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Chen JS, Huang JH, Chiu KM, Chiang CY. Extent of Left Ventricular Mass Regression and Impact of Global Left Ventricular Afterload on Cardiac Events and Mortality after Aortic Valve Replacement. J Clin Med 2022; 11:jcm11247482. [PMID: 36556098 PMCID: PMC9783780 DOI: 10.3390/jcm11247482] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/09/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022] Open
Abstract
Patient-prosthesis mismatch (PPM) causes a high transvalvular pressure gradient and residual left ventricular (LV) hypertrophy, consequently influencing long-term results. This study aimed to find the relationships between hemodynamic parameters and LV mass regression and determine the risk predictors of major adverse cardiovascular and cerebral events (MACCE) after aortic valve replacement (AVR) for aortic stenosis. Methods and Results: Preoperative and postoperative Doppler echocardiography data were evaluated for 120 patients after AVR. The patients' mean age was 67.7 years; 55% of the patients were male. Forty-four (37%) patients suffered from MACCE during a mean follow-up period of 3.6 ± 2 years. The following hemodynamic parameters at follow-up were associated with lower relative indexed LV mass (LVMI) regression: lower postoperative indexed effective orifice area, greater mean transvalvular pressure gradient (MPG), greater stroke work loss (SWL), and concentric or eccentric LV remodeling mode. The following hemodynamic parameters at follow-up were associated with a higher risk of MACCE: higher valvuloarterial impedance (ZVA), greater SWL, greater MPG, greater relative wall thickness, greater LVMI, and hypertrophic LV remodeling mode. Lower relative LVMI regression was associated with a higher risk of MACCE (hazard ratio, 1.01: 95% confidence interval, 1.003-1.03). The corresponding cutoff of relative LVMI regression was -14%. Conclusions: Changes in hemodynamic parameters were independently associated with relative LVMI regression. Impaired reverse remodeling and persistent residual LV hypertrophy were independent risk predictors of MACCE. An LVMI regression lower than 14% indicated higher MACCE. A postoperative ZVA greater than 3.5 mmHg/mL/m2 was an independent risk predictor of cardiac events and mortality after AVR. Preventive strategies should be used at the time of the operation to avoid PPM.
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Affiliation(s)
- Jer-Shen Chen
- Department of Cardiovascular Surgery, Cardiovascular Center, Far Eastern Memorial Hospital, New Taipei City 220216, Taiwan
- Department of Healthcare Administration, Asian Eastern University of Science and Technology, New Taipei City 220303, Taiwan
| | - Jih-Hsin Huang
- Department of Cardiovascular Surgery, Cardiovascular Center, Far Eastern Memorial Hospital, New Taipei City 220216, Taiwan
- Department of Applied Cosmetology, LeeMing Institute of Technology, New Taipei City 243083, Taiwan
| | - Kuan-Ming Chiu
- Department of Cardiovascular Surgery, Cardiovascular Center, Far Eastern Memorial Hospital, New Taipei City 220216, Taiwan
- Department of Electrical Engineering, Yuan Ze University, Taoyuan 320315, Taiwan
| | - Chih-Yao Chiang
- Department of Cardiovascular Surgery, Cardiovascular Center, Far Eastern Memorial Hospital, New Taipei City 220216, Taiwan
- Division of Cardiovascular Surgery, Department of Surgery, School of Medicine, National Defense Medical Center, Taipei 114201, Taiwan
- Correspondence: ; Tel.: +886-2-7728-1618; Fax: +886-2-7738-6057
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Yamamoto N, Ito H, Inoue K, Futsuki A, Hirano K, Shomura Y, Ozu Y, Katayama Y, Komada T, Takao M. Impact of valvuloarterial impedance on left ventricular reverse remodeling after aortic valve neocuspidization. J Cardiothorac Surg 2022; 17:13. [PMID: 35093156 PMCID: PMC8800295 DOI: 10.1186/s13019-022-01760-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 01/15/2022] [Indexed: 01/19/2023] Open
Abstract
Background Aortic valve neocuspidization (AVNeo) has emerged as a promising aortic valve procedure, and is expected to have a larger effective orifice area (EOA) than commercially available bioprostheses. It is, however, unclear which indices could facilitate left ventricular (LV) reverse remodeling after AVNeo. The aim of this study is to verify the impact of global left ventricular afterload on the LV reverse remodeling following AVNeo. Methods Data-available consecutive 38 patients (median age, 77; interquartile range, 72.8–82.0) undergoing AVNeo for severe aortic stenosis were enrolled in this study. Preoperative and the last follow-up echocardiographic data were retrospectively analyzed including the valvuloarterial impedance (Zva), a marker of global LV afterload. Reduction in LV geometry index (LVGI) and relative wall thickness (RWT) were used as an indicator for LV reverse remodeling. Results The Zva reduced in 24 patients (63.2%) during the follow-up period (median, 12 months). Reduction in Zva significantly correlated to improvement of LV geometry (LVGI (r = 0.400, p = 0.013) and RWT (r = 0.627, p < 0.001)), whereas increase in EOA index did not significantly correlate to LVGI (r = 0.009, p = 0.957), or RWT (r = 0.105, p = 0.529)). The reduction in Zva was the multivariate predictor of LV reverse remodeling. Conclusions Low global LV afterload led to significant LV reverse remodeling even after AVNeo, which could achieve better valve performance than the conventional bioprostheses.
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3
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Ngiam JN, Chew NWS, Pramotedham T, Tan BYQ, Sim HW, Ruan W, Sia CH, Kong WKF, Yeo TC, Poh KK. Low Relative Valve Load is Associated With Paradoxical Low-Flow Aortic Stenosis Despite Preserved Left Ventricular Ejection Fraction and Adverse Clinical Outcomes. Heart Lung Circ 2021; 31:128-135. [PMID: 34116941 DOI: 10.1016/j.hlc.2021.05.075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 03/03/2021] [Accepted: 05/03/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Paradoxical low-flow (LF) severe aortic stenosis (AS) despite preserved left ventricular (LV) ejection fraction (LVEF) has been shown to be distinct from normal-flow (NF) AS, with a poorer prognosis. Relative valve load (RVL) is a novel echocardiographic haemodynamic index based on the ratio of transaortic mean pressure gradient to the global valvulo-arterial impedance (Zva) in order to estimate the contribution of the valvular afterload to the global LV load. We aimed to determine the usefulness of RVL in LF AS versus NF AS. METHOD A total of 450 consecutive patients with medically managed severe AS (aortic valve area <1.0 cm2) with preserved LVEF (>50%) were studied. Patients were divided into LF (stroke volume index <35 mL/m2) or NF, and high RVL or low RVL. Baseline clinical and echocardiographic profiles, as well as clinical outcomes, were compared. RESULTS There were 149 (33.1%) patients with LF. Despite higher global impedance in LF (Zva 6.3±2.4 vs 3.9±0.9 mmHg/mL/m2; p<0.001) compared with NF, the RVL in LF AS was significantly lower (5.4±2.7 vs 9.8±5.1 mL/m2; p<0.001). On multivariable analysis, low RVL (≤7.51) remained independently associated with poor clinical outcomes on Cox regression (hazard ratio, 1.31; 95% confidence interval, 1.03-1.68), with 53.2% sensitivity and 70.3% specificity. This was comparable to other prognostic indices in AS. Kaplan-Meier curves demonstrated that low RVL was associated with increased mortality. CONCLUSIONS Increased systemic arterial afterload may be important in the pathophysiology of LF AS. Low RVL was an independent predictor of poor clinical outcomes in medically managed severe AS. There may be a greater role in the attenuation of systemic arterial afterload in AS to improve outcomes.
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Affiliation(s)
- Jinghao N Ngiam
- Department of Medicine, National University Health System, Singapore
| | - Nicholas W S Chew
- Department of Medicine, National University Health System, Singapore
| | | | - Benjamin Y Q Tan
- Department of Medicine, National University Health System, Singapore
| | - Hui-Wen Sim
- Department of Cardiology, National University Heart Centre Singapore, National University Health System, Singapore
| | - Wen Ruan
- National Heart Centre Singapore, Singapore
| | - Ching-Hui Sia
- Department of Cardiology, National University Heart Centre Singapore, National University Health System, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - William K F Kong
- Department of Cardiology, National University Heart Centre Singapore, National University Health System, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Tiong-Cheng Yeo
- Department of Cardiology, National University Heart Centre Singapore, National University Health System, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Kian-Keong Poh
- Department of Cardiology, National University Heart Centre Singapore, National University Health System, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
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4
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Yousef A, Hibbert B, Feder J, Bernick J, Russo J, MacDonald Z, Glover C, Dick A, Boodhwani M, Lam BK, Ruel M, Labinaz M, Burwash IG. A novel echocardiographic hemodynamic index for predicting outcome of aortic stenosis patients following transcatheter aortic valve replacement. PLoS One 2018; 13:e0195641. [PMID: 29698407 PMCID: PMC5919479 DOI: 10.1371/journal.pone.0195641] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 03/26/2018] [Indexed: 11/29/2022] Open
Abstract
Objective Transcatheter aortic valve replacement (TAVR) reduces left ventricular (LV) afterload and improves prognosis in aortic stenosis (AS) patients. However, LV afterload consists of both valvular and arterial loads, and the benefits of TAVR may be attenuated if the arterial load dominates. We proposed a new hemodynamic index, the Relative Valve Load (RVL), a ratio of mean gradient (MG) and valvuloarterial impedance (Zva), to describe the relative contribution of the valvular load to the global LV load, and examined whether RVL predicted patient outcome following TAVR. Methods A total of 258 patients with symptomatic severe AS (indexed aortic valve area (AVA)<0.6cm2/m2, AR≤2+) underwent successful TAVR at the University of Ottawa Heart Institute and had clinical follow-up to 1-year post-TAVR. Pre-TAVR MG, AVA, percent stroke work loss (%SWL), Zva and RVL were measured by echocardiography. The primary endpoint was all cause mortality at 1-year post TAVR. Results There were 53 deaths (20.5%) at 1-year. RVL≤7.95ml/m2 had a sensitivity of 60.4% and specificity of 75.1% for identifying all cause mortality at 1-year post-TAVR and provided better specificity than MG<40 mmHg, AVA>0.75cm2, %SWL≤25% and Zva>5mmHg/ml/m2 despite equivalent or better sensitivity. In multivariable Cox analysis, RVL≤7.95ml/m2 was an independent predictor of all cause mortality (HR 3.2, CI 1.8–5.9; p<0.0001). RVL≤7.95ml/m2 was predictive of all cause mortality in both low flow and normal flow severe AS. Conclusions RVL is a strong predictor of all-cause mortality in severe AS patients undergoing TAVR. A pre-procedural RVL≤7.95ml/m2 identifies AS patients at increased risk of death despite TAVR and may assist with decision making on the benefits of TAVR.
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Affiliation(s)
- Altayyeb Yousef
- Division of Cardiology, University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Benjamin Hibbert
- Division of Cardiology, University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Joshua Feder
- Division of Cardiology, University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Jordan Bernick
- Division of Cardiology, University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Juan Russo
- Division of Cardiology, University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Zachary MacDonald
- Division of Cardiology, University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Christopher Glover
- Division of Cardiology, University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Alexander Dick
- Division of Cardiology, University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Munir Boodhwani
- Division of Cardiac Surgery, University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Buu-Khanh Lam
- Division of Cardiac Surgery, University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Marc Ruel
- Division of Cardiac Surgery, University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Marino Labinaz
- Division of Cardiology, University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Ian G. Burwash
- Division of Cardiology, University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
- * E-mail:
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5
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Dobutamine Stress Echocardiography for Management of Low-Flow, Low-Gradient Aortic Stenosis. J Am Coll Cardiol 2018; 71:475-485. [DOI: 10.1016/j.jacc.2017.11.052] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Revised: 11/02/2017] [Accepted: 11/20/2017] [Indexed: 01/08/2023]
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6
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Abstract
Aortic stenosis (AS) is the most common primary valve disorder in the elderly with an increasing prevalence. It is increasingly clear that it is also a disease of the left ventricle (LV) rather than purely the aortic valve. The transition from left ventricular hypertrophy to fibrosis results in the eventual adverse effects on systolic and diastolic function. Appropriate selection of patients for aortic valve intervention is crucial, and current guidelines recommend aortic valve replacement in severe AS with symptoms or in asymptomatic patients with left ventricular ejection fraction (LVEF) <50 %. LVEF is not a sensitive marker and there are other parameters used in multimodality imaging techniques, including longitudinal strain, exercise stress echo and cardiac MRI that may assist in detecting subclinical and subtle LV dysfunction. These findings offer potentially better ways to evaluate patients, time surgery, predict recovery and potentially offer targets for specific therapies. This article outlines the pathophysiology behind the LV response to aortic stenosis and the role of advanced multimodality imaging in describing it.
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7
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Ito H, Mizumoto T, Shomura Y, Sawada Y, Kajiyama K, Shimpo H. The impact of global left ventricular afterload on left ventricular reverse remodeling after aortic valve replacement. J Card Surg 2017; 32:530-536. [DOI: 10.1111/jocs.13190] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- Hisato Ito
- Department of Cardiothoracic Surgery; Anjo Kosei Hospital; 28 Higashi-Hirokute Anjo City Aichi 446-8602 Japan
- Department of Thoracic and Cardiovascular Surgery; Mie University; 2-174 Edobashi Tsu Mie 514-8507 Japan
| | - Toru Mizumoto
- Department of Cardiothoracic Surgery; Anjo Kosei Hospital; 28 Higashi-Hirokute Anjo City Aichi 446-8602 Japan
| | - Yu Shomura
- Department of Cardiothoracic Surgery; Anjo Kosei Hospital; 28 Higashi-Hirokute Anjo City Aichi 446-8602 Japan
| | - Yasuhiro Sawada
- Department of Cardiothoracic Surgery; Anjo Kosei Hospital; 28 Higashi-Hirokute Anjo City Aichi 446-8602 Japan
| | - Ko Kajiyama
- Department of Cardiothoracic Surgery; Anjo Kosei Hospital; 28 Higashi-Hirokute Anjo City Aichi 446-8602 Japan
| | - Hideto Shimpo
- Department of Thoracic and Cardiovascular Surgery; Mie University; 2-174 Edobashi Tsu Mie 514-8507 Japan
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8
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Ngiam JN, Tan BYQ, Sia CH, Lee GK, Kong WK, Chan YH, Poh KK. Comparing characteristics and clinical and echocardiographic outcomes in low-flow vs normal-flow severe aortic stenosis with preserved ejection fraction in an Asian population. Echocardiography 2017; 34:638-648. [DOI: 10.1111/echo.13525] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
| | | | - Ching-Hui Sia
- University Medicine Cluster; National University Health System; Singapore
| | - Glenn K.M. Lee
- University Medicine Cluster; National University Health System; Singapore
| | - William K.F. Kong
- Department of Cardiology; National University Heart Center Singapore; Singapore
| | - Yiong-Huak Chan
- Biostatistics Unit; Yong Loo Lin School of Medicine; National University of Singapore; Singapore
| | - Kian-Keong Poh
- Department of Cardiology; National University Heart Center Singapore; Singapore
- Yong Loo Lin School of Medicine; National University of Singapore; Singapore
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9
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Cardiac Imaging for Assessing Low-Gradient Severe Aortic Stenosis. JACC Cardiovasc Imaging 2017; 10:185-202. [DOI: 10.1016/j.jcmg.2017.01.002] [Citation(s) in RCA: 116] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 12/26/2016] [Accepted: 01/05/2017] [Indexed: 12/13/2022]
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10
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Abstract
OPINION STATEMENT Severe low-gradient (LG) aortic stenosis (AS) [aortic valve area (AVA) ≤ 1.0 cm(2), mean pressure gradient (MG) < 40 mmHg] represents a frequently encountered and challenging clinical dilemma. A systematic approach, which often requires several imaging modalities, should be undertaken to confirm the hemodynamic findings and rule out measurement error. Low-flow conditions often account for the discrepancy and can be present whether the left ventricular ejection fraction (LVEF) is depressed or normal. In patients with classical low-flow (LF), LG AS in which LVEF is reduced (<40-50 %), dobutamine stress echocardiography (DSE) should be used to distinguish patients with true severe AS and pseudo-severe AS, as well as to evaluate for the presence of left ventricular contractile or flow reserve. Surgical or transcatheter aortic valve replacement (AVR) should likely be reserved for those patients with true severe AS. Patient outcome with medical or surgical management generally relates to patient functional capacity, stenosis severity, and left ventricular functional reserve. Patients with severe LG AS with preserved LVEF can have a stroke volume that is either normal (>35 mL/m(2)) or low (<35 mL/m(2)). New data suggest that DSE can identify pseudo-severe AS in up to 30 % of patients with severe LF-LG AS with preserved LVEF. AVR should likely be restricted to those patients with true severe AS, although there is currently little data to support this strategy. Symptomatic patients with severe LG AS with preserved LVEF, whether they have normal or low flow, should be offered AVR. Transcatheter AVR provides an alternative therapeutic option in the high-risk patient.
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11
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Burwash IG. Echocardiographic Evaluation of Aortic Stenosis - Normal Flow and Low Flow Scenarios. Eur Cardiol 2014; 9:92-99. [PMID: 30310493 PMCID: PMC6159432 DOI: 10.15420/ecr.2014.9.2.92] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Accepted: 11/11/2014] [Indexed: 02/07/2023] Open
Abstract
The echocardiographic evaluation of the patient with aortic stenosis (AS) has evolved in recent years, beyond confirming the diagnosis and measuring the resting mean pressure gradient or valve area. New echocardiographic approaches have developed to address the clinical dilemmas related to discordant haemodynamic data, asymptomatic haemodynamically severe AS and low-flow, low-gradient AS in order to better evaluate the disease severity, enhance the risk stratification of patients and provide important prognostic information. This article reviews the echocardiographic evaluation of the AS patient and focuses on the echocardiographic assessment of the haemodynamic severity, the prediction of clinical outcome and the use of echocardiography to guide patient management in the presence of normal flow and low flow scenarios.
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Affiliation(s)
- Ian G Burwash
- University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
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12
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Mookadam F, Moustafa SE, Khandheria B. Management of aortic valve disease in the presence of left ventricular dysfunction. Expert Rev Cardiovasc Ther 2014; 8:259-68. [DOI: 10.1586/erc.09.171] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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13
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Svensson LG, Adams DH, Bonow RO, Kouchoukos NT, Miller DC, O'Gara PT, Shahian DM, Schaff HV, Akins CW, Bavaria JE, Blackstone EH, David TE, Desai ND, Dewey TM, D'Agostino RS, Gleason TG, Harrington KB, Kodali S, Kapadia S, Leon MB, Lima B, Lytle BW, Mack MJ, Reardon M, Reece TB, Reiss GR, Roselli EE, Smith CR, Thourani VH, Tuzcu EM, Webb J, Williams MR. Aortic Valve and Ascending Aorta Guidelines for Management and Quality Measures. Ann Thorac Surg 2013; 95:S1-66. [DOI: 10.1016/j.athoracsur.2013.01.083] [Citation(s) in RCA: 160] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2012] [Revised: 12/24/2012] [Accepted: 01/15/2013] [Indexed: 12/31/2022]
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Rieck ÅE, Cramariuc D, Boman K, Gohlke-Bärwolf C, Staal EM, Lønnebakken MT, Rossebø AB, Gerdts E. Hypertension in Aortic Stenosis. Hypertension 2012; 60:90-7. [DOI: 10.1161/hypertensionaha.112.194878] [Citation(s) in RCA: 100] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The impact of hypertension on left ventricular structure and outcome during progression of aortic valve stenosis has not been reported from a large prospective study. Data from 1616 patients with asymptomatic aortic stenosis randomized to placebo-controlled treatment with combined simvastatin and ezetimibe in the Simvastatin Ezetimibe in Aortic Stenosis Study were used. The primary study end point included combined cardiovascular death, aortic valve events, and ischemic cardiovascular events. Hypertension was defined as history of hypertension or elevated baseline blood pressure. Left ventricular hypertrophy was defined as left ventricular mass/height
2.7
≥46.7 g/m
2.7
in women and ≥49.2 g/m
2.7
in men and concentric geometry as relative wall thickness ≥0.43. Baseline peak aortic jet velocity and aortic stenosis progression rate did not differ between hypertensive (n=1340) and normotensive (n=276) patients. During 4.3 years of follow-up, the prevalence of concentric left ventricular hypertrophy increased 3 times in both groups. Hypertension predicted 51% higher incidence of abnormal LV geometry at final study visit independent of other confounders (
P
<0.01). In time-varying Cox regression, hypertension did not predict increased rate of the primary study end point. However, hypertension was associated with a 56% higher rate of ischemic cardiovascular events and a 2-fold increased mortality (both
P
<0.01), independent of aortic stenosis severity, abnormal left ventricular geometry, in-treatment systolic blood pressure, and randomized study treatment. No impact on aortic valve replacement was found. In conclusion, among patients with initial asymptomatic mild-to-moderate aortic stenosis, hypertension was associated with more abnormal left ventricular structure and increased cardiovascular morbidity and mortality.
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Affiliation(s)
- Åshild E. Rieck
- From the Institute of Medicine (A.E.R., M.T.L., E.G.), University of Bergen, Bergen, Norway; Department of Heart Disease (D.C., M.T.L., E.G.), Haukeland University Hospital, Bergen, Norway; Department of Medicine (K.B.), Skellefteaa Hospital and Umeaa University, Skellefteaa, Sweden; Herz-Zentrum Bad Krozingen (C.G.-B.), Bad Krozingen, Germany; Department of Cardiology (E.M.S.), Stavanger University Hospital, Stavanger, Norway; Division of Cardiology (A.B.R.), Aker University Hospital, Oslo, Norway
| | - Dana Cramariuc
- From the Institute of Medicine (A.E.R., M.T.L., E.G.), University of Bergen, Bergen, Norway; Department of Heart Disease (D.C., M.T.L., E.G.), Haukeland University Hospital, Bergen, Norway; Department of Medicine (K.B.), Skellefteaa Hospital and Umeaa University, Skellefteaa, Sweden; Herz-Zentrum Bad Krozingen (C.G.-B.), Bad Krozingen, Germany; Department of Cardiology (E.M.S.), Stavanger University Hospital, Stavanger, Norway; Division of Cardiology (A.B.R.), Aker University Hospital, Oslo, Norway
| | - Kurt Boman
- From the Institute of Medicine (A.E.R., M.T.L., E.G.), University of Bergen, Bergen, Norway; Department of Heart Disease (D.C., M.T.L., E.G.), Haukeland University Hospital, Bergen, Norway; Department of Medicine (K.B.), Skellefteaa Hospital and Umeaa University, Skellefteaa, Sweden; Herz-Zentrum Bad Krozingen (C.G.-B.), Bad Krozingen, Germany; Department of Cardiology (E.M.S.), Stavanger University Hospital, Stavanger, Norway; Division of Cardiology (A.B.R.), Aker University Hospital, Oslo, Norway
| | - Christa Gohlke-Bärwolf
- From the Institute of Medicine (A.E.R., M.T.L., E.G.), University of Bergen, Bergen, Norway; Department of Heart Disease (D.C., M.T.L., E.G.), Haukeland University Hospital, Bergen, Norway; Department of Medicine (K.B.), Skellefteaa Hospital and Umeaa University, Skellefteaa, Sweden; Herz-Zentrum Bad Krozingen (C.G.-B.), Bad Krozingen, Germany; Department of Cardiology (E.M.S.), Stavanger University Hospital, Stavanger, Norway; Division of Cardiology (A.B.R.), Aker University Hospital, Oslo, Norway
| | - Eva M. Staal
- From the Institute of Medicine (A.E.R., M.T.L., E.G.), University of Bergen, Bergen, Norway; Department of Heart Disease (D.C., M.T.L., E.G.), Haukeland University Hospital, Bergen, Norway; Department of Medicine (K.B.), Skellefteaa Hospital and Umeaa University, Skellefteaa, Sweden; Herz-Zentrum Bad Krozingen (C.G.-B.), Bad Krozingen, Germany; Department of Cardiology (E.M.S.), Stavanger University Hospital, Stavanger, Norway; Division of Cardiology (A.B.R.), Aker University Hospital, Oslo, Norway
| | - Mai Tone Lønnebakken
- From the Institute of Medicine (A.E.R., M.T.L., E.G.), University of Bergen, Bergen, Norway; Department of Heart Disease (D.C., M.T.L., E.G.), Haukeland University Hospital, Bergen, Norway; Department of Medicine (K.B.), Skellefteaa Hospital and Umeaa University, Skellefteaa, Sweden; Herz-Zentrum Bad Krozingen (C.G.-B.), Bad Krozingen, Germany; Department of Cardiology (E.M.S.), Stavanger University Hospital, Stavanger, Norway; Division of Cardiology (A.B.R.), Aker University Hospital, Oslo, Norway
| | - Anne B. Rossebø
- From the Institute of Medicine (A.E.R., M.T.L., E.G.), University of Bergen, Bergen, Norway; Department of Heart Disease (D.C., M.T.L., E.G.), Haukeland University Hospital, Bergen, Norway; Department of Medicine (K.B.), Skellefteaa Hospital and Umeaa University, Skellefteaa, Sweden; Herz-Zentrum Bad Krozingen (C.G.-B.), Bad Krozingen, Germany; Department of Cardiology (E.M.S.), Stavanger University Hospital, Stavanger, Norway; Division of Cardiology (A.B.R.), Aker University Hospital, Oslo, Norway
| | - Eva Gerdts
- From the Institute of Medicine (A.E.R., M.T.L., E.G.), University of Bergen, Bergen, Norway; Department of Heart Disease (D.C., M.T.L., E.G.), Haukeland University Hospital, Bergen, Norway; Department of Medicine (K.B.), Skellefteaa Hospital and Umeaa University, Skellefteaa, Sweden; Herz-Zentrum Bad Krozingen (C.G.-B.), Bad Krozingen, Germany; Department of Cardiology (E.M.S.), Stavanger University Hospital, Stavanger, Norway; Division of Cardiology (A.B.R.), Aker University Hospital, Oslo, Norway
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Namboodiri N, Shajeem O, Tharakan J, Sankarkumar R, Titus T, Ajitkumar V, Sivasankaran S, Krishnamoorthy KM, Harikrishnan SP. Hemodynamic performance evaluation of TTK Chitra heart valve prosthesis in the aortic position using Doppler echocardiography. Int J Cardiol 2010; 141:102-5. [DOI: 10.1016/j.ijcard.2008.11.081] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2008] [Accepted: 11/16/2008] [Indexed: 11/16/2022]
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Clavel MA, Burwash IG, Mundigler G, Dumesnil JG, Baumgartner H, Bergler-Klein J, Sénéchal M, Mathieu P, Couture C, Beanlands R, Pibarot P. Validation of Conventional and Simplified Methods to Calculate Projected Valve Area at Normal Flow Rate in Patients With Low Flow, Low Gradient Aortic Stenosis: The Multicenter TOPAS (True or Pseudo Severe Aortic Stenosis) Study. J Am Soc Echocardiogr 2010; 23:380-6. [DOI: 10.1016/j.echo.2010.02.002] [Citation(s) in RCA: 102] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2009] [Indexed: 10/19/2022]
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New concepts in valvular hemodynamics: implications for diagnosis and treatment of aortic stenosis. Can J Cardiol 2009; 23 Suppl B:40B-47B. [PMID: 17932586 DOI: 10.1016/s0828-282x(07)71009-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Aortic valve stenosis (AS) is the third-most frequent heart disease after coronary artery disease and arterial hypertension, and it is associated with a high incidence of adverse outcomes. Recent data support the notion that AS is not an isolated disease uniquely limited to the valve. Indeed, AS is frequently associated with abnormalities of the systemic arterial system, and, in particular, with reduced arterial compliance, which may have important consequences for the pathophysiology and clinical outcome of this disease. Moreover, AS may also be associated with left ventricular systolic dysfunction and reduced transvalvular flow rate, which pose important challenges with regards to diagnostic evaluation and clinical decision making in AS patients. Hence, the assessment of AS severity, as well as its therapeutic management, should be conducted with the use of a comprehensive evaluation that includes not only the aortic valve, but also the systemic arterial system and the left ventricle because these three entities are tightly coupled from both a pathophysiological and a hemodynamic standpoint.
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Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O'Gara PT, O'Rourke RA, Otto CM, Shah PM, Shanewise JS, Nishimura RA, Carabello BA, Faxon DP, Freed MD, Lytle BW, O'Gara PT, O'Rourke RA, Shah PM. 2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1998 guidelines for the management of patients with valvular heart disease). Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 2008; 52:e1-142. [PMID: 18848134 DOI: 10.1016/j.jacc.2008.05.007] [Citation(s) in RCA: 1055] [Impact Index Per Article: 65.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O'Gara PT, O'Rourke RA, Otto CM, Shah PM, Shanewise JS. 2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2008; 118:e523-661. [PMID: 18820172 DOI: 10.1161/circulationaha.108.190748] [Citation(s) in RCA: 802] [Impact Index Per Article: 50.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Steinhauser ML, Stone PH. Risk stratification and management of aortic stenosis with concomitant left ventricular dysfunction. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2007; 9:490-500. [DOI: 10.1007/s11936-007-0044-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
PURPOSE OF REVIEW Valve replacement improves symptoms and survival in symptomatic severe aortic stenosis. Low-flow, low-gradient aortic stenosis, however, is an especially challenging subset as valve replacement has a significant risk, and may fail to alleviate symptoms or improve left ventricular function. This article reviews the potential problems in evaluating aortic stenosis severity in low-flow, low-gradient aortic stenosis, the utility of dobutamine challenge to identify patients most likely to benefit from surgery, and the factors predicting patient outcome. RECENT FINDINGS Low-flow, low-gradient aortic stenosis consists of a heterogeneous group of patients with 'true' severe aortic stenosis, in whom afterload mismatch results from a severely stenotic valve; and 'pseudo-severe' aortic stenosis, where the valve is only mildly or moderately stenotic, but appears severe due to limitations in determining disease severity under low-flow conditions. Valve replacement is likely to benefit the former group, but may have little benefit to the latter. Dobutamine challenge can distinguish 'true' and 'pseudo-severe' aortic stenosis, and can evaluate contractile reserve, one of the strongest predictors of patient outcome. Strategies to avoid prosthesis-patient mismatch should be considered to optimize postoperative outcome. SUMMARY Dobutamine challenge can identify low-flow, low-gradient aortic stenosis patients most likely to benefit from valve replacement and provides important prognostic information on the operative risks and long-term outcome.
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Affiliation(s)
- Ian G Burwash
- Department of Medicine, Division of Cardiology, University of Ottawa Heart Institute, University of Ottawa, Ontario, Canada.
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Echocardiographic Assessment of Valvular Heart Disease. CARDIOVASCULAR MEDICINE 2007. [DOI: 10.1007/978-1-84628-715-2_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Little SH, Chan KL, Burwash IG. Impact of blood pressure on the Doppler echocardiographic assessment of severity of aortic stenosis. Heart 2006; 93:848-55. [PMID: 17135222 PMCID: PMC1994465 DOI: 10.1136/hrt.2006.098392] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVE To investigate the impact of blood pressure (BP) on the Doppler echocardiographic (Doppler-echo) evaluation of severity of aortic stenosis (AS). METHODS Handgrip exercise or phenylephrine infusion was used to increase BP in 22 patients with AS. Indices of AS severity (mean pressure gradient (DeltaP(mean)), aortic valve area (AVA), valve resistance, percentage left ventricular stroke work loss (% LVSW loss) and the energy loss coefficient (ELCo)) were measured at baseline, peak BP intervention and recovery. RESULTS From baseline to peak intervention, mean (SD) BP increased (99 (8) vs 121 (10) mm Hg, p<0.001), systemic vascular resistance (SVR) increased (1294 (264) vs 1552 (372) dynexs/cm(5), p<0.001) and mean (SD) transvalvular flow rate (Q(mean)) decreased (323 (67) vs 306 (66) ml/s, p = 0.02). There was no change in DeltaP(mean) (36 (13) vs 36 (14) mm Hg, p = NS). However, there was a decrease in AVA (1.15 (0.32) vs 1.09 (0.33) cm(2), p = 0.02) and ELCo (1.32 (0.40) vs 1.24 (0.42) cm(2), p = 0.04), and an increase in valve resistance (153 (63) vs 164 (74) dynexs/cm(5), p = 0.02), suggesting a more severe valve stenosis. In contrast, % LVSW loss decreased (19.8 (6) vs 16.5 (6)%, p<0.001), suggesting a less severe valve stenosis. There was an inverse relationship between the change in mean BP and AVA (r = -0.34, p = 0.02); however, only the change in Q(mean) was an independent predictor of the change in AVA (r = 0.81, p<0.001). CONCLUSIONS Acute BP elevation due to increased SVR can affect the Doppler-echo evaluation of AS severity. However, the impact of BP on the assessment of AS severity depends primarily on the associated change in Q(mean), rather than on an independent effect of SVR or arterial compliance, and can result in a valve appearing either more or less stenotic depending on the direction and magnitude of the change in Q(mean).
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Affiliation(s)
- Stephen H Little
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
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Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O'Gara PT, O'Rourke RA, Otto CM, Shah PM, Shanewise JS, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Lytle BW, Nishimura R, Page RL, Riegel B. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing Committee to Revise the 1998 guidelines for the management of patients with valvular heart disease) developed in collaboration with the Society of Cardiovascular Anesthesiologists endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. J Am Coll Cardiol 2006; 48:e1-148. [PMID: 16875962 DOI: 10.1016/j.jacc.2006.05.021] [Citation(s) in RCA: 1091] [Impact Index Per Article: 60.6] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Bonow RO, Carabello BA, Kanu C, de Leon AC, Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O'Gara PT, O'Rourke RA, Otto CM, Shah PM, Shanewise JS, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Lytle BW, Nishimura R, Page RL, Riegel B. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): developed in collaboration with the Society of Cardiovascular Anesthesiologists: endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. Circulation 2006; 114:e84-231. [PMID: 16880336 DOI: 10.1161/circulationaha.106.176857] [Citation(s) in RCA: 1387] [Impact Index Per Article: 77.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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ACC/AHA 2006 Practice Guidelines for the Management of Patients With Valvular Heart Disease: Executive Summary. J Am Coll Cardiol 2006. [DOI: 10.1016/j.jacc.2006.05.030] [Citation(s) in RCA: 131] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Blais C, Burwash IG, Mundigler G, Dumesnil JG, Loho N, Rader F, Baumgartner H, Beanlands RS, Chayer B, Kadem L, Garcia D, Durand LG, Pibarot P. Projected valve area at normal flow rate improves the assessment of stenosis severity in patients with low-flow, low-gradient aortic stenosis: the multicenter TOPAS (Truly or Pseudo-Severe Aortic Stenosis) study. Circulation 2006; 113:711-21. [PMID: 16461844 DOI: 10.1161/circulationaha.105.557678] [Citation(s) in RCA: 177] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND We sought to investigate the use of a new parameter, the projected effective orifice area (EOAproj) at normal transvalvular flow rate (250 mL/s), to better differentiate between truly severe (TS) and pseudo-severe (PS) aortic stenosis (AS) during dobutamine stress echocardiography (DSE). Changes in various parameters of stenosis severity have been used to differentiate between TS and PS AS during DSE. However, the magnitude of these changes lacks standardization because they are dependent on the variable magnitude of the transvalvular flow change occurring during DSE. METHODS AND RESULTS The use of EOAproj to differentiate TS from PS AS was investigated in an in vitro model and in 23 patients with low-flow AS (indexed EOA <0.6 cm2/m2, left ventricular ejection fraction < or =40%) undergoing DSE and subsequent aortic valve replacement. For an individual valve, EOA was plotted against transvalvular flow (Q) at each dobutamine stage, and valve compliance (VC) was derived as the slope of the regression line fitted to the EOA versus Q plot; EOAproj was calculated as EOAproj=EOArest+VCx(250-Q(rest)), where EOArest and Q(rest) are the EOA and Q at rest. Classification between TS and PS was based on either response to flow increase (in vitro) or visual inspection at surgery (in vivo). EOAproj was the most accurate parameter in differentiating between TS and PS both in vitro and in vivo. In vivo, 15 of 23 patients (65%) had TS and 8 of 23 (35%) had PS. The percentage of correct classification was 83% for EOAproj and 91% for indexed EOAproj compared with percentages of 61% to 74% for the other echocardiographic parameters usually used for this purpose. CONCLUSIONS EOAproj provides a standardized evaluation of AS severity with DSE and improves the diagnostic accuracy for distinguishing TS and PS AS in patients with low-flow, low-gradient AS.
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Affiliation(s)
- Claudia Blais
- Research Center of Laval Hospital/Quebec Heart Institute, Laval University, Sainte-Foy, Quebec, Canada
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Garcia D, Barenbrug PJC, Pibarot P, Dekker ALAJ, van der Veen FH, Maessen JG, Dumesnil JG, Durand LG. A ventricular-vascular coupling model in presence of aortic stenosis. Am J Physiol Heart Circ Physiol 2005; 288:H1874-84. [PMID: 15604131 DOI: 10.1152/ajpheart.00754.2004] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
In patients with aortic stenosis, the left ventricular afterload is determined by the degree of valvular obstruction and the systemic arterial system. We developed an explicit mathematical model formulated with a limited number of independent parameters that describes the interaction among the left ventricle, an aortic stenosis, and the arterial system. This ventricular-valvular-vascular (V3) model consists of the combination of the time-varying elastance model for the left ventricle, the instantaneous transvalvular pressure-flow relationship for the aortic valve, and the three-element windkessel representation of the vascular system. The objective of this study was to validate the V3 model by using pressure-volume loop data obtained in six patients with severe aortic stenosis before and after aortic valve replacement. There was very good agreement between the estimated and the measured left ventricular and aortic pressure waveforms. The total relative error between estimated and measured pressures was on average (standard deviation) 7.5% (SD 2.3) and the equation of the corresponding regression line was y = 0.99 x − 2.36 with a coefficient of determination r2 = 0.98. There was also very good agreement between estimated and measured stroke volumes ( y = 1.03 x + 2.2, r2 = 0.96, SEE = 2.8 ml). Hence, this mathematical V3 model can be used to describe the hemodynamic interaction among the left ventricle, the aortic valve, and the systemic arterial system.
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Affiliation(s)
- Damien Garcia
- Biomedical Engineering Laboratory, Clinical Research Institute of Montreal, 110 Pine Avenue West, Montreal, Quebec, Canada H2W 1R7.
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Licker M, Ellenberger C, Murith N, Tassaux D, Sierra J, Diaper J, Morel DR. Cardiovascular response to acute normovolaemic haemodilution in patients with severe aortic stenosis: assessment with transoesophageal echocardiography. Anaesthesia 2004; 59:1170-7. [PMID: 15549975 DOI: 10.1111/j.1365-2044.2004.03899.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Using multiplane transoesophageal echocardiography (TOE), we investigated the haemodynamic response to acute normovolaemic haemodilution (ANH) in anaesthetised patients with critical aortic stenosis. Twenty-eight patients were randomly assigned to ANH or control groups. In the control group, haemodynamic data remained unchanged over a 20-min period. In the ANH group, haemoglobin levels decreased from a mean (SD) of 134 (7) to 91 (9) g x l(-1) (p < 0.001) whereas stroke volume, central venous pressure and left ventricular (LV) end-diastolic area all increased significantly (mean (SD) +15 (6) ml; +2.0 (1.1) mmHg; +2.1 (0.8) cm2, respectively). During ANH, the accelerated blood flow through the stenotic valve caused an increased loss (SD) in LV stroke work: from 24 (8)% to 30 (10)%), (p < 0.01). Hence, lowering viscosity with ANH resulted in improved venous return, higher cardiac preload and increased stroke volume. However, this adaptive haemodynamic response was limited by less efficient LV stroke work due to dissipation of fluid kinetic energy.
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Affiliation(s)
- M Licker
- Department of Anaesthesiology, Pharmacology & Surgical Intensive Care, University Hospital of Geneva, Geneva, Switzerland.
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Ruel M, Rubens FD, Masters RG, Pipe AL, Bédard P, Hendry PJ, Lam BK, Burwash IG, Goldstein WG, Brais MP, Keon WJ, Mesana TG. Late incidence and predictors of persistent or recurrent heart failure in patients with aortic prosthetic valves. J Thorac Cardiovasc Surg 2004; 127:149-59. [PMID: 14752425 DOI: 10.1016/j.jtcvs.2003.07.043] [Citation(s) in RCA: 106] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND We examined factors associated with persistent or recurrent congestive heart failure after aortic valve replacement. METHODS Patients who underwent aortic valve replacement with contemporary prostheses (n = 1563) were followed up with annual clinical assessment and echocardiography. The effect of demographic, comorbid, and valve-related variables on the composite outcome of New York Heart Association class III or IV symptoms or congestive heart failure death after surgery was evaluated with stratified log-rank tests, Cox proportional hazard models, and logistic regression. Factors associated with all-cause death were also examined. Prediction models were bootstrapped 1000 times. RESULTS Total follow-up was 6768 patient-years (mean, 4.3 +/- 3.3 years; range, 60 days to 17.1 years). Freedom from congestive heart failure or congestive heart failure death was 98.6% +/- 0.3%, 88.6% +/- 1.0%, 73.9% +/- 2.3%, and 45.2% +/- 8.5% at 1, 5, 10, and 15 years, respectively. Age, preoperative New York Heart Association class, left ventricular grade, atrial fibrillation, coronary artery disease, smoking, and redo status predicted congestive heart failure after surgery (all P <.05). Larger prosthesis size and effective orifice area, both absolute and indexed for body surface area, were independently associated with freedom from congestive heart failure. Increased transprosthesis gradients were predicted by prosthesis-patient mismatch and were associated with congestive heart failure after surgery. Mismatch defined as an effective orifice area/body surface area of 0.80 cm(2)/m(2) or less was a significant predictor of congestive heart failure events after surgery, but mismatch defined as an effective orifice area/body surface area of 0.85 cm(2)/m(2) or less was not. Small prosthesis size and mismatch were not significantly associated with all-cause mortality. CONCLUSIONS These analyses identify independent predictors of congestive heart failure symptoms and congestive heart failure death late after aortic valve replacement and indicate that prosthesis size has a significant effect on this cardiac end point, but not on overall survival after aortic valve replacement.
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Affiliation(s)
- Marc Ruel
- Division of Cardiac Surgery, Department of Epidemiology, University of Ottawa, Ontario, Canada.
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Abstract
PURPOSE OF REVIEW Echocardiographic assessment plays a major role in the evaluation of aortic stenosis (AS). Because of its proven accuracy, ease of applicability, and safety, it is replacing cardiac catheterization for the assessment of AS in many centers. RECENT FINDINGS In this review, we discuss the basic principles of echocardiographic assessment of AS and clinically challenging scenarios including AS with low cardiac output state or other structural heart disease. Dobutamine stress echocardiography is a useful tool for assessing low cardiac output AS. The role of transesophageal echocardiography in the evaluation of AS is also reviewed. SUMMARY Echocardiographic techniques provide critical information in the assessment of patients with known or suspected AS and guide decision-making regarding the appropriateness of valve replacement.
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Affiliation(s)
- Yuka Mochizuki
- Tufts-New England Medical Center, Boston, Massachusetts 02111, USA
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Beauchesne LM, deKemp R, Chan KL, Burwash IG. Temporal variations in effective orifice area during ejection in patients with valvular aortic stenosis. J Am Soc Echocardiogr 2003; 16:958-64. [PMID: 12931108 DOI: 10.1016/s0894-7317(03)00472-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Effective orifice area (EOA) is the standard index for assessing aortic stenosis (AS) severity. However, EOA varies during ejection and a single measurement at 1 ejection time point may not fully describe the hemodynamic severity of a stenotic aortic valve. We investigated whether the dynamic change in EOA during ejection differs between patients with severe AS (EOA </= 1.0 cm(2)) (n = 15) and age-/sex-matched control patients (n = 15), and whether the ejection pattern varies with AS severity (n = 45). In patients with severe AS, maximum left ventricular outflow tract velocity (V(LVOT)) and transvalvular velocity (V(AS)) occurred later in the ejection period (EP) when compared with control patients (V(LVOT) 47 +/- 8 vs 29 +/- 8%, P =.0001; V(AS) 36 +/- 7 vs 27 +/- 8%, P =.003). Maximum V(LVOT) occurred later than maximum V(AS) in patients with severe AS (47 +/- 8 vs 36 +/- 7%, P =.0005), but simultaneously in control patients (29 +/- 8 vs 27 +/- 8%, P = NS). Patients with severe AS had a slower EOA opening rate than control patients (4 +/- 1 vs 41 +/- 38 cm(2)/s, P =.002) and reached 80% and 100% of maximum EOA later in the EP (43 +/- 26 vs 15 +/- 6%, P =.001; 70 +/- 20 vs 48 +/- 30%, P =.03). EOA tended to increase between 10% and 90% of the EP in patients with severe AS, but had a plateau in control patients (slope 0.38 +/- 0.26 vs 0.02 +/- 0.25% change in EOA per 1% change of EP, P =.0006). In patients with severe AS, EOA was >/=80% of maximum EOA for a shorter duration during ejection compared with control patients (49 +/- 25 vs 64 +/- 14%, P =.05). EOA opening rate, time to maximum V(LVOT), time to maximum V(AS), and time to 80% of maximum EOA correlated with mean pressure gradient (r = -0.80, 0.63, 0.42, and 0.54, respectively, n = 45). Indices of ejection dynamics and valve kinetics differ in patients with AS and may provide further insight into the hemodynamic or physiologic severity of a stenotic aortic valve.
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Affiliation(s)
- Luc M Beauchesne
- Department of Medicine, University of Ottawa Heart Institute, University of Ottawa.
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