202, USA
| | - Syed H Jafri
- Indiana University School of Medicine, Krannert Institute of Cardiology, Indianapolis, USA
| | - Roopa A Rao
- Indiana University School of Medicine, Krannert Institute of Cardiology, Indianapolis, USA
| | - Anjan K Sinha
- Indiana University School of Medicine, Krannert Institute of Cardiology, Indianapolis, USA
| | - Maya E Guglin
- Indiana University School of Medicine, Krannert Institute of Cardiology, Indianapolis, USA
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Javadikasgari H, McGurk S, Newell PC, Awtry JA, Sabe AA, Kaneko T. Evolving Concept of Aortic Valve Replacement in Asymptomatic Patients With Severe Aortic Stenosis. Ann Thorac Surg 2024; 117:796-803. [PMID: 37660965 DOI: 10.1016/j.athoracsur.2023.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 08/06/2023] [Accepted: 08/14/2023] [Indexed: 09/05/2023]
Abstract
BACKGROUND Surgical treatment of asymptomatic severe aortic stenosis (AS) has been gaining attention ever since the results of the Early Surgery Versus Conventional Treatment in Very Severe Aortic Stenosis (RECOVERY) and Aortic Valve replacement versus conservative treatment in Asymptomatic seveRe aortic stenosis (AVATAR) trials showed survival benefits with early surgical aortic valve replacement (SAVR). This study analyzed the long-term clinical and echocardiographic outcomes of SAVR in asymptomatic severe AS. METHODS Between 2002 and 2020, 272 patients with asymptomatic severe AS and a left ventricular ejection fraction ≥50% underwent SAVR with or without concomitant aortic surgery and met the study criteria. The median follow-up was 8.5 years (interquartile range, 6-12.8 years), for a total of 2584 patient-years. The time course of the left ventricular mass index (LVMI) and the average E/E' (ratio of the Doppler-derived E wave to the tissue Doppler-derived E' wave) were assessed using 594 postoperative echocardiograms. The association of preoperative LVMI and average E/E' with survival was assessed using Cox proportional hazards. RESULTS There was no operative mortality. On longitudinal analyses, LVMI improved in patients who presented with moderate or severe preoperative left ventricular hypertrophy (LVH). However, after the early decline in average E/E', there was a late increase to greater than upper limit normal, particularly in patients with a preoperative average E/E'≥14. Postoperative survival was 100%, 94%, 84%, and 76% at 1, 5, 10, and 15 years, respectively, comparable to age- and sex-matched expected survival on the basis of the US general population. On adjusted Cox survival analysis, only moderate to severe LVH was associated with a survival penalty (hazard ratio], 2.32; 95% CI, 1.02-5.27; P = .045). CONCLUSIONS In asymptomatic patients with AS, SAVR restores survival and improves LVH, but patients with diastolic dysfunction are left with persistent dysfunction. Presentation with moderate or severe LVH at the time of surgery translated to a survival penalty. This observational study supports early SAVR in this population before development of LVH, although further investigation is needed.
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Affiliation(s)
- Hoda Javadikasgari
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Siobhan McGurk
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Paige C Newell
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jake A Awtry
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ashraf A Sabe
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Tsuyoshi Kaneko
- Mary Culver Department of Surgery, Washington University School of Medicine, St Louis, Missouri
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Geuens L, Van Hoof L, Van De Bruaene A, Rega F, Meuris B, Verbrugghe P. Aortic valve replacement in non-elderly: the gap between reality, guidelines and evidence. Eur J Cardiothorac Surg 2023; 64:ezad318. [PMID: 37756688 DOI: 10.1093/ejcts/ezad318] [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: 01/31/2023] [Revised: 08/22/2023] [Accepted: 09/24/2023] [Indexed: 09/29/2023] Open
Abstract
OBJECTIVES There are several treatment options for non-elderly adults (18-60 years) in need of aortic valve replacement (AVR): a mechanical or biological substitute, a homograft, the Ross procedure or nowadays even transcatheter aortic valve replacement. This study evaluated the current opinions and practices of cardiac surgeons and cardiologists concerning AVR strategies in this patient group. METHODS A 43-item online survey was sent out to several scientific organizations, individual cardiac surgeons, cardiologists and residents/fellows worldwide. RESULTS Two hundred twenty-two physicians from 33 different countries answered the survey. The UK (24%), Belgium (23%) and North America (22%) are best represented. A mechanical valve is the most frequently used substitute in non-elderly. With increasing patient age, the popularity of a biological valve increases. Transcatheter aortic valve replacement and the Ross procedure are each used in <10% of this cohort. Only 12% of the cardiac surgeons has experience with the Ross surgery. In 23%, the patient seems not to be involved in the decision on the type of valve substitute. CONCLUSIONS The preferred surgical treatment for non-elderly patients in need of AVR differs widely. To enable a shared decision-making process including patient preferences, there is more need for collaboration between cardiac departments, as well as education and scientific research about patient-centred outcomes of the different AVR techniques.
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Affiliation(s)
- Lise Geuens
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Lucas Van Hoof
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | | | - Filip Rega
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Bart Meuris
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Peter Verbrugghe
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
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Ehrlich T, Abeln KB, Froede L, Burgard C, Giebels C, Schäfers HJ. Valve-sparing aortic root replacement-for all patients? J Thorac Cardiovasc Surg 2023:S0022-5223(23)00781-X. [PMID: 37696427 DOI: 10.1016/j.jtcvs.2023.08.055] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 08/22/2023] [Accepted: 08/26/2023] [Indexed: 09/13/2023]
Abstract
BACKGROUND Valve-sparing root replacement (VSRR) has been associated with good survival and low rates of valve-related complications (VRCs). Whether these advantages are present irrespective of patient comorbidity or age is unclear. The aim of this study was to analyze survival and frequency of VRCs in relation to patient comorbidity and age. METHODS Between October 1995 and December 2021, 1156 patients with a bicuspid or tricuspid aortic valve were treated by root remodeling. The mean patient age was 53.3 ± 14 years, and 973 (84%) were male. The mean duration of follow-up was 6.7 ± 5.5 years (median, 5.9 years), and follow-up was 95% complete (7746 patient-years). We analyzed the population according to comorbidity and age at surgery. A discriminating cutoff for the effect of age was determined using receiver operating characteristic curve (ROC) analysis. RESULTS Mean survival at 15 years was 74.7 ± 2.5%. Deceased patients were older (mean, 65.3 ± 12 years vs 51.6 ± 14.1 years; P < .001) at the time of surgery and had more comorbidities (coronary artery disease [CAD], 28.4% vs 9.8%; P < .001). The sole significant adjusted predictor was age (P < .001). By ROC analysis (area under the curve, 0.780), the optimal cutoff for age was 61 years. Survival was 87.1 ± 2.8% at 15 years in patients age <61 years, compared to 55.3 ± 4.3% in patients age >61 years (P < .0001). Using competing risk analysis, VRC-free survival at 15 years was 66.8% at 15 years, including 76.7% in patients age <61 years and 52.4% in those age >61 years (P < .0001). CONCLUSIONS VSRR is associated with a low incidence of VRC and excellent durability. Survival is decreased in the presence of comorbidities, mainly CAD, and patient age >61 years. Despite lower survival, freedom from VRC is good.
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Affiliation(s)
- Tristan Ehrlich
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany
| | - Karen B Abeln
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany
| | - Lennart Froede
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany
| | - Christian Burgard
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany
| | - Christian Giebels
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany
| | - Hans-Joachim Schäfers
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany.
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Yang HR, Xiong TY, Zhang Y, He JJ, Feng Y, Chen M. Concomitant aortic regurgitation predicts better left ventricular reverse remodeling after transcatheter aortic valve replacement. BMC Cardiovasc Disord 2023; 23:354. [PMID: 37460957 PMCID: PMC10353111 DOI: 10.1186/s12872-023-03377-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 07/02/2023] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND We aim to determine predictors of inadequate left ventricular mass index (LVMi) regression at mid-term after transcatheter aortic valve replacement (TAVR), including the potential role of epicardial adipose tissue (EAT). METHODS We retrospectively reviewed patients with both echocardiographic assessments and multi-slice computed tomography (MSCT) obtained one year after TAVR. The change of LVMi, the volume and the average CT attenuation of EAT from baseline to one-year follow-up was calculated. Patients were divided into two groups by the percentage change of LVMi at a cut-off of 15%. RESULTS A total of 152 patients were included with a median age of 74 years (interquartile range [IQR] 69-78 years) and 56.6% being male. LVMi decreased (P < 0.0001) while EAT volume increased and the average CT attenuation decreased (both P < 0.0001) at one year. Baseline atrial fibrillation (P = 0.042), mitral regurgitation ≥ mild (P = 0.006), aortic regurgitation (AR) > mild (P = 0.001) and the change in the average CT attenuation of EAT (P = 0.026) were different between the decrease of LVMi ≥ 15% and < 15%. AR > mild at baseline was the only statistically significant predictor of a decrease of LVMi < 15% at one year (OR 0.33, 95% CI: 0.13 to 0.84, P = 0.021) in multivariate regression. CONCLUSIONS Concomitant more-than-mild AR might predict better left ventricular reverse remodeling regression after TAVR.
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Affiliation(s)
- Hao-Ran Yang
- Department of Cardiology and Laboratory of Heart Valve Disease, West China Hospital, Sichuan University, #37 Guoxue Alley, Chengdu, 610041, PR China
| | - Tian-Yuan Xiong
- Department of Cardiology and Laboratory of Heart Valve Disease, West China Hospital, Sichuan University, #37 Guoxue Alley, Chengdu, 610041, PR China
| | - Yi Zhang
- Department of Cardiology and Laboratory of Heart Valve Disease, West China Hospital, Sichuan University, #37 Guoxue Alley, Chengdu, 610041, PR China
| | - Jing-Jing He
- Department of Cardiology and Laboratory of Heart Valve Disease, West China Hospital, Sichuan University, #37 Guoxue Alley, Chengdu, 610041, PR China
| | - Yuan Feng
- Department of Cardiology and Laboratory of Heart Valve Disease, West China Hospital, Sichuan University, #37 Guoxue Alley, Chengdu, 610041, PR China
| | - Mao Chen
- Department of Cardiology and Laboratory of Heart Valve Disease, West China Hospital, Sichuan University, #37 Guoxue Alley, Chengdu, 610041, PR China.
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Rezaeian N, Hosseini L, Samiei N, Azimian M, Rashidinejad A, Toloueitabar Y, Mehdi Hemmati Komasi M, Shayan L, Asadian S. Aortic Valve Area and Strain Measurements by Cardiac MRI and Transthoracic Echocardiography in Severe Aortic Stenosis with Normal Left Ventricular Function. IRANIAN JOURNAL OF MEDICAL SCIENCES 2023; 48:370-378. [PMID: 37456208 PMCID: PMC10349161 DOI: 10.30476/ijms.2022.94552.2590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 06/17/2022] [Accepted: 07/10/2022] [Indexed: 07/18/2023]
Abstract
Background Transthoracic echocardiography (TTE) is the recommended imaging technique for the evaluation of patients with aortic stenosis (AS). However, in cases with inconclusive findings, cardiac magnetic resonance (CMR) planimetry is used to grade AS severity. This study aimed to compare the results derived from TTE and CMR in patients with severe AS with normal left ventricular (LV) function. Methods In a prospective study, 20 patients with severe AS were recruited and data derived from TTE and CMR modalities were compared with the archived records of 28 age- and sex-matched healthy controls. The data included aortic valve area (AVA), MRI-derived biventricular global strains, and TTE-derived global longitudinal strain (GLS). SPSS software was used to analyze the data with independent samples t test, intraclass correlation coefficient (ICC), and Pearson correlation. P<0.05 was considered statistically significant. Results An excellent agreement was found in AVA values derived from CMR and TTE with an average ICC of 0.932 (95% CI=0.829-0.973). There was a significant difference in LV-GLS, LV global radial strain (GRS), right ventricular (RV) GRS, and RV global circumferential strain between the groups. A good correlation was found between CMR- and TTE-derived GLS with an average ICC of 0.721 (95% C=0.255-0.896). The mean aortic valve pressure gradient in TTE had a significant inverse linear correlation with LV-GRS in CMR (r=-0.537). All P values were <0.05. Conclusion There was a good agreement between AVA and strain values derived from cardiac MRI and TTE. The myocardial strain was impaired in patients with severe AS and normal LV function and correlated with disease severity.
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Affiliation(s)
- Nahid Rezaeian
- Department of Radiology, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Leila Hosseini
- Department of Echocardiography, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Niloufar Samiei
- Heart Valves Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Maryam Azimian
- Department of Radiology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Alireza Rashidinejad
- Department of Interventional Cardiology, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Yaser Toloueitabar
- Department of Cardiac Surgery, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | | | - Leila Shayan
- Trauma Research Center, Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Sanaz Asadian
- Department of Radiology, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
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Anastasiou V, Daios S, Bazmpani MA, Moysidis DV, Zegkos T, Karamitsos T, Ziakas A, Kamperidis V. Shifting from Left Ventricular Ejection Fraction to Strain Imaging in Aortic Stenosis. Diagnostics (Basel) 2023; 13:diagnostics13101756. [PMID: 37238238 DOI: 10.3390/diagnostics13101756] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 05/07/2023] [Accepted: 05/12/2023] [Indexed: 05/28/2023] Open
Abstract
Adverse ventricular remodeling is an inflexion point of disease progression in aortic stenosis (AS) and a major determinant of prognosis. Intervention before irreversible myocardial damage is of paramount importance to sustain favorable post-operative outcomes. Current guidelines recommend a left ventricular ejection fraction (LVEF)-based strategy to determine the threshold for intervention in AS. However, LVEF has several pitfalls: it denotes the left ventricular cavity volumetric changes and it is not suited to detecting subtle signs of myocardial damage. Strain has emerged as a contemporary imaging biomarker that describes intramyocardial contractile force, providing information on subclinical myocardial dysfunction due to fibrosis. A large body of evidence advocates its use to determine the switch from adaptive to maladaptive myocardial changes in AS, and to refine thresholds for intervention. Although mainly studied in echocardiography, studies exploring the role of strain in multi-detector row computed tomography and cardiac magnetic resonance are emerging. This review, therefore, summarizes contemporary evidence on the role of LVEF and strain imaging in AS prognosis, aiming to move from an LVEF-based to a strain-based approach for risk stratification and therapeutic decision-making in AS.
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Affiliation(s)
- Vasileios Anastasiou
- First Department of Cardiology, AHEPA Hospital, Medical School, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece
| | - Stylianos Daios
- First Department of Cardiology, AHEPA Hospital, Medical School, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece
| | - Maria-Anna Bazmpani
- First Department of Cardiology, AHEPA Hospital, Medical School, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece
| | - Dimitrios V Moysidis
- First Department of Cardiology, AHEPA Hospital, Medical School, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece
| | - Thomas Zegkos
- First Department of Cardiology, AHEPA Hospital, Medical School, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece
| | - Theodoros Karamitsos
- First Department of Cardiology, AHEPA Hospital, Medical School, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece
| | - Antonios Ziakas
- First Department of Cardiology, AHEPA Hospital, Medical School, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece
| | - Vasileios Kamperidis
- First Department of Cardiology, AHEPA Hospital, Medical School, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece
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Brega C, Albertini A. Aortic Root Surgery in Adults: An Unsolved Problem. AORTA (STAMFORD, CONN.) 2023; 11:29-35. [PMID: 36848909 PMCID: PMC9970757 DOI: 10.1055/s-0042-1757949] [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] [Indexed: 03/01/2023]
Abstract
Nowadays, despite the rapid advancements in interventional cardiology, open surgery still deals with aortic root diseases, to assure the best "ad hoc" treatment. In case of middle-aged adult patients, the optimal operation still represents a matter of debate. A review of the last 10-year literature was conducted, focusing on patients below 65 to 70 years of age. Because of the small sample and the heterogeneity of the papers, no metanalysis was possible. Bentall-de Bono procedure, valve sparing, and Ross operations are the surgical options currently available. The main issues in the Bentall - de Bono operation are lifelong anticoagulation therapy and cavitation in case of mechanical prosthesis implantation and structural valve degeneration in case of biological Bentall. As transcatheter procedures are currently performed as valve in valve, biological prosthesis may be preferable, if the diameter may prevent postoperative high gradients. Conservative techniques, such as remodeling and reimplantation, preferred in the young, guarantee physiologic aortic root dynamics and impose surgical analysis of the aortic root structures to get a durable result. The Ross operation, which shows excellent performance, involves autologous pulmonary valve implantation and is performed only in experienced and high-volume centers. Due to its technical difficulty, it requires a steep learning curve and presents some limitations in specific aortic valve diseases. All three have advantages and downsides, and no ideal solution has still been reported.
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Affiliation(s)
- Carlotta Brega
- Department of Cardiovascular Surgery, GVM Care and Research, Cotignola, RA, Italy,Address for correspondence Carlotta Brega, MD Maria Cecilia Hospital, GVM Care and ResearchVia Corriera 1, 48033 Cotignola, RAItaly
| | - Alberto Albertini
- Department of Cardiovascular Surgery, GVM Care and Research, Cotignola, RA, Italy
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Asheghan MM, Javadikasgari H, Attary T, Rouhollahi A, Straughan R, Willi JN, Awal R, Sabe A, de la Cruz KI, Nezami FR. Predicting one-year left ventricular mass index regression following transcatheter aortic valve replacement in patients with severe aortic stenosis: A new era is coming. Front Cardiovasc Med 2023; 10:1130152. [PMID: 37082454 PMCID: PMC10111021 DOI: 10.3389/fcvm.2023.1130152] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 03/16/2023] [Indexed: 04/22/2023] Open
Abstract
Aortic stenosis (AS) is the most common valvular heart disease in the western world, particularly worrisome with an ever-aging population wherein postoperative outcome for aortic valve replacement is strongly related to the timing of surgery in the natural course of disease. Yet, guidelines for therapy planning overlook insightful, quantified measures from medical imaging to educate clinical decisions. Herein, we leverage statistical shape analysis (SSA) techniques combined with customized machine learning methods to extract latent information from segmented left ventricle (LV) shapes. This enabled us to predict left ventricular mass index (LVMI) regression a year after transcatheter aortic valve replacement (TAVR). LVMI regression is an expected phenomena in patients undergone aortic valve replacement reported to be tightly correlated with survival one and five year after the intervention. In brief, LV geometries were extracted from medical images of a cohort of AS patients using deep learning tools, and then analyzed to create a set of statistical shape models (SSMs). Then, the supervised shape features were extracted to feed a support vector regression (SVR) model to predict the LVMI regression. The average accuracy of the predictions was validated against clinical measurements calculating root mean square error and R 2 score which yielded the satisfactory values of 0.28 and 0.67, respectively, on test data. Our work reveals the promising capability of advanced mathematical and bioinformatics approaches such as SSA and machine learning to improve medical output prediction and treatment planning.
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Affiliation(s)
- Mohammad Mostafa Asheghan
- Division of Thoracic and Cardiac Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Hoda Javadikasgari
- Division of Thoracic and Cardiac Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Taraneh Attary
- Bio-Intelligence Unit, Sharif Brain Center, Electrical Engineering Department, Sharif University of Technology, Tehran, Iran
| | - Amir Rouhollahi
- Division of Thoracic and Cardiac Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Ross Straughan
- Division of Thoracic and Cardiac Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - James Noel Willi
- Division of Thoracic and Cardiac Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Rabina Awal
- Mechanical Engineering Department, University of Louisiana at Lafayette, Louisiana, LA, United States
| | - Ashraf Sabe
- Division of Thoracic and Cardiac Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Kim I. de la Cruz
- Division of Thoracic and Cardiac Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Farhad R. Nezami
- Division of Thoracic and Cardiac Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
- Correspondence: Farhad R. Nezami
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10
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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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11
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Bouhout I, Kalfa D, Shah A, Goldstone AB, Harrington J, Bacha E. Surgical Management of Complex Aortic Valve Disease in Young Adults: Repair, Replacement, and Future Alternatives. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2022; 25:28-37. [PMID: 35835514 DOI: 10.1053/j.pcsu.2022.04.002] [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: 10/27/2021] [Revised: 03/17/2022] [Accepted: 04/29/2022] [Indexed: 11/11/2022]
Abstract
The ideal aortic valve substitute in young adults remains unknown. Prosthetic valves are associated with a suboptimal survival and carry a significant risk of valve-related complications in young patients, mainly reinterventions with tissue valves and, thromboembolic events and major bleeding with mechanical prostheses. The Ross procedure is the only substitute that restores a survival curve similar to that of a matched general population, and permits a normal life without functional limitations. Though the risk of reintervention is the Achilles' heel of this procedure, it is very low in patients with aortic stenosis and can be mitigated in patients with aortic regurgitation by tailored surgical techniques. Finally, the Ozaki procedure and the transcatheter aortic valve implantation are seen by many as future alternatives but lack evidence and long-term follow-up in this specific patient population.
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Affiliation(s)
- Ismail Bouhout
- Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Columbia University, New York, New York
| | - David Kalfa
- Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Columbia University, New York, New York
| | - Amee Shah
- Division of Pediatric Cardiology, Department of Pediatrics, Columbia University, New York, New York
| | - Andrew B Goldstone
- Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Columbia University, New York, New York
| | - Jamie Harrington
- Division of Pediatric Cardiology, Department of Pediatrics, Columbia University, New York, New York
| | - Emile Bacha
- Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Columbia University, New York, New York.
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12
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Mazine A, David TE, Stoklosa K, Chung J, Lafreniere-Roula M, Ouzounian M. Improved Outcomes Following the Ross Procedure Compared With Bioprosthetic Aortic Valve Replacement. J Am Coll Cardiol 2022; 79:993-1005. [PMID: 35272805 DOI: 10.1016/j.jacc.2021.12.026] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 11/15/2021] [Accepted: 12/08/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND The ideal aortic valve substitute for young and middle-aged adults remains elusive. OBJECTIVES This study sought to compare the long-term outcomes of patients undergoing the Ross procedure and those receiving bioprosthetic aortic valve replacements (AVRs). METHODS Consecutive patients aged 16-60 years who underwent a Ross procedure or surgical bioprosthetic AVR at the Toronto General Hospital between 1990 and 2014 were identified. Propensity score matching was used to account for differences in baseline characteristics. The primary outcome was all-cause mortality. Secondary outcomes included valve reintervention, valve deterioration, endocarditis, thromboembolic events, and permanent pacemaker implantation. RESULTS Propensity score matching yielded 108 pairs of patients. The median age was 41 years (IQR: 34-47 years). Baseline characteristics were similar between the matched groups. There was no operative mortality in either group. Mean follow-up was 14.5 ± 7.2 years. All-cause mortality was lower following the Ross procedure (HR: 0.35; 95% CI: 0.14-0.90; P = 0.028). Using death as a competing risk, the Ross procedure was associated with lower rates of reintervention (HR: 0.21; 95% CI: 0.10-0.41; P < 0.001), valve deterioration (HR: 0.25; 95% CI: 0.14-0.45; P < 0.001), thromboembolic events (HR: 0.15; 95% CI: 0.05-0.50; P = 0.002), and permanent pacemaker implantation (HR: 0.22; 95% CI: 0.07-0.64; P = 0.006). CONCLUSIONS In this propensity-matched study, the Ross procedure was associated with better long-term survival and freedom from adverse valve-related events compared with bioprosthetic AVR. In specialized centers with sufficient expertise, the Ross procedure should be considered the primary option for young and middle-aged adults undergoing AVR.
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Affiliation(s)
- Amine Mazine
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital and the University of Toronto, Toronto, Ontario, Canada
| | - Tirone E David
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital and the University of Toronto, Toronto, Ontario, Canada
| | - Klaudiusz Stoklosa
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital and the University of Toronto, Toronto, Ontario, Canada
| | - Jennifer Chung
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital and the University of Toronto, Toronto, Ontario, Canada
| | - Myriam Lafreniere-Roula
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital and the University of Toronto, Toronto, Ontario, Canada
| | - Maral Ouzounian
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital and the University of Toronto, Toronto, Ontario, Canada.
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13
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Tanaka D, Mazine A, Ouzounian M, El-Hamamsy I. Supporting the Ross procedure: preserving root physiology while mitigating autograft dilatation. Curr Opin Cardiol 2022; 37:180-190. [PMID: 35081548 DOI: 10.1097/hco.0000000000000949] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The purpose of this article is to describe the optimized approach to nonrepairable aortic valve disease in young adults with a Ross procedure, while preserving the dynamic physiology of the aortic root. RECENT FINDINGS As the techniques for supporting pulmonary autografts continue to be refined, and the applicability of the Ross procedure continues to expand, an assessment of the various techniques based on aortic root physiology is warranted. Semi-resorbable scaffolds show promise in ovine models for improving the Ross procedure. Recent long-term outcomes for the Dacron inclusion technique in comparison to more physiologic methods of support emphasize the importance of balancing the prevention of early dilatation with the preservation of root haemodynamics. As this review will synthesize, the dynamic physiology of the root may be preserved even in patients at a higher risk of autograft dilatation. SUMMARY The favourable long-term outcomes of the Ross procedure can be partly attributed to the ability of the autograft to restore dynamism to the neoaortic root. Patient-specific modifications that respect root physiology can tailor the Ross procedure to address each patient's risk factors for early dilatation and late failure. As such, the Ross procedure should be recognized as an increasingly favourable solution for a wide spectrum of nonpreservable aortic valve disease in young adults.
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Affiliation(s)
| | | | - Maral Ouzounian
- Division of Cardiovascular Surgery, Peter Munk Cardiac Center, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Ismail El-Hamamsy
- Department of Cardiovascular Surgery, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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14
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Hemodynamic performance of INSPIRIS RESILIA aortic bioprosthesis for severe aortic stenosis: 2-year follow-up in Japanese cohort. J Artif Organs 2022; 25:323-328. [DOI: 10.1007/s10047-022-01316-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 01/24/2022] [Indexed: 10/19/2022]
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15
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Panç C, Güler A, Doğan AC, Gülmez R, Güner A, Çelik Ö. Fragmented QRS complex may predict long-term mortality after isolated surgical aortic valve replacement in patients with severe aortic stenosis. Interact Cardiovasc Thorac Surg 2022; 34:26-32. [PMID: 34999796 PMCID: PMC8923387 DOI: 10.1093/icvts/ivab214] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 07/02/2021] [Accepted: 07/07/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Fragmented QRS (fQRS), related to myocardial fibrosis, is an important prognostic marker of cardiovascular events and mortality. Aortic stenosis (AS), the most frequent valvular heart disease in developed countries, causes myocardial fibrosis due to ventricular pressure overload. The current study aimed to investigate whether fQRS is associated with long-term mortality after isolated surgical aortic valve replacement (SAVR) in patients with severe AS. METHODS A total of 289 patients who underwent SAVR for severe AS between May 2009 and January 2020 with interpretable electrocardiogram were included. Patients were divided into 2 groups according to the presence of fQRS. Kaplan-Meier survival analyses were used to detect cumulative survival rates. Univariable and multivariable Cox proportional hazards models were used to determine the predictors of all-cause mortality. RESULTS fQRS occurred in 126 (43.5%) patients. A total of 59 (20.4%) patients died over a follow-up period of 54 ± 32 months. All-cause mortality was higher in the fQRS group (23 [14.1%] vs 36 [28.6], log-rank test P = 0.002) in the long term. The presence of fQRS [hazard ratio (HR): 1.802, confidence interval (CI): 1.035-3.135, P = 0.037], electrocardiographic left ventricular strain (HR: 1.836, CI: 1.036-3.254, P = 0.038) and history of stroke or transient ischaemic attack (HR: 3.130, CI: 1.528-6.412, P = 0.002) were independent predictors of all-cause mortality in the multivariable Cox regression model. CONCLUSIONS fQRS is associated with a 1.8-fold increase in long-term mortality in patients undergoing isolated SAVR for severe AS. Detecting fQRS in electrocardiograms may provide prognostic information about the long-term outcomes.
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Affiliation(s)
- Cafer Panç
- Department of Cardiology, University of Health Sciences, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, İstanbul, Turkey
| | - Arda Güler
- Department of Cardiology, University of Health Sciences, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, İstanbul, Turkey
| | - Arda Can Doğan
- Department of Cardiology, University of Health Sciences, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, İstanbul, Turkey
| | - Recep Gülmez
- Department of Cardiology, University of Health Sciences, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, İstanbul, Turkey
| | - Ahmet Güner
- Department of Cardiology, University of Health Sciences, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, İstanbul, Turkey
| | - Ömer Çelik
- Department of Cardiology, University of Health Sciences, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, İstanbul, Turkey
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16
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OUP accepted manuscript. Eur J Cardiothorac Surg 2022; 62:6570590. [DOI: 10.1093/ejcts/ezac263] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 03/29/2022] [Accepted: 04/14/2022] [Indexed: 11/13/2022] Open
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17
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Mazine A, El-Hamamsy I. Tailoring the Ross procedure for patients with aortic regurgitation. JTCVS Tech 2021; 10:383-389. [PMID: 34977760 PMCID: PMC8690315 DOI: 10.1016/j.xjtc.2021.06.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 06/03/2021] [Indexed: 12/30/2022] Open
Affiliation(s)
- Amine Mazine
- Division of Cardiac Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Ismail El-Hamamsy
- Department of Cardiovascular Surgery, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY
- Address for reprints: Ismail El-Hamamsy, MD, PhD, Department of Cardiovascular Surgery, Mount Sinai Hospital, 1190, Fifth Ave, New York, NY 10029.
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18
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Desai MY, Alashi A, Popovic ZB, Wierup P, Griffin BP, Thamilarasan M, Johnston D, Svensson LG, Lever HM, Smedira NG. Outcomes in Patients With Obstructive Hypertrophic Cardiomyopathy and Concomitant Aortic Stenosis Undergoing Surgical Myectomy and Aortic Valve Replacement. J Am Heart Assoc 2021; 10:e018435. [PMID: 34533040 PMCID: PMC8649531 DOI: 10.1161/jaha.120.018435] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Hypertrophic cardiomyopathy (HCM) and aortic stenosis can cause obstruction to the flow of blood out of the left ventricular outflow tract into the aorta, with obstructive HCM resulting in dynamic left ventricular outflow tract obstruction and moderate or severe aortic stenosis causing fixed obstruction caused by calcific degeneration. We sought to report the characteristics and longer-term outcomes of patients with severe obstructive HCM who also had concomitant moderate or severe aortic stenosis requiring surgical myectomy and aortic valve replacement. Methods and Results We studied 191 consecutive patients (age 67±6 years, 52% men) who underwent myectomy and aortic valve (AV) replacement (90% bioprosthesis) at our center between June 2002 and June 2018. Clinical and echo data including left ventricular outflow tract gradient and indexed AV area were recorded. The primary outcome was death. Prevalence of hypertension (63%) and hyperlipidemia (75%) were high, with a Society of Thoracic Surgeons score of 5±4, and 70% of participants had no HCM-related sudden death risk factors. Basal septal thickness and indexed AV area were 1.9±0.4 cm and 0.72±0.2 cm2/m2, respectively, while 100% of patients had dynamic left ventricular outflow tract gradient >50 mm Hg. At 6.5±4 years, 52 (27%) patients died (1.5% in-hospital deaths). One-, 2-, and 5-year survival in the current study sample was 94%, 91%, and 83%, respectively, similar to an age-sex-matched general US population. On multivariate Cox survival analysis, age (hazard ratio [HR], 1.65; 95% CI, 1.24-2.18), chronic kidney disease (HR, 1.58; 95% CI, 1.21-2.32), and right ventricular systolic pressure on preoperative echocardiography (HR, 1.28; 95% CI, 1.05-1.57) were associated with longer-term mortality, but traditional HCM risk factors did not. Conclusions In symptomatic patients with severely obstructive HCM and moderate or severe aortic stenosis undergoing a combined surgical myectomy and AV replacement at our center, the observed postoperative mortality was significantly lower than the expected mortality, and the longer-term survival was similar to a normal age-sex-matched US population.
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Affiliation(s)
- Milind Y Desai
- Hypertrophic Cardiomyopathy and Valve Center Heart and Vascular Institute Cleveland Clinic Cleveland OH
| | - Alaa Alashi
- Hypertrophic Cardiomyopathy and Valve Center Heart and Vascular Institute Cleveland Clinic Cleveland OH
| | - Zoran B Popovic
- Hypertrophic Cardiomyopathy and Valve Center Heart and Vascular Institute Cleveland Clinic Cleveland OH
| | - Per Wierup
- Hypertrophic Cardiomyopathy and Valve Center Heart and Vascular Institute Cleveland Clinic Cleveland OH
| | - Brian P Griffin
- Hypertrophic Cardiomyopathy and Valve Center Heart and Vascular Institute Cleveland Clinic Cleveland OH
| | - Maran Thamilarasan
- Hypertrophic Cardiomyopathy and Valve Center Heart and Vascular Institute Cleveland Clinic Cleveland OH
| | - Douglas Johnston
- Hypertrophic Cardiomyopathy and Valve Center Heart and Vascular Institute Cleveland Clinic Cleveland OH
| | - Lars G Svensson
- Hypertrophic Cardiomyopathy and Valve Center Heart and Vascular Institute Cleveland Clinic Cleveland OH
| | - Harry M Lever
- Hypertrophic Cardiomyopathy and Valve Center Heart and Vascular Institute Cleveland Clinic Cleveland OH
| | - Nicholas G Smedira
- Hypertrophic Cardiomyopathy and Valve Center Heart and Vascular Institute Cleveland Clinic Cleveland OH
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19
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Mazine A, El-Hamamsy I. The Ross procedure is an excellent operation in non-repairable aortic regurgitation: insights and techniques. Ann Cardiothorac Surg 2021; 10:463-475. [PMID: 34422558 DOI: 10.21037/acs-2021-rp-25] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 06/10/2021] [Indexed: 11/06/2022]
Abstract
The Ross procedure is the best operation to treat aortic stenosis (AS) in young and middle-aged adults. However, its role in non-repairable aortic regurgitation (AR) remains debated since many historical series have reported an increased risk of pulmonary autograft dilatation and subsequent need for reintervention in these patients. Some have attributed these findings to an unrecognized and poorly characterized inherited genetic defect that prevents adaptive remodelling of the pulmonary autograft. Herein, we review the contemporary evidence surrounding the use of the Ross procedure in young adults with AR and put forth the argument that with proper technical refinements, the Ross procedure may still be the best operation to treat these patients. We believe that by tailoring the operation to the patient's anatomy and ensuring strict postoperative blood pressure control, one can achieve excellent results with the Ross procedure, including in this challenging patient population.
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Affiliation(s)
- Amine Mazine
- Division of Cardiac Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Ismail El-Hamamsy
- Department of Cardiovascular Surgery, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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20
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Patel PM, Chiou E, Cao Y, Binongo J, Guyton RA, Leshnower B, Grubb KJ, Chen EP. Isolated Redo Aortic Valve Replacement Versus Valve-in-Valve Transcatheter Valve Replacement. Ann Thorac Surg 2021; 112:539-545. [DOI: 10.1016/j.athoracsur.2020.08.048] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 07/25/2020] [Accepted: 08/31/2020] [Indexed: 01/08/2023]
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21
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Barletta G, Del Bene MR, Venditti F, Pilato G, Stefàno P. Surgical aortic valve replacement and left ventricular remodeling: Survival and sex-related differences. Echocardiography 2021; 38:1095-1103. [PMID: 34028878 DOI: 10.1111/echo.15122] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 05/02/2021] [Accepted: 05/07/2021] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVES To analyze how left ventricular (LV) remodeling and hypertrophy geometry evolve after surgical aortic valve replacement (SAVR) in octogenarian patients, and identify potential sex-related differences and implications for long-term outcomes. METHODS In 170 patients with aortic stenosis ([AS], age 80 ± 4 years, 59% women), hypertrophy geometry and remodeling (LV index) were reanalyzed one year post-SAVR. The six-year outcomes were evaluated. RESULTS Pre-SAVR, 65% of the women and 38.6% of the men (P < .001) showed adaptive remodeling. Concentric hypertrophy was prevalent in adaptive remodeling, and mixed and dilated hypertrophy were more prevalent in maladaptive remodeling. At one year, the remodeling patterns and sex distribution were similar to those observed pre-SAVR, but the LV index decreased in women and increased in men (P < .0001). Women with adaptive remodeling had a higher incidence of persistent concentric hypertrophy with higher LV filling pressures. Long-term survival was better in women and worse in men with adaptive remodeling (P = .039). Men with adaptive remodeling and men with concentric hypertrophy had the highest risk of cardiac death. This risk was similar between sexes for patients with maladaptive remodeling and dilated hypertrophy. Women with LV ejection fraction >55% had a lower risk of cardiac death than men. CONCLUSIONS The long-term outcomes of SAVR differ between sexes in older patients with AS and adaptive LV remodeling. The LV index facilitates studying the pathways of adaptation to AS. The follow-up shifts help explain the sex differences in long-term outcomes post-SAVR. Concentric hypertrophy is associated with the highest risk of cardiac death in men.
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Affiliation(s)
| | | | | | - Giuseppe Pilato
- Diagnostic Cardiology, Careggi University Hospital, Florence, Italy
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22
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Romeo JLR, Papageorgiou G, da Costa FFD, Sievers HH, Bogers AJJC, El-Hamamsy I, Skillington PD, Wynne R, Mastrobuoni S, El Khoury G, Takkenberg JJM, Mokhles MM. Long-term Clinical and Echocardiographic Outcomes in Young and Middle-aged Adults Undergoing the Ross Procedure. JAMA Cardiol 2021; 6:539-548. [PMID: 33656518 DOI: 10.1001/jamacardio.2020.7434] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance There is no ideal valve substitute for young adults requiring aortic valve replacement. Multicenter data supporting use of the Ross procedure with respect to long-term postoperative valve-related mortality and reintervention, as well as function of the autograft and pulmonary homograft, are needed. Objective To determine the long-term clinical and echocardiographic outcomes in young and middle-aged patients undergoing the Ross procedure. Design, Setting, and Participants A retrospective multicenter international cohort study with a median follow-up period of 9.2 years was conducted in 5 experienced centers regularly performing the Ross procedure. Consecutive patients aged 18 to 65 years were included by each center between 1991 and 2018. Main Outcomes and Measures Survival and autograft-related and homograft-related reintervention. Serial echocardiographic measurements of valve function were analyzed using mixed-effects modeling. Results During the study period, 1431 patients (74.3% men; n = 1063) were operated on at a median age of 48.5 years (mean [SD], 47.7 [9.5]; range, 18.1-65; interquartile range, 42.7-54.0). Implantation techniques were root inclusion in 355 (24.9%), root replacement in 485 (34.0%), and subcoronary implantation in 587 (41.1%). Right ventricular outflow tract reconstruction was performed with homografts in 98.6% (n = 1189) and bioprostheses in 1.4% (n = 17). Ten patients (0.7%) died before discharge. Median follow-up was 9.2 years (13 015 total patient-years). Survival after 10 and 15 years was 95.1% (95% CI, 93.8%-96.5%) and 88.5% (95% CI, 85.9%-91.1%), respectively. Freedom from autograft and homograft reintervention after 15 years was 92.0% and 97.2%, respectively. Late events were autograft endocarditis in 14 patients (0.11% per patient-year), homograft endocarditis in 11 patients (0.08% per patient-year), and stroke in 37 patients (0.3% per patient-year). Conclusions and Relevance Given its excellent short-term and long-term outcome in young and middle-aged adults in this study, the Ross procedure should be considered in young and middle-aged adults who require aortic valve replacement. Patients should be referred to an experienced center with a program dedicated to the Ross procedure.
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Affiliation(s)
- Jamie L R Romeo
- Department of Cardio-Thoracic Surgery Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Grigorios Papageorgiou
- Department of Cardio-Thoracic Surgery Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Francisco F D da Costa
- Department of Cardiac Surgery, Santa Casa de Curitiba, Pontifícia Universidade Católica do Paraná, Curitiba, Paraná, Brazil
| | - Hans H Sievers
- Department of Cardiac and Thoracic Vascular Surgery, University of Lübeck, Lübeck, Germany
| | - Ad J J C Bogers
- Department of Cardio-Thoracic Surgery Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Ismail El-Hamamsy
- Department of Cardiovascular Surgery, CHU Sainte Justine, Montreal, Canada, Montreal, Quebec, Canada
| | - Peter D Skillington
- Department of Cardiothoracic Surgery, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Rochelle Wynne
- Department of Cardiothoracic Surgery, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Western Sydney Local Health District, Blacktown Clinical School, Western Sydney University, Penrith, New South Wales, Australia
| | - Stefano Mastrobuoni
- Department of Cardiovascular and Thoracic Surgery, St Luc University Clinic, Brussels, Belgium
| | - Gebrine El Khoury
- Department of Cardiovascular and Thoracic Surgery, St Luc University Clinic, Brussels, Belgium
| | - Johanna J M Takkenberg
- Department of Cardio-Thoracic Surgery Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Mostafa M Mokhles
- Department of Cardio-Thoracic Surgery Erasmus Medical Centre, Rotterdam, the Netherlands.,Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
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The Choice of Pulmonary Autograft in Aortic Valve Surgery: A State-of-the-Art Primer. BIOMED RESEARCH INTERNATIONAL 2021; 2021:5547342. [PMID: 33937396 PMCID: PMC8060091 DOI: 10.1155/2021/5547342] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 03/31/2021] [Accepted: 04/05/2021] [Indexed: 11/18/2022]
Abstract
The Ross procedure has long been seen as an optimal operation for a select few. The detractors of it highlight the issue of an additional harvesting of the pulmonary artery, subjecting the native PA to systemic pressures and the need for reintervention as reasons to avoid it. However, the PA is a living tissue and capable of adapting and remodeling to growth. We therefore review the current evidence available to discuss the indications, contraindications, harvesting techniques, and modifications in a state-of-the-art narrative review of the PA as an aortic conduit. Due to the lack of substantial well-designed randomized controlled trials (RCTs), we also highlight the areas of need to reiterate the importance of the Ross procedure as part of the surgical armamentarium.
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Kostakou PM, Tryfou ES, Kostopoulos VS, Markos LI, Damaskos DS, Olympios CD, Kouris NT. Segmentally impaired left ventricular longitudinal strain: a new predictive diagnostic parameter for asymptomatic patients with severe aortic stenosis and preserved ejection fraction. Perfusion 2021; 37:402-409. [PMID: 33752549 DOI: 10.1177/0267659121995998] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION This study aims to investigate the correlation between severe aortic stenosis (sAS) and impairment of left ventricular global longitudinal strain (LVGLS) in particular segments, using two-dimensional speckle tracking echocardiography in patients with sAS and normal ejection fraction of left ventricle (LVEF). METHODS The study included 53 consecutive patients with asymptomatic sAS and preserved LVEF. The regional longitudinal systolic LV wall strain was evaluated at the area opposite of the aorta as the median strain value of the basal, middle, and apical segments of the lateral and posterior walls and was compared to the average strain value of the interventricular septum (IVS) at the same views. RESULTS LVGLS was decreased and was not statistically different between three- and four-chamber views (-12.5 ± 3.6 vs -11.4 ± 5.5%, p = 0.2). The average strain values of the lateral and posterior walls were statistically reduced compared to the average value of the IVS (lateral vs IVS: -7.8 ± 3.7 vs -10 ± 5.3%, p = 0.005, posterior vs IVS: -7.7 ± 4.2 vs -10.3 ± 3.8%, p < 0.0001). There was no significant difference between lateral and posterior walls (-7.8 ± 3.7 vs -7.7 ± 4.2%, p = 0.9). CONCLUSIONS The strain of lateral and posterior walls of left ventricle, which lay just opposite to the aortic valve seem to be more reduced compared to other walls in patients with sAS and preserved LVEF possibly due to their anatomical position. This impairment seems to be the reason of the overall LVGLS reduction. Regional strain could be used as an extra tool for the estimation of the severity of AS as well as for prognostic information in asymptomatic patients.
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Affiliation(s)
- Peggy M Kostakou
- Cardiology Department, General Hospital of Elefsina 'Thriassio', Athens, Greece
| | - Elsie S Tryfou
- Cardiology Department, General Hospital of Elefsina 'Thriassio', Athens, Greece
| | | | - Lambros I Markos
- Cardiology Department, General Hospital of Elefsina 'Thriassio', Athens, Greece
| | | | | | - Nikos T Kouris
- Cardiology Department, General Hospital of Elefsina 'Thriassio', Athens, Greece
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25
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Ösken A, Ünal Dayı Ş, Özcan KS, Keskin M, Kemaloğlu Öz T, Poyraz E, Gürkan U, Akgöz H, Çam N. Speckle tracking echocardiography in severe patient-prosthesis mismatch. Herz 2021; 46:375-380. [PMID: 33687479 DOI: 10.1007/s00059-021-05031-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 07/06/2020] [Accepted: 02/06/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Although aortic valve replacement (AVR) when successfully performed boasts low mortality rates in selected patients, prosthesis-patient mismatch (PPM) can be found in the majority of these individuals. Limited research is available supporting the benefit of two-dimensional speckle tracking echocardiography (2D-STE) in patients with severe PPM. This study sought to assess myocardial strain using 2D-STE to determine the relationship between subclinical left ventricular (LV) dysfunction and aortic PPM in patients undergoing AVR with preserved LV ejection fraction. MATERIAL AND METHODS We retrospectively examined all consecutive patients with isolated AVR who presented to our center from 2005 to 2018. The data of 1086 patients were analyzed. Severe PPM was defined as an indexed effective orifice area of 0.65 cm2/m2 or less. As a result of the detailed assessment, 54 patients meeting the eligibility criteria were included in the study. Baseline data were collected and compared between the two groups of patients with severe PPM (n = 27) and those with normofunctional aortic prosthesis valve as a control group (n = 27). All patients underwent baseline echocardiography. Global longitudinal strain (GLS) and global circumferential strain (GCS) were evaluated by 2D-STE. RESULTS When compared with controls, patients with severe PPM had significantly decreased GLS (18.6 ± 2.9 vs. 21.4 ± 2.1; p < 0.01) and GCS (17.2 ± 3.6 vs. 21.7 ± 2.1; p < 0.01) values. CONCLUSION In addition to standard clinical and echocardiographic parameters, GLS and GCS suggest subclinical dysfunction and have incremental value in patients with severe PPM.
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Affiliation(s)
- Altuğ Ösken
- Department of Cardiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey. .,Department of Cardiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Tibbiye cad. 13, Haydarpasa/Istanbul/Turkey, 34668, İstanbul, Turkey.
| | - Şennur Ünal Dayı
- Department of Cardiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Kazım Serhan Özcan
- Department of Cardiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Muhammed Keskin
- Department of Cardiology, Sultan II. Abdulhamid Han Training and Research Hospital, Istanbul, Turkey
| | - Tuğba Kemaloğlu Öz
- Department of Cardiology, Istinye University Faculty of Medicine, Istanbul, Turkey
| | - Esra Poyraz
- Department of Cardiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Ufuk Gürkan
- Department of Cardiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Haldun Akgöz
- Department of Cardiology, Acibadem University Faculty of Medicine, Istanbul, Turkey
| | - Neşe Çam
- Department of Cardiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
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Abecasis J, Gomes Pinto D, Ramos S, Masci PG, Cardim N, Gil V, Félix A. Left Ventricular Remodeling in Degenerative Aortic Valve Stenosis. Curr Probl Cardiol 2021; 46:100801. [PMID: 33588124 DOI: 10.1016/j.cpcardiol.2021.100801] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 01/14/2021] [Indexed: 01/15/2023]
Abstract
Aortic stenosis was once considered a pure isolated valve obstacle challenging left ventricle driving force of contraction and flow generation. Left ventricular (LV) adaptation was merely interpreted as a uniform hypertrophic response to increased afterload. However, in these last 2 decades cardiac imaging research and some histopathology correlation studies brought insight towards the complex interaction between the vasculature, the valve and the myocardium. Verily, LV remodeling in this setting is a complex multidetermined process that goes further beyond myocardial hypertrophy. Ultrastructural changes involving both diffuse and replacement fibrosis of the myocardium take part and might explain the transition of clinical phenotypes with distinct prognosis, from compensated hypertrophy to LV maladaptive dysfunction and heart failure. Presently, the combined appropriate use of echocardiography and cardiac magnetic resonance may better assess the global LV afterload, hypertrophy and geometric remodeling, global and regional LV function, beyond ejection fraction, and structural changes that include the fibrotic burden of the myocardium. As a whole these may not only better stratify individual risk of disease progression but also identify patients benefiting from earlier valve intervention. In this paper, we review the maladaptive response of the LV to chronic pressure overload, describing the different signaling pathways and mechanisms that underly both hypertrophy and remodeling. Histomorphology changes in this setting are described and we try to make sense of the use of new imaging tools for LV characterization.
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Affiliation(s)
- João Abecasis
- Nova Medical School, Lisboa, Portugal; Cardiology Department, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Lisboa, Portugal; Cardiology Department, Hospital dos Lusíadas, Lisboa, Portugal.
| | - Daniel Gomes Pinto
- Nova Medical School, Lisboa, Portugal; Pathology Department, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Lisboa, Portugal
| | - Sância Ramos
- Pathology Department, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Lisboa, Portugal; Faculdade Ciências da Saúde, Universidade da Beira Interior, Covilhã, Portugal
| | | | - Nuno Cardim
- Nova Medical School, Lisboa, Portugal; Hospital da Luz, Lisboa, Portugal
| | - Victor Gil
- Cardiology Department, Hospital dos Lusíadas, Lisboa, Portugal; Faculdade de Medicina de Lisboa, Portugal
| | - Ana Félix
- Nova Medical School, Lisboa, Portugal; Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisboa, Portugal
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Stelzer P, Mejia J, Varghese R. Operative risks of the Ross procedure. J Thorac Cardiovasc Surg 2021; 161:905-915.e3. [PMID: 33451826 DOI: 10.1016/j.jtcvs.2020.11.161] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 10/31/2020] [Accepted: 11/17/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND The risk of the Ross procedure continues to be debated. We sought to determine the immediate outcomes of the Ross procedure in a large consecutive cohort that included patients undergoing reoperative cardiac surgery and/or concomitant cardiac procedures. METHODS Between March 1987 and September 2019, 702 patients underwent a full root Ross procedure. There were 530 male patients and 172 female patients, with a mean age of 41.6 years. One hundred and one patients had at least one previous sternotomy; 323 patients had concomitant procedures. Patients were stratified into 2 groups: simple and complex. Simple Ross patients were those who had no previous sternotomy and had only minor concomitant procedures performed at the time of their Ross, such as aortoplasty or closure of patent foramen ovale. The complex Ross group included patients with at least one previous sternotomy and/or additional procedures that we deemed complex, such as ascending aortic replacement and mitral valve repair. Complexity and group outcomes were evaluated in consecutive terciles of time. RESULTS There were 7 (1%) operative deaths. Morbidity affected 46 other patients (6.6%). The simple Ross group comprised 419 patients (59.7%), with mortality in 3 (0.7%) and morbidity in 20 (4.8%). The complex Ross comprised 283 patients (40.3%), with mortality in 4 (1.4%) and morbidity in 26 (9.2%). Simple Ross cases decreased in volume over time, with complex cases increasing from 34% to 48%. CONCLUSIONS Excellent results can be achieved with the Ross procedure despite broader indications that include patients with previous sternotomy and with the need for concomitant procedures.
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Affiliation(s)
- Paul Stelzer
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Javier Mejia
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Robin Varghese
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
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28
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Park K, Park TH, Jo YS, Cho YR, Park JS, Kim MH, Kim YD. Prognostic effect of increased left ventricular wall thickness in severe aortic stenosis. Cardiovasc Ultrasound 2021; 19:5. [PMID: 33407517 PMCID: PMC7788729 DOI: 10.1186/s12947-020-00234-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 12/16/2020] [Indexed: 01/19/2023] Open
Abstract
Background It is unclear whether increased left ventricular (LV) thickness is associated with worse clinical outcomes in severe aortic stenosis (AS). The aim of this study was to determine the effect of increased LV wall thickness (LVWT) on major clinical outcomes in patients with severe AS. Methods and results This study included 290 severe AS patients (mean age 69.4 ± 11.0 years; 136 females) between January 2008 and December 2018. For outcome assessment, the endpoint was defined as death from all causes, cardiovascular death, and the aortic valve replacement (AVR) surgery rate. During follow-up (48.7 ± 39.0 months), 157 patients had AVR, 43 patients died, and 28 patients died from cardiovascular causes. Patients with increased LVWT underwent AVR surgery much more than those without LVWT (60.0% vs. 39.0%, p < 0.001). Furthermore, in patients with increased LVWT, the all-cause and cardiovascular death rates were significantly lower in the AVR group than in the non-AVR group (8.8% vs. 27.3%, p < 0.001, 4.8%, vs. 21.0%, p < 0.001). Multivariate analysis revealed that increased LVWT, age, dyspnea, and AVR surgery were significantly correlated with cardiovascular death. Conclusions In patients with severe AS, increased LVWT was associated with a higher AVR surgery rate and an increased rate of cardiovascular death independent of other well-known prognostic variates. Thus, these findings suggest that increased LVWT might be used as a potential prognostic factor in severe AS patients.
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Affiliation(s)
- Kyungil Park
- Division of Cardiology, Department of Internal Medicine, Dong-A University Hospital, Daeshingongwon-Ro 26, Seo-gu, Busan, 602-715, Republic of Korea
| | - Tae-Ho Park
- Division of Cardiology, Department of Internal Medicine, Dong-A University Hospital, Daeshingongwon-Ro 26, Seo-gu, Busan, 602-715, Republic of Korea.
| | - Yoon-Seong Jo
- Division of Cardiology, Department of Internal Medicine, Dong-A University Hospital, Daeshingongwon-Ro 26, Seo-gu, Busan, 602-715, Republic of Korea
| | - Young-Rak Cho
- Division of Cardiology, Department of Internal Medicine, Dong-A University Hospital, Daeshingongwon-Ro 26, Seo-gu, Busan, 602-715, Republic of Korea
| | - Jong-Sung Park
- Division of Cardiology, Department of Internal Medicine, Dong-A University Hospital, Daeshingongwon-Ro 26, Seo-gu, Busan, 602-715, Republic of Korea
| | - Moo-Hyun Kim
- Division of Cardiology, Department of Internal Medicine, Dong-A University Hospital, Daeshingongwon-Ro 26, Seo-gu, Busan, 602-715, Republic of Korea
| | - Young-Dae Kim
- Division of Cardiology, Department of Internal Medicine, Dong-A University Hospital, Daeshingongwon-Ro 26, Seo-gu, Busan, 602-715, Republic of Korea
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Yoshida K, Holmes JW. Computational models of cardiac hypertrophy. PROGRESS IN BIOPHYSICS AND MOLECULAR BIOLOGY 2021; 159:75-85. [PMID: 32702352 PMCID: PMC7855157 DOI: 10.1016/j.pbiomolbio.2020.07.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 06/05/2020] [Accepted: 07/02/2020] [Indexed: 02/07/2023]
Abstract
Cardiac hypertrophy, defined as an increase in mass of the heart, is a complex process driven by simultaneous changes in hemodynamics, mechanical stimuli, and hormonal inputs. It occurs not only during pre- and post-natal development but also in adults in response to exercise, pregnancy, and a range of cardiovascular diseases. One of the most exciting recent developments in the field of cardiac biomechanics is the advent of computational models that are able to accurately predict patterns of heart growth in many of these settings, particularly in cases where changes in mechanical loading of the heart play an import role. These emerging models may soon be capable of making patient-specific growth predictions that can be used to guide clinical interventions. Here, we review the history and current state of cardiac growth models and highlight three main limitations of current approaches with regard to future clinical application: their inability to predict the regression of heart growth after removal of a mechanical overload, inability to account for evolving hemodynamics, and inability to incorporate known growth effects of drugs and hormones on heart growth. Next, we outline growth mechanics approaches used in other fields of biomechanics and highlight some potential lessons for cardiac growth modeling. Finally, we propose a multiscale modeling approach for future studies that blends tissue-level growth models with cell-level signaling models to incorporate the effects of hormones in the context of pregnancy-induced heart growth.
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Affiliation(s)
- Kyoko Yoshida
- Department of Biomedical Engineering, University of Virginia, Box 800759, Health System, Charlottesville, VA, 22908, USA.
| | - Jeffrey W Holmes
- Department of Biomedical Engineering, Robert M. Berne Cardiovascular Research Center, University of Virginia, Box 800759, Health System, Charlottesville, VA, 22908, USA.
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30
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Tam DY, Wijeysundera HC, Naimark D, Gaudino M, Webb JG, Cohen DJ, Fremes SE. Impact of Transcatheter Aortic Valve Durability on Life Expectancy in Low-Risk Patients With Severe Aortic Stenosis. Circulation 2020; 142:354-364. [DOI: 10.1161/circulationaha.119.044559] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Recent clinical trial results showed that transcatheter aortic valve replacement (TAVR) is noninferior and may be superior to surgical aortic valve replacement (SAVR) for mortality, stroke, and rehospitalization. However, the impact of transcatheter valve durability remains uncertain.
Methods:
Discrete event simulation was used to model hypothetical scenarios of TAVR versus SAVR durability in which TAVR failure times were varied to determine the impact of TAVR valve durability on life expectancy in a cohort of low-risk patients similar to those in recent trials. Discrete event simulation modeling was used to estimate the tradeoff between a less invasive procedure with unknown valve durability (TAVR) and that of a more invasive procedure with known durability (SAVR). Standardized differences were calculated, and a difference >0.10 was considered clinically significant. In the base-case analysis, patients with structural valve deterioration requiring reoperation were assumed to undergo a valve-in-valve TAVR procedure. A sensitivity analysis was conducted to determine the impact of TAVR valve durability on life expectancy in younger age groups (40, 50, and 60 years).
Results:
Our cohort consisted of patients with aortic stenosis at low surgical risk with a mean age of 73.4±5.9 years. In the base-case scenario, the standardized difference in life expectancy was <0.10 between TAVR and SAVR until transcatheter valve prosthesis failure time was 70% shorter than that of surgical prostheses. At a transcatheter valve failure time <30% compared with surgical valves, SAVR was the preferred option. In younger patients, life expectancy was reduced when TAVR durability was 30%, 40%, and 50% shorter than that of surgical valves in 40-, 50-, and 60-year-old patients, respectively.
Conclusions:
According to our simulation models, the durability of TAVR valves must be 70% shorter than that of surgical valves to result in reduced life expectancy in patients with demographics similar to those of recent trials. However, in younger patients, this threshold for TAVR valve durability was substantially higher. These findings suggest that durability concerns should not influence the initial treatment decision concerning TAVR versus SAVR in older low-risk patients on the basis of current evidence supporting TAVR valve durability. However, in younger low-risk patients, valve durability must be weighed against other patient factors such as life expectancy.
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Affiliation(s)
- Derrick Y. Tam
- Division of Cardiac Surgery, Departments of Surgery (D.Y.T., S.E.F.), University of Toronto, ON, Canada
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, and Institute of Health Policy, Management and Evaluation (D.Y.T., H.C.W., D.N., S.E.F.), University of Toronto, ON, Canada
| | - Harindra C. Wijeysundera
- Medicine (H.C.W.), University of Toronto, ON, Canada
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, and Institute of Health Policy, Management and Evaluation (D.Y.T., H.C.W., D.N., S.E.F.), University of Toronto, ON, Canada
- ICES, Toronto, ON, Canada (H.C.W.)
| | - David Naimark
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, and Institute of Health Policy, Management and Evaluation (D.Y.T., H.C.W., D.N., S.E.F.), University of Toronto, ON, Canada
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medical College, New York (M.G.)
| | - John G. Webb
- Center for Heart Valve Innovation, St. Paul’s Hospital, University of British Columbia, Vancouver, Canada (J.G.W.)
| | | | - Stephen E. Fremes
- Division of Cardiac Surgery, Departments of Surgery (D.Y.T., S.E.F.), University of Toronto, ON, Canada
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, and Institute of Health Policy, Management and Evaluation (D.Y.T., H.C.W., D.N., S.E.F.), University of Toronto, ON, Canada
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Tam DY, Azizi PM, Fremes SE, Chikwe J, Gaudino M, Wijeysundera HC. The cost-effectiveness of transcatheter aortic valve replacement in low surgical risk patients with severe aortic stenosis. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2020; 7:556-563. [DOI: 10.1093/ehjqcco/qcaa058] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 06/29/2020] [Accepted: 07/01/2020] [Indexed: 11/12/2022]
Abstract
Abstract
Aims
The economic value of transcatheter aortic valve replacement (TAVR) in low surgical risk patients with severe, symptomatic aortic stenosis is not known. Our objective was to determine the cost-effectiveness of balloon-expandable TAVR and self-expandable TAVR relative to surgical aortic valve replacement (SAVR) in low-risk patients.
Methods and results
A fully probabilistic Markov cohort model was constructed to estimate differences in costs and effectiveness [quality-adjusted life years (QALYs)] over the patient’s life-time time from the third-party payer’s perspective. Clinical outcomes modelled were alive/well (no complications), permanent stroke, ≥moderate paravalvular leak, new pacemaker, rehospitalization, and death. A network meta-analysis of the PARTNER 3 and Evolut Low Risk trial was performed to compare balloon-expandable TAVR, self-expandable TAVR, and SAVR for the efficacy inputs. Incremental-cost effectiveness ratios (ICER) were calculated. The total life-time costs in the balloon-expandable TAVR, self-expandable-TAVR, and SAVR arms were $37 330 ± 4724, $39 660 ± 4862, and $34 583 ± 6731, respectively, and total life-time QALYs gained were 9.15 ± 3.23, 9.13 ± 3.23, and 9.05 ± 3.20, respectively. The ICERs for balloon-expandable TAVR and self-expandable TAVR against SAVR were $27 196/QALY and $59 641/QALY, respectively. Balloon-expandable TAVR was less costly and more effective than self-expandable TAVR. There was substantial uncertainty, with 53% and 58% of model iterations showing balloon-expandable TAVR to be the preferred option at willingness-to-pay thresholds of $50 000/QALY and $100 000/QALY, respectively.
Conclusion
Compared with SAVR, TAVR, particularly with balloon-expandable prostheses may be a cost-effective option for patients with severe aortic stenosis at low surgical risk.
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Affiliation(s)
- Derrick Y Tam
- Division of Cardiac Surgery, Department of Surgery, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Paymon M Azizi
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Stephen E Fremes
- Division of Cardiac Surgery, Department of Surgery, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Joanna Chikwe
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York—Presbyterian Hospital, New York, NY, USA
| | - Harindra C Wijeysundera
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Division of Cardiology, Department of Medicine, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Room A202, Toronto, ON M4N 3M5, Canada
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Bohbot Y, Renard C, Manrique A, Levy F, Maréchaux S, Gerber BL, Tribouilloy C. Usefulness of Cardiac Magnetic Resonance Imaging in Aortic Stenosis. Circ Cardiovasc Imaging 2020; 13:e010356. [PMID: 32370617 DOI: 10.1161/circimaging.119.010356] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
The objective of this review is to provide an overview of the role of cardiac magnetic resonance (CMR) in aortic stenosis (AS). Although CMR is undeniably the gold standard for assessing left ventricular volume, mass, and function, the assessment of the left ventricular repercussions of AS by CMR is not routinely performed in clinical practice, and its role in evaluating and quantifying AS is not yet well established. CMR is an imaging modality integrating myocardial function and disease, which could be particularly useful in a pathology like AS that should be considered as a global myocardial disease rather than an isolated valve disease. In this review, we discuss the emerging potential of CMR for the diagnosis and prognosis of AS. We detail its utility for studying all aspects of AS, including valve anatomy, flow quantification, left ventricular volumes, mass, remodeling, and function, tissue mapping, and 4-dimensional flow magnetic resonance imaging. We also discuss different clinical situations where CMR could be useful in AS, for example, in low-flow low-gradient AS to confirm the low-flow state and to understand the reason for the left ventricular dysfunction or when there is a suspicion of associated cardiac amyloidosis.
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Affiliation(s)
- Yohann Bohbot
- Department of Cardiology (Y.B., C.T.), Amiens University Hospital, France.,UR UPJV 7517, Jules Verne University of Picardie, Amiens, France (Y.B., S.M., C.T.)
| | - Cédric Renard
- Department of Radiology (C.R.), Amiens University Hospital, France
| | - Alain Manrique
- Department of Nuclear Medicine, CHU Cote de Nacre, Normandy University, Caen, France (A.M.)
| | - Franck Levy
- Department of Cardiology, Centre Cardio-Thoracique De Monaco (F.L.)
| | - Sylvestre Maréchaux
- UR UPJV 7517, Jules Verne University of Picardie, Amiens, France (Y.B., S.M., C.T.).,Groupement des Hôpitaux de l'Institut Catholique de Lille/Faculté libre de médecine, Université Lille Nord de France (S.M.)
| | - Bernhard L Gerber
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium (B.L.G.).,Division of Cardiology, Cliniques Universitaires Saint-Luc, Brussels, Belgium (B.L.G.)
| | - Christophe Tribouilloy
- Department of Cardiology (Y.B., C.T.), Amiens University Hospital, France.,UR UPJV 7517, Jules Verne University of Picardie, Amiens, France (Y.B., S.M., C.T.)
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Ehrlich T, de Kerchove L, Vojacek J, Boodhwani M, El-Hamamsy I, De Paulis R, Lansac E, Bavaria JE, El Khoury G, Schäfers HJ. State-of-the art bicuspid aortic valve repair in 2020. Prog Cardiovasc Dis 2020; 63:457-464. [PMID: 32380025 DOI: 10.1016/j.pcad.2020.04.010] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 04/13/2020] [Indexed: 02/07/2023]
Abstract
Patients with a bicuspid aortic valve (BAV) frequently require surgical intervention for aortic regurgitation (AR) and/or aneurysm. Valve-preserving surgery and repair of regurgitant BAVs have evolved into an increasingly used alternative to replacement. Anatomic predictors of possible repair failures have been identified and solutions developed. Using current techniques most non-calcified BAVs can be preserved or repaired. Excellent repair durability and freedom from valve-related complications can be achieved if all pathologic components of aortic valve and root including annular dilatation are corrected. Anatomic variations must be addressed using tailored approaches.
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Affiliation(s)
- Tristan Ehrlich
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany
| | - Laurent de Kerchove
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain and Division of Cardiothoracic and Vascular Surgery, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Jan Vojacek
- Department of Cardiac Surgery, University Hospital Hradec K0ralove, Czech Republic
| | - Munir Boodhwani
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Canada
| | - Ismail El-Hamamsy
- Department of Cardiovascular Surgery, Mount Sinai Hospital, Icahn Scholl of Medicine at Mount Sinai, New York, USA
| | | | - Emmanuel Lansac
- Departement of Cardiac Surgery, Institut Mutualiste Montsouris, Paris, France
| | - Joseph E Bavaria
- Division of Cardiac Surgery, University of Pennsylvania, Philadelphia, United States of America
| | - Gebrine El Khoury
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain and Division of Cardiothoracic and Vascular Surgery, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Hans-Joachim Schäfers
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany.
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Chau KH, Douglas PS, Pibarot P, Hahn RT, Khalique OK, Jaber WA, Cremer P, Weissman NJ, Asch FM, Zhang Y, Gertz ZM, Elmariah S, Clavel MA, Thourani VH, Daubert M, Alu MC, Leon MB, Lindman BR. Regression of Left Ventricular Mass After Transcatheter Aortic Valve Replacement. J Am Coll Cardiol 2020; 75:2446-2458. [DOI: 10.1016/j.jacc.2020.03.042] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 03/15/2020] [Indexed: 12/20/2022]
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A new non-invasive index for prognosis evaluation in patients with aortic stenosis. Sci Rep 2020; 10:7333. [PMID: 32355310 PMCID: PMC7193646 DOI: 10.1038/s41598-020-63777-z] [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: 11/30/2019] [Accepted: 03/31/2020] [Indexed: 11/09/2022] Open
Abstract
The global left ventricular (LV) contractility index, dσ*/dtmax measures the maximal rate of change in pressure-normalized LV wall stress. We aim to describe the trend of dσ*/dtmax in differing severity of aortic stenosis (AS) with preserved left ventricular ejection fraction (LVEF) and the association of dσ*/dtmax with clinical outcomes in moderate AS and severe AS. We retrospectively studied a total of 1738 patients with AS (550 mild AS, 738 moderate AS, 450 severe AS) and preserved LVEF ≥ 50% diagnosed from 1st January 2001 to 31st December 2015. dσ*/dtmax worsened with increasing severity of AS despite preserved LVEF (mild AS: 3.69 ± 1.28 s-1, moderate AS: 3.17 ± 1.09 s-1, severe AS: 2.58 ± 0.83 s-1, p < 0.001). Low dσ*/dtmax < 2.8 s-1 was independently associated with a higher composite outcome of aortic valve replacement, congestive cardiac failure admissions and all-cause mortality (adjusted hazard ratio 1.48, 95% CI: 1.25-1.77, p < 0.001). In conclusion, dσ*/dtmax declined with worsening AS despite preserved LVEF. Low dσ*/dtmax < 2.8 s-1 was independently associated with adverse clinical outcomes in moderate AS and severe AS with preserved LVEF.
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36
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Concepts of Bicuspid Aortic Valve Repair: A Review. Ann Thorac Surg 2020; 109:999-1006. [DOI: 10.1016/j.athoracsur.2019.09.019] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 08/16/2019] [Accepted: 09/03/2019] [Indexed: 12/27/2022]
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37
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Lindman BR, Dweck MR, Lancellotti P, Généreux P, Piérard LA, O’Gara PT, Bonow RO. Management of Asymptomatic Severe Aortic Stenosis. JACC Cardiovasc Imaging 2020; 13:481-493. [DOI: 10.1016/j.jcmg.2019.01.036] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 01/02/2019] [Accepted: 01/22/2019] [Indexed: 12/19/2022]
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38
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Elbadawi A, Elgendy IY, Mentias A, Saad M, Mohamed AH, Choudhry MW, Ogunbayo GO, Gilani S, Jneid H. Outcomes of urgent versus nonurgent transcatheter aortic valve replacement. Catheter Cardiovasc Interv 2019; 96:189-195. [PMID: 31647180 DOI: 10.1002/ccd.28563] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 10/13/2019] [Indexed: 11/11/2022]
Abstract
BACKGROUND There is a paucity of data regarding the outcomes of transcatheter valve replacement (TAVR) performed in an urgent clinical setting. METHODS The Nationwide Inpatient Sample (NIS) database years 2011-2014 was used to identify hospitalizations for TAVR in the urgent setting. Using propensity score matching, we compared patients who underwent TAVR in nonurgent versus urgent settings. RESULTS Among 42,154 hospitalizations in which TAVR was performed, 10,114 (24%) underwent urgent TAVR. There was an uptrend in the rate of urgent TAVR procedures (p = .001). The rates of in-hospital mortality among this group did not change during the study period (p = .713). Nonurgent TAVR was associated with lower mortality (odds ratio [OR] = 0.78; 95% confidence interval [CI]: 0.69-0.89, p < .001) compared with urgent TAVR. Nonurgent TAVR was associated with lower incidence of cardiogenic shock (OR = 0.46; 95%CI: 0.40-0.53 p < .001), use of mechanical circulatory support devices (OR = 0.69; 95%CI: 0.59-0.82, p < .001), AKI (OR = 0.60; 95%CI: 0.56-0.64 p < .001), hemodialysis (OR = 0.67; 95%CI: 0.56-0.80 p < .001), major bleeding (OR = 0.94; 95%CI: 0.89-0.99 p = .045) and shorter length of stay (7.08 ± 6.317 vs. 12.39 ± 9.737 days, p < .001). There was no difference in acute stroke (OR = 0.96; 95%CI: 0.81-1.14, p = .636), vascular complications (OR = 1.07; 95%CI: 0.89-1.29, p = .492), and pacemaker insertions (OR = 0.92; 95%CI: 0.84-1.01, p = .067) between both groups. Among those undergoing urgent TAVR, subgroup analysis showed higher mortality in patients ≤80 years (p = .033), women (p < .001), chronic kidney disease (p = .001), heart failure (p < .001), and liver disease (p = .003). CONCLUSION In this large nationwide analysis, almost a quarter of TAVR procedures were performed in the urgent settings. Although urgent TAVR was associated with higher mortality and increased complications compared with nonurgent TAVR, the absolute difference in in-hospital mortality was not remarkably higher. Thus, urgent TAVR can be considered as a reasonable approach when indicated.
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Affiliation(s)
- Ayman Elbadawi
- Department of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, Texas
| | - Islam Y Elgendy
- Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Amgad Mentias
- Division of Cardiovascular Medicine, University of Iowa, Iowa City, Iowa
| | - Marwan Saad
- Cardiovascular Institute, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Ahmed H Mohamed
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York
| | | | - Gbolahan O Ogunbayo
- Department of Cardiovascular Medicine, University of Kentucky, Lexington, Kentucky
| | - Syed Gilani
- Department of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, Texas
| | - Hani Jneid
- Division of Cardiovascular Medicine, Baylor School of Medicine, Houston, Texas
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40
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Hemodynamic Performance and Outcomes of Mosaic Valve for Aortic Stenosis with Decreased Left Ventricular Function: Results from J-MOVE Study. ASAIO J 2019; 66:532-538. [PMID: 31335365 DOI: 10.1097/mat.0000000000001040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
We evaluated impact of a small-sized Mosaic porcine bioprosthesis on hemodynamic performance and outcomes in patients with aortic stenosis (AS) and low left ventricular ejection fraction (LVEF) in a Japan multicenter cohort. Of 1,202 patients enrolled, 105 (8.7%) who had LVEF < 50% and AS underwent aortic valve replacement (AVR). Fifty-two patients received Mosaic porcine bioprosthesis ≤ 21 mm (S-AVR), and 53 received a bioprosthesis ≥ 23 mm (L-AVR). The median follow-up period was 3.1 [1.2, 5.1] years. At 5 years, LVEF significantly improved from median 41.2 [33.8, 45.9]% to 64.2 [49.8, 72.5]% in S-AVR (p < 0.001) and from median 43.2 [37.3, 46.8]% to 61.2 [47.2, 68.0]% in L-AVR (p < 0.001). The left ventricular mass index significantly decreased from median 158.4 [122.2, 194.9] to 110.0 [83.6, 129.4] gm/m in S-AVR (p < 0.001) and from median 169.8 [132.2, 203.6] to 109.6 [101.8, 132.4] gm/m in L-AVR (p < 0.001). There were no significant differences between S-AVR and L-AVR groups regarding freedom from cardiac death (93.1 ± 3.9% vs. 96.2 ± 3.8%; p = 0.119) and valve-related death (97.6 ± 2.4% vs. 100.0 ± 0.0%; p = 0.953). Clinical outcomes and improved hemodynamic performance were similar in both groups.
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41
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Long-Term Survival After Surgical Aortic Valve Replacement: Expectations and Reality. J Am Coll Cardiol 2019; 74:34-35. [PMID: 31272549 DOI: 10.1016/j.jacc.2019.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 05/06/2019] [Indexed: 10/26/2022]
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42
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Lansac E, Youssefi P, de Heer F, Bavaria J, De Kerchove L, El-Hamamsy I, Elkhoury G, Enriquez-Sarano M, Jondeau LDG, Kluin J, Pibarot P, Schäfers HJ, Vanoverschelde JL, Takkenberg JJM. Aortic Valve Surgery in Nonelderly Patients: Insights Gained From AVIATOR. Semin Thorac Cardiovasc Surg 2019; 31:643-649. [PMID: 31229691 DOI: 10.1053/j.semtcvs.2019.05.033] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 05/02/2019] [Indexed: 11/11/2022]
Abstract
Aortic valve surgery in non-elderly patients represents a very challenging patient population. The younger the patient is at the point of aortic valve intervention, the longer their anticipated life expectancy will be, with longer exposure to valve-related complications and risk for re-operation. Although the latest international guidelines recommend aortic valve repair in patients with aortic valve insufficiency, what we see in the real world is that the vast majority of these aortic valves are replaced. However, current prosthetic valves has now been shown to lead to significant loss of life expectancy for non-elderly patients up to 50% for patients in their 40s undergoing mechanical aortic valve replacement. Bioprostheses carry an even worse long-term survival, with higher rates of re-intervention. The promise of trans-catheter valve-in-valve technology is accentuating the trend of bioprosthetic implantation in younger patients, without yet the appropriate evidence. In contrast, aortic valve repair has shown excellent outcomes in terms of quality of life, freedom from re-operation and freedom from major adverse valve-related events with similar life expectancy to general population as it is also found for the Ross procedure, the only available living valve substitute. We are at a time when the paradigm of aortic valve surgery needs to change for the better. To better serve our patients, we must acquire high quality real-world evidence from multiple centers globally - this is the vision of the AVIATOR registry and our common responsibility.
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Affiliation(s)
- Emmanuel Lansac
- Department of Cardiac Surgery, Institut Mutualiste Montsouris, Paris, France.
| | - Pouya Youssefi
- Department of Cardiac Surgery, Institut Mutualiste Montsouris, Paris, France
| | - Frederiek de Heer
- Department of Cardiothoracic Surgery, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Joseph Bavaria
- Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Laurent De Kerchove
- Department of Cardiovascular and Thoracic Surgery, Cliniques Universitaires Saint-Luc, Bruxelles, Belgium
| | - Ismail El-Hamamsy
- Department of Cardiac Surgery, Montreal Heart Institute, Montréal, Canada
| | - Gebrine Elkhoury
- Department of Cardiovascular and Thoracic Surgery, Cliniques Universitaires Saint-Luc, Bruxelles, Belgium
| | | | | | - Jolanda Kluin
- Department of Cardiothoracic Surgery, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Philippe Pibarot
- Department of Cardiology, Quebec Heart and Lung Institute, Quebec City, Quebec, Canada
| | - Hans-Joachim Schäfers
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg, Germany
| | - Jean-Louis Vanoverschelde
- Department of Cardiovascular and Thoracic Surgery, Cliniques Universitaires Saint-Luc, Bruxelles, Belgium
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Yamashita K, Fukushima S, Shimahara Y, Hamatani Y, Kanzaki H, Fukuda T, Izumi C, Yasuda S, Kobayashi J, Fujita T. Early outcomes of transcatheter aortic valve implantation for degenerated aortic bioprostheses in Japanese patients: insights from the AORTIC VIV study. Gen Thorac Cardiovasc Surg 2019; 67:1038-1047. [DOI: 10.1007/s11748-019-01133-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 04/25/2019] [Indexed: 01/12/2023]
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44
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Aalaei-Andabili SH, Bavry AA. Left Ventricular Diastolic Dysfunction and Transcatheter Aortic Valve Replacement Outcomes: A Review. Cardiol Ther 2019; 8:21-28. [PMID: 30847743 PMCID: PMC6525224 DOI: 10.1007/s40119-019-0134-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Indexed: 12/23/2022] Open
Abstract
Aortic stenosis (AS) is the most common valvular disease that can lead to increased afterload, left ventricular (LV) remodeling, and myocardial fibrosis. We reviewed the literature addressing the impact of transcatheter aortic valve replacement (TAVR) on LV remodeling and patients' outcomes by elimination of AS-related high afterload. TAVR reduces afterload and improves LV remodeling recovery. However, myocardial fibrosis may not completely reverse after the TAVR. The LV diastolic dysfunction (LVDD) induced by AS is an independent predictor of post-TAVR mortality, and mortality increases with severity of LVDD. The impact of diastolic dysfunction on patient outcomes emerges at 30 days but continues to persist during mid-term follow-up. Based on severity of the baseline LVDD, some patients may tolerate post-TAVR aortic regurgitation (AR), but even minimal post-TAVR AR in patients with severe baseline LVDD can have an additive negative impact on survival. It is crucial to consider TAVR prior to development of advanced LVDD. Appropriate device selection and deployment technique are important in improvement of TAVR outcomes via elimination of AR.
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Affiliation(s)
| | - Anthony A Bavry
- Department of Medicine, University of Florida, Gainesville, FL, USA.
- North Florida/South Georgia Veterans Health System, Gainesville, FL, USA.
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45
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Girdauskas E, Petersen J, Sachweh J, Kozlik-Feldmann R, Sinning C, Rickers C, von Kodolitsch Y, Reichenspurner H. Aortic valve repair in adult congenital heart disease. Cardiovasc Diagn Ther 2019; 8:789-798. [PMID: 30740326 DOI: 10.21037/cdt.2018.11.01] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Aortic valve repair in adult congenital heart disease (ACHD) went through a major development during the last two decades to become an increasingly established treatment option in experienced heart valve repair centers. This mini-review addresses valve-sparing treatment strategies in the two most common clinical entities of patients with adult congenital aortic valve disease, namely those presenting with bicuspid (BAV) and unicuspid (UAV) aortic valve disease. Both diseases are integral components of the continuum of congenital aortic valve diseases and represent one of the most common reasons of cardiovascular morbidity in young and otherwise healthy adult patients. The review will highlight the most important advantages of aortic valve sparing procedures as compared to the conventional valve replacement strategy. New treatment aspects will be reviewed including minimally-invasive surgical approaches for aortic valve repair as well as modern protocols of enhanced perioperative recovery which will potentially improve the perioperative recovery and quality of life of the patients undergoing valve-sparing surgical procedures in the future.
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Affiliation(s)
- Evaldas Girdauskas
- Department of Cardiac and Cardiovascular Surgery, University Heart Center Hamburg, Hamburg, Germany.,German Center of Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Johannes Petersen
- Department of Cardiac and Cardiovascular Surgery, University Heart Center Hamburg, Hamburg, Germany.,German Center of Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Jörg Sachweh
- Department of Pediatric Cardiology and Cardiac Surgery, University Heart Center Hamburg, Hamburg, Germany
| | - Rainer Kozlik-Feldmann
- Department of Pediatric Cardiology and Cardiac Surgery, University Heart Center Hamburg, Hamburg, Germany
| | - Christoph Sinning
- German Center of Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany.,Department of General and Interventional Cardiology, University Heart Center Hamburg, Hamburg, Germany
| | - Carsten Rickers
- Department of Pediatric Cardiology and Cardiac Surgery, University Heart Center Hamburg, Hamburg, Germany
| | - Yskert von Kodolitsch
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Hamburg, Germany
| | - Hermann Reichenspurner
- Department of Cardiac and Cardiovascular Surgery, University Heart Center Hamburg, Hamburg, Germany.,German Center of Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
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Del Bene MR, Barletta G, Venditti F, Di Mario C, Blanzola C, Stefàno P. Left ventricular mass regression after aortic valve replacement: Sex differences or effect of different methods of indexation? Echocardiography 2018; 36:219-228. [DOI: 10.1111/echo.14221] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 11/07/2018] [Accepted: 11/08/2018] [Indexed: 11/30/2022] Open
Affiliation(s)
| | | | | | - Carlo Di Mario
- Structural Interventional CardiologyCareggi University Hospital Florence Italy
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47
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Mazine A, El-Hamamsy I, Verma S, Peterson MD, Bonow RO, Yacoub MH, David TE, Bhatt DL. Ross Procedure in Adults for Cardiologists and Cardiac Surgeons. J Am Coll Cardiol 2018; 72:2761-2777. [DOI: 10.1016/j.jacc.2018.08.2200] [Citation(s) in RCA: 92] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 08/19/2018] [Indexed: 01/07/2023]
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Colli A, Bizzotto E, Besola L, Gregori D, Toto F, Manzan E, Gerosa G. Risk stratification of severe aortic stenosis according to new guidelines: long term outcomes. J Thorac Dis 2018; 10:5833-5841. [PMID: 30505491 DOI: 10.21037/jtd.2018.09.152] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background Current ESC and ACC/AHA guidelines for the management of valvular heart disease assign a class Ia indication for aortic valve replacement (AVR) only to patients with symptomatic severe aortic valve stenosis and asymptomatic patients with depressed left ventricular ejection fraction (LVEF <50%) or positive exercise test. We examined the long-term outcomes for patients undergoing AVR for aortic stenosis over a 11-year period at our institution compared to current international guidelines for AVR. Methods Patients who had undergone isolated AVR for severe aortic valve stenosis between January 2001 and December 2012 were selected. The population was divided into subgroups based on preoperative LVEF (< or ≥50%) and on presence/absence of symptoms (NYHA =I or ≥II, respectively). Results We identified 607 patients with a median follow-up (FU) time of 5.75 years (IQR 3.24-8.00 years). The presence of symptoms did not have a significant impact on cardiovascular mortality (P=0.201). Patients with LVEF <50% displayed a higher long-term cardiovascular mortality rate (P=0.015). Multivariate analysis showed that preserved LVEF was a protective factor for asymptomatic patients (P=0.021), while preoperative LVEF did not affect the mortality rate in symptomatic patients (HR 0.88; 95% CI, 0.54-1.44). Correspondingly, asymptomatic patients with reduced LVEF were found to be at a higher risk of long-term mortality compared to the other groups (P=0.011). The only other independent risk factor for death was age (HR 6.46; 95% CI, 2.22-18.76). Conclusions According to our data, current international class I indications for symptomatic patients ensure good long-term survival, while class I indications for asymptomatic patients with reduced LVEF are associated with poor long-term survival. Our results suggest that early surgery should also be considered also for asymptomatic patients with preserved LVEF, particularly in cases of very low operative risk.
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Affiliation(s)
- Andrea Colli
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Eleonora Bizzotto
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Laura Besola
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Dario Gregori
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Francesca Toto
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Erica Manzan
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Gino Gerosa
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
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Fung MJ, Thomas L, Leung DY. Alterations in Layer-Specific Left Ventricular Global Longitudinal and Circumferential Strain in Patients With Aortic Stenosis: A Comparison of Aortic Valve Replacement versus Conservative Management Over a 12-Month Period. J Am Soc Echocardiogr 2018; 32:92-101. [PMID: 30236621 DOI: 10.1016/j.echo.2018.07.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Impairment in left ventricular (LV) systolic strain in aortic stenosis (AS) is well documented. However, alterations in layer-specific LV global longitudinal strain (GLS) and global circumferential strain (GCS) and their recovery following surgical aortic valve replacement (AVR) have not been established. The aim of this study was to examine layer-specific changes in GLS and GCS in patients with AS undergoing AVR and compare these patients with those managed conservatively over 12 months. METHODS Eighty-six patients (mean age, 68.8 ± 12 years; 60 men) with AS (19 mild, 15 moderate, and 52 severe) were prospectively recruited. Patients with coronary disease or other significant valvular disease were excluded. Forty patients (46.5%) with severe AS underwent AVR. All patients underwent baseline echocardiography. Patients managed conservatively underwent follow-up echocardiography at 12 months. Patients undergoing AVR underwent follow-up echocardiography at 1 week and 3, 6, and 12 months after AVR. RESULTS There was worsening in subendocardial but not subepicardial or transmural GLS even in mild AS (-20.9 ± 1.0% vs -20.6 ± 0.8%, P = .012). In moderate AS, worsening in subendocardial (-19.6 ± 0.9% vs -18.2 ± 1.5%, P = .003), subepicardial (-14.9 ± 1.0% vs -13.8 ± 1.2%, P = .004), and transmural (-17.1 ± 0.9% vs -15.8 ± 1.3%, P = .03) GLS and a trend toward significant worsening in subendocardial GCS (-29.8 ± 5.16% vs -27.5 ± 5%, P = .054) were seen. Conservatively managed patients with severe AS had significant worsening in subendocardial (-16.1 ± 1.6% vs -13.9 ± 2.6%, P = .021), subepicardial (-11.6 ± 1.1% vs -10.1 ± 2.1%, P = .027), and transmural (-13.6 ± 1.3% vs -11.8 ± 2.3%, P = .02) GLS and subendocardial (-24.9 ± 3.6% vs -20.8 ± 4.5%, P = .002) and transmural (-16.9 ± 1.7% vs -14.3 ± 3.5%, P = .04) GCS on follow-up. Patients after AVR demonstrated significant improvement in GLS (from 3 months) and GCS (from 6 months) in both myocardial layers. CONCLUSIONS Patients with AS managed conservatively had worsening of GLS over 12 months despite preserved LV ejection fraction, detected earliest in the subendocardial layer. GCS became progressively impaired in moderate and severe AS. Improvement in LV strain after AVR was seen earlier with GLS (from 3 months) than with GCS (from 6 months) in both myocardial layers.
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Affiliation(s)
- Matle J Fung
- Cardiology Department, Liverpool Hospital, Liverpool, Sydney, Australia; South Western Sydney Clinical School, Faculty of Medicine, The University of New South Wales, Sydney, Australia.
| | - Liza Thomas
- Cardiology Department, Liverpool Hospital, Liverpool, Sydney, Australia; South Western Sydney Clinical School, Faculty of Medicine, The University of New South Wales, Sydney, Australia; Cardiology Department, Westmead Hospital, Westmead, Sydney, Australia; Faculty of Medicine, The University of Sydney, Sydney, Australia
| | - Dominic Y Leung
- Cardiology Department, Liverpool Hospital, Liverpool, Sydney, Australia; South Western Sydney Clinical School, Faculty of Medicine, The University of New South Wales, Sydney, Australia
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Tam DY, Hughes A, Wijeysundera HC, Fremes SE. Cost-Effectiveness of Self-Expandable Transcatheter Aortic Valves in Intermediate-Risk Patients. Ann Thorac Surg 2018; 106:676-683. [DOI: 10.1016/j.athoracsur.2018.03.069] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 03/09/2018] [Accepted: 03/26/2018] [Indexed: 11/27/2022]
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