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García-Blas S, Pernias V, González D'Gregorio J, Fernández-Cisnal A, Bonanad C, Sastre C, Valero E, Miñana G, Zaharia G, Núñez J, Sanchis J. Carbohydrate antigen 125-guided pre-TAVI medical optimization: impact on quality of life and clinical outcomes. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2024; 77:750-758. [PMID: 38311024 DOI: 10.1016/j.rec.2024.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 01/17/2024] [Indexed: 02/06/2024]
Abstract
INTRODUCTION AND OBJECTIVES Carbohydrate antigen 125 (CA125), a biomarker associated with fluid overload, has proven useful in managing diuretic therapy in heart failure. We aimed to evaluate the impact of diuretic optimization guided by CA125 before transcatheter aortic valve implantation (TAVI) on outcomes. METHODS This prospective interventional study enrolled patients scheduled for TAVI, in whom baseline CA125 was measured 2 weeks before TAVI. Patients with CA125 ≥ 20 U/mL underwent diuretic up-titration before TAVI. Three groups were included: group I) baseline CA125 <20 U/mL; IIa) CA125 ≥ 20 U/mL that decreased after treatment, and IIb) CA125 ≥ 20 U/mL that did not decrease. The primary outcome was changes in the Kansas City Cardiomyopathy Questionnaire at 3 and 12 months. The secondary endpoint was clinical events. RESULTS The study included 184 patients (115 group I, 46 IIa, and 23 IIb). Groups I and IIa exhibited early and sustained improvements in the Kansas City Cardiomyopathy Questionnaire (group I: 18.9 points [95%CI, 15.7-22.1; P <.001] at 90 days, and 18.1 [95%CI, 14.9-21.4, P <.001] at 1 year; group IIa: 21.1 points [95%CI, 15.4-26.7; P <.001] and 19.5 [95%CI, 13.9-25.1; P <.001] respectively). In contrast, in group IIb there was no significant improvement at 90 days (P=.12), with improvement being significant only at 1 year (17.8 points, 95%CI, 5.9-29.6; P=.003). Over a median follow-up of 20.7 months, there were 63 (27.83%) deaths or heart failure admissions. Multivariate analysis showed a lower risk of events in group I vs IIb (HR, 0.28; 95%CI, 0.14-0.58; P <.001), and IIa vs IIb (HR, 0.24; 95%CI, 0.11-0.55; P <.001). CONCLUSIONS Patients with persistently high CA125 despite diuretic therapy pre-TAVI showed slower functional recovery and poorer clinical outcomes after TAVI.
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Affiliation(s)
- Sergio García-Blas
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, Valencia, Spain; Instituto de Investigación Sanitaria (INCLIVA), Valencia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain.
| | - Vicente Pernias
- Servicio de Cardiología, Hospital General de Castellón, Castellón, Spain
| | | | - Agustín Fernández-Cisnal
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, Valencia, Spain; Instituto de Investigación Sanitaria (INCLIVA), Valencia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Clara Bonanad
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, Valencia, Spain; Instituto de Investigación Sanitaria (INCLIVA), Valencia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Departamento de Medicina, Universidad de Valencia, Valencia, Spain
| | - Clara Sastre
- Servicio de Cardiología, Hospital Francesc de Borja, Gandía, Valencia, Spain
| | - Ernesto Valero
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, Valencia, Spain; Instituto de Investigación Sanitaria (INCLIVA), Valencia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Gema Miñana
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, Valencia, Spain; Instituto de Investigación Sanitaria (INCLIVA), Valencia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Departamento de Medicina, Universidad de Valencia, Valencia, Spain
| | - Georgiana Zaharia
- Instituto de Investigación Sanitaria (INCLIVA), Valencia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Julio Núñez
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, Valencia, Spain; Instituto de Investigación Sanitaria (INCLIVA), Valencia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Departamento de Medicina, Universidad de Valencia, Valencia, Spain
| | - Juan Sanchis
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, Valencia, Spain; Instituto de Investigación Sanitaria (INCLIVA), Valencia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Departamento de Medicina, Universidad de Valencia, Valencia, Spain
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Dahl JS, Julakanti R, Ali M, Scott CG, Padang R, Pellikka PA. Cardiac Damage in Early Aortic Stenosis: Is the Valve to Blame? JACC Cardiovasc Imaging 2024; 17:1031-1040. [PMID: 38904570 DOI: 10.1016/j.jcmg.2024.05.003] [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: 01/25/2024] [Revised: 04/30/2024] [Accepted: 05/02/2024] [Indexed: 06/22/2024]
Abstract
BACKGROUND Despite the close association between aortic stenosis (AS) and cardiac damage (CD), it is unclear if CD is limited to patients with moderate and severe AS and which factors affect its progression. Although altered valvular hemodynamic status may drive the development of CD in AS, commonly occurring comorbidities may contribute. OBJECTIVES The aim of this study was to determine the prevalence of and factors associated with CD in mild AS. METHODS This retrospective study included 9,611 patients with mild AS (peak aortic valve velocity [Vmax] 2-3 m/s and description of abnormal aortic valve) from 2010 through 2021. CD was staged using the Genereux classification. RESULTS All but 20% (n = 1,901; stage 0) of patients with mild AS demonstrated CD: 1,613 (17%) stage 1, 4,843 (50%) stage 2, 891 (9%) stage 3, and 363 (4%) stage 4. Patients with higher stages had more comorbidities (hypertension, heart failure, ischemic heart disease, stroke, peripheral arterial disease, chronic kidney disease, chronic pulmonary disease, and diabetes mellitus) but had valvular hemodynamic status similar to those without CD. CD stage did not worsen with higher Vmax range (stage >1 in 64% with Vmax <2.5 m/s vs 61% with Vmax ≥2.5 m/s) but increased with the number of comorbidities, with stage >1 occurring in 50%, 53%, 60%, 66%, 72%, and 73% in the presence of 0, 1, 2, 3, 4, and 5 or more comorbidities, respectively. CONCLUSIONS CD was highly prevalent in patients with mild AS. Among patients with mild AS, there was no relationship between the degree of CD and AS severity; instead, CD was highly associated with comorbidities.
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Affiliation(s)
- Jordi S Dahl
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Raghav Julakanti
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Mulham Ali
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Christopher G Scott
- Department Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - Ratnasari Padang
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Patricia A Pellikka
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.
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Fortuni F, Grayburn PA. The Need for Comprehensive Risk Phenotyping in Aortic Stenosis. JACC Cardiovasc Imaging 2024; 17:1041-1043. [PMID: 39001734 DOI: 10.1016/j.jcmg.2024.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Accepted: 05/16/2024] [Indexed: 07/15/2024]
Affiliation(s)
- Federico Fortuni
- Division of Cardiology, Baylor Research Institute, Plano, Texas, USA; Department of Cardiology, San Giovanni Battista Hospital, Foligno, Italy; Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Paul A Grayburn
- Division of Cardiology, Baylor Research Institute, Plano, Texas, USA.
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Bruno F, Rampone JM, Islas F, Gorla R, Gallone G, Melillo F, Leone PP, Cimaglia P, Pastore MC, Franzone A, Landra F, Scudeler L, Jimenez-Quevedo P, Viva T, Piroli F, Bragato R, Trichilo M, Degiovanni A, Salizzoni S, Ilardi F, Andreis A, Nombela-Franco L, Tusa M, Toselli M, Conrotto F, Montorfano M, Manzo R, Cameli M, Patti G, Stefanini G, Testa L, La Torre M, Giannini F, Agricola E, Escaned J, De Filippo O, De Ferrari GM, D'Ascenzo F. Echocardiographic and clinical features of patients developing prosthesis-patient mismatch after transcatheter aortic valve replacement: Insights from the Recovery-TAVR registry. Am Heart J 2024; 275:128-137. [PMID: 38838970 DOI: 10.1016/j.ahj.2024.05.015] [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: 12/11/2023] [Revised: 05/26/2024] [Accepted: 05/27/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND The impact of prosthesis-patient mismatch (PPM) on major endpoints after transcatheter aortic valve replacement (TAVR) is controversial and the effects on progression of heart damage are poorly investigated. Therefore, our study aims to evaluate the prevalence and predictors of PPM in a "real world" cohort of patients at intermediate and low surgical risk, its impact on mortality and the clinical-echocardiographic progression of heart damage. METHODS 963 patients who underwent TAVR procedure between 2017 and 2021, from the RECOVERY-TAVR international multicenter observational registry, were included in this analysis. Multiparametric echocardiographic data of these patients were analyzed at 1-year follow-up (FU). Clinical and echocardiographic features were stratified by presence of PPM and PPM severity, as per the most current international recommendations, using VARC-3 criteria. RESULTS 18% of patients developed post-TAVR. PPM, and 7.7% of the whole cohort had severe PPM. At baseline, 50.3% of patients with PPM were male (vs 46.2% in the cohort without PPM, P = .33), aged 82 (IQR 79-85y) years vs 82 (IQR 78-86 P = .46), and 55.6% had Balloon-Expandable valves implanted (vs 46.8% of patients without PPM, P = .04); they had smaller left ventricular outflow tract (LVOT) diameter (20 mm, IQR 19-21 vs 20 mm, IQR 20-22, P = .02), reduced SVi (34.2 vs 38 mL/m2, P < .01) and transaortic flow rate (190.6 vs 211 mL/s, P < .01). At predischarge FU patients with PPM had more paravalvular aortic regurgitation (moderate-severe AR 15.8% vs 9.2%, P < .01). At 1-year FU, maladaptive alterations of left ventricular parameters were found in patients with PPM, with a significant increase in end-systolic diameter (33 mm vs 28 mm, P = .03) and a significant increase in left ventricle end systolic indexed volume in those with moderate and severe PPM (52 IQR 42-64 and 52, IQR 41-64 vs 44 IQR 35-59 in those without, P = .02)). No evidence of a significant impact of PPM on overall (P = .71) and CV (P = .70) mortality was observed. Patients with moderate/severe PPM had worse NYHA functional class at 1 year (NYHA III-IV 13% vs 7.8%, P = .03). Prosthesis size≤23 mm (OR 11.6, 1.68-80.1) was an independent predictor of PPM, while SVi (OR 0.87, 0.83-0.91, P < .001) and LVOT diameter (OR 0.79, 0.65-0.95, P = .01) had protective effect. CONCLUSIONS PPM was observed in 18% of patients undergoing TAVR. Echocardiographic evaluations demonstrated a PPM-related pattern of early ventricular maladaptive alterations, possibly precursor to a reduction in cardiac function, associated with a significant deterioration in NYHA class at 1 year. These findings emphasize the importance of prevention of PPM of any grade in patients undergoing TAVR procedure, especially in populations at risk.
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Affiliation(s)
- Francesco Bruno
- Department of Medical Sciences, Division of Cardiology, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Joao Matteo Rampone
- Department of Medical Sciences, Division of Cardiology, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Fabian Islas
- Department of Cardiology, Hospital Clínico San Carlos, IDISSC, and Universidad Complutense de Madrid, Madrid, Spain
| | - Riccardo Gorla
- Department of Clinical and Interventional Cardiology, IRCCS Policlinico San Donato, Milan, Italy
| | - Guglielmo Gallone
- Department of Medical Sciences, Division of Cardiology, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | | | - Pier Pasquale Leone
- Department of Cardiology, IRCCS Humanitas Research Hospital, Rozzano-Milan, Italy
| | - Paolo Cimaglia
- Department of Cardiology, GVM Care and Research, Maria Cecilia Hospital, Ravenna, Italy
| | - Maria Concetta Pastore
- Department of Cardiology, Azienda Ospedaliero Universitaria "Maggiore Della Carita", Novara, Italy
| | - Anna Franzone
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Federico Landra
- Department of Cardiovascular Diseases, University of Siena, Policlinico "Le Scotte", Viale Bracci 1, 53100 Siena, Italy
| | - Luca Scudeler
- Department of Medical Sciences, Division of Cardiology, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Pilar Jimenez-Quevedo
- Department of Cardiology, Hospital Clínico San Carlos, IDISSC, and Universidad Complutense de Madrid, Madrid, Spain
| | - Tommaso Viva
- Department of Clinical and Interventional Cardiology, IRCCS Policlinico San Donato, Milan, Italy
| | - Francesco Piroli
- Department of Cardiology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Renato Bragato
- Department of Cardiology, IRCCS Humanitas Research Hospital, Rozzano-Milan, Italy
| | - Michele Trichilo
- Department of Cardiology, GVM Care and Research, Maria Cecilia Hospital, Ravenna, Italy
| | - Anna Degiovanni
- Department of Cardiology, Azienda Ospedaliero Universitaria "Maggiore Della Carita", Novara, Italy
| | - Stefano Salizzoni
- Cardiovascular and Thoracic Department, Division of Cardiac Surgery, Città Della Salute e Della Scienza Hospital and University of Turin, Turin, Italy
| | - Federica Ilardi
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Alessandro Andreis
- Department of Medical Sciences, Division of Cardiology, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Luis Nombela-Franco
- Department of Cardiology, Hospital Clínico San Carlos, IDISSC, and Universidad Complutense de Madrid, Madrid, Spain
| | - Maurizio Tusa
- Department of Clinical and Interventional Cardiology, IRCCS Policlinico San Donato, Milan, Italy
| | - Marco Toselli
- Department of Cardiology, GVM Care and Research, Maria Cecilia Hospital, Ravenna, Italy
| | - Federico Conrotto
- Department of Medical Sciences, Division of Cardiology, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | | | - Rachele Manzo
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Matteo Cameli
- Department of Cardiovascular Diseases, University of Siena, Policlinico "Le Scotte", Viale Bracci 1, 53100 Siena, Italy
| | - Giuseppe Patti
- Department of Cardiology, Azienda Ospedaliero Universitaria "Maggiore Della Carita", Novara, Italy
| | - Giulio Stefanini
- Department of Cardiology, IRCCS Humanitas Research Hospital, Rozzano-Milan, Italy
| | - Luca Testa
- Department of Clinical and Interventional Cardiology, IRCCS Policlinico San Donato, Milan, Italy
| | - Michele La Torre
- Cardiovascular and Thoracic Department, Division of Cardiac Surgery, Città Della Salute e Della Scienza Hospital and University of Turin, Turin, Italy
| | - Francesco Giannini
- Department of Cardiology, GVM Care and Research, Maria Cecilia Hospital, Ravenna, Italy
| | | | - Javier Escaned
- Department of Cardiology, Hospital Clínico San Carlos, IDISSC, and Universidad Complutense de Madrid, Madrid, Spain
| | - Ovidio De Filippo
- Department of Medical Sciences, Division of Cardiology, Città della Salute e della Scienza, University of Turin, Turin, Italy.
| | - Gaetano M De Ferrari
- Department of Medical Sciences, Division of Cardiology, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Fabrizio D'Ascenzo
- Department of Medical Sciences, Division of Cardiology, Città della Salute e della Scienza, University of Turin, Turin, Italy
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Hahn RT, Lindenfeld J, Lim SD, Mack MJ, Burkhoff D. Structural Cardiac Interventions in Patients With Heart Failure: JACC Scientific Statement. J Am Coll Cardiol 2024; 84:832-847. [PMID: 39168570 DOI: 10.1016/j.jacc.2024.05.061] [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: 03/29/2024] [Revised: 05/13/2024] [Accepted: 05/28/2024] [Indexed: 08/23/2024]
Abstract
Pathologic left ventricular remodeling and valvular heart disease may contribute to the clinical presentation and outcomes of patients presenting with heart failure, and limit the effectiveness of guideline-directed medical therapy. Although surgical interventions including surgical ventricular restoration techniques and valve repair or replacement are effective therapies, there is growing evidence that transcatheter interventions may be options for patients with persistent symptoms of heart failure despite optimal medical therapy, where surgical options may be limited. This scientific statement will review the current available and investigational percutaneous strategies for the management of structural contributors to heart failure: dilated left ventricular cardiomyopathies and valvular heart disease.
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Affiliation(s)
- Rebecca T Hahn
- Division of Cardiology, Columbia University Medical Center, New York, New York, USA; Cardiovascular Research Foundation, New York, New York, USA.
| | - JoAnn Lindenfeld
- Advanced Heart Failure, Vanderbilt Heart and Vascular Institute, Nashville, Tennessee, USA
| | - Scott D Lim
- Department of Medicine, University of Virginia, Charlottesville, Virginia, USA; Division of Cardiology, St Paul's Hospital, Vancouver, British Columbia, Canada
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Silva I, Ternacle J, Hahn RT, Salah-Annabi M, Dahou A, Krapf L, Salaun E, Guzzetti E, Xu K, Clavel MA, Bernier M, Beaudoin J, Cremer PC, Jaber W, Rodriguez L, Asch FM, Weismann NJ, Bax J, Ajmone N, Alu MC, Kallel F, Mack MJ, Webb JG, Kapadia S, Makkar R, Kodali S, Herrmann HC, Thourani V, Leon MB, Pibarot P. Left and right ventricular longitudinal systolic function following aortic valve replacement in the PARTNER 2 trial and registry. Eur Heart J Cardiovasc Imaging 2024; 25:1276-1286. [PMID: 38693866 DOI: 10.1093/ehjci/jeae114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Revised: 04/15/2024] [Accepted: 04/17/2024] [Indexed: 05/03/2024] Open
Abstract
AIMS Evaluation of left and right ventricular (RV) longitudinal systolic function may enhance risk stratification following aortic valve replacement (AVR). The study objective was to evaluate the changes in left and RV longitudinal systolic function and RV-pulmonary artery (RV-PA) coupling from baseline to 30 days and 1 year after AVR. METHODS AND RESULTS Left ventricular (LV) longitudinal strain (LS), tricuspid annulus plane systolic excursion (TAPSE), and RV-PA coupling were evaluated in patients from the PARTNER 2A surgical AVR (SAVR) arm (n = 985) and from the PARTNER 2 SAPIEN 3 registry (n = 719). TAPSE and RV-PA coupling decreased significantly following SAVR, but remained stable following TAVR. Lower LV LS, TAPSE, or RV-PA coupling at baseline was associated with increased risk of the composite of death, hospitalization, and stroke at 5 years [adjusted hazard ratios (HRs) for LV LS < 15%: 1.24, 95% confidence interval (CI) 1.05-1.45, P = 0.001; TAPSE < 14 mm: 1.44, 95% CI 1.21-1.73, P < 0.001; RV-PA coupling < 0.55 mm/mmHg: 1.32, 95% CI 1.07-1.63, P = 0.011]. Reduced TAPSE at baseline was the most powerful predictor of the composite endpoint at 5 years. Patients with LV ejection fraction <50% at baseline had increased risk of the primary endpoint with SAVR (HR: 1.34, 95% CI 1.08-1.68, P = 0.009) but not with TAVR (HR: 1.12, 95% CI 0.88-1.42). Lower RV-PA coupling at 30 days showed the strongest association with cardiac mortality. CONCLUSION SAVR but not TAVR was associated with a marked deterioration in RV longitudinal systolic function and RV-PA coupling. Lower TAPSE and RV-PA coupling at 30 days were associated with inferior clinical outcomes at 5 years. In patients with LVEF < 50%, TAVR was associated with superior 5-year outcomes.
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Affiliation(s)
- Iria Silva
- Department of Cardiology, Québec Heart & Lung Institute, Laval University, 2725 chemin Ste-Foy, Quebec City, Québec G1V-4G5, Canada
- Department of Cardiology, Central University Hospital of Asturias, Oviedo, Spain
| | - Julien Ternacle
- Haut-Leveque Cardiology Hospital, Bordeaux University, Pessac, France
| | - Rebecca T Hahn
- Department of Medicine, Columbia University Medical Center, New York, NY, USA
| | | | | | - Laura Krapf
- Haut-Leveque Cardiology Hospital, Bordeaux University, Pessac, France
| | - Erwan Salaun
- Department of Cardiology, Québec Heart & Lung Institute, Laval University, 2725 chemin Ste-Foy, Quebec City, Québec G1V-4G5, Canada
| | - Ezequiel Guzzetti
- Département de cardiologie, Centre Hospitalier Affilié Universitaire Régional, Trois-Rivières, Québec, Canada
| | - Ke Xu
- Edwards Lifesciences, Irvine, CA, USA
| | - Marie-Annick Clavel
- Department of Cardiology, Québec Heart & Lung Institute, Laval University, 2725 chemin Ste-Foy, Quebec City, Québec G1V-4G5, Canada
| | - Mathieu Bernier
- Department of Cardiology, Québec Heart & Lung Institute, Laval University, 2725 chemin Ste-Foy, Quebec City, Québec G1V-4G5, Canada
| | - Jonathan Beaudoin
- Department of Cardiology, Québec Heart & Lung Institute, Laval University, 2725 chemin Ste-Foy, Quebec City, Québec G1V-4G5, Canada
| | - Paul C Cremer
- Department of Cardiology, Cleveland Clinic, Cleveland, OH, USA
| | - Wael Jaber
- Department of Cardiology, Cleveland Clinic, Cleveland, OH, USA
| | | | - Federico M Asch
- Cardiovascular Core Laboratories, MedStar Heart and Vascular Institute and Georgetown University, Washington, DC, USA
| | - Neil J Weismann
- Cardiovascular Core Laboratories, MedStar Heart and Vascular Institute and Georgetown University, Washington, DC, USA
| | - Jeroen Bax
- Hart Long Centrum Leiden, Leiden University, Leiden, The Netherlands
| | - Nina Ajmone
- Hart Long Centrum Leiden, Leiden University, Leiden, The Netherlands
| | - Maria C Alu
- Division of Cardiology, Columbia University Irving Medical Center; Presbyterian Hospital; Cardiovascular Research Foundation, New York, NY, USA
| | | | - Michael J Mack
- Department of Cardiovascular and Thoracic Surgery, Baylor Scott & White Cardiac Surgery Specialists, Plano, TX, USA
| | - John G Webb
- Centre for Cardiovascular Innovation, St Paul's and Vancouver General Hospital, Vancouver, Canada
| | - Samir Kapadia
- Department of Cardiology, Cleveland Clinic, Cleveland, OH, USA
| | - Raj Makkar
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Susheel Kodali
- Department of Medicine, Columbia University Medical Center, New York, NY, USA
| | - Howard C Herrmann
- Division of Cardiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Vinod Thourani
- Department of Cardiovascular Surgery, Marcus Valve Center, Piedmont Heart Institute, Atlanta, GA, USA
| | - Martin B Leon
- Department of Medicine, Columbia University Medical Center, New York, NY, USA
| | - Philippe Pibarot
- Department of Cardiology, Québec Heart & Lung Institute, Laval University, 2725 chemin Ste-Foy, Quebec City, Québec G1V-4G5, Canada
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Barnes C, Sharma H, Gamble J, Dawkins S. Management of secondary mitral regurgitation: from drugs to devices. Heart 2024; 110:1099-1106. [PMID: 37607812 PMCID: PMC11347202 DOI: 10.1136/heartjnl-2022-322001] [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] [Indexed: 08/24/2023] Open
Abstract
Severe secondary mitral regurgitation carries a poor prognosis with one in five patients dying within 12 months of diagnosis. Fortunately, there are now a number of safe and effective therapies available to improve outcomes. Here, we summarise the most up-to-date treatments. Optimal guideline-directed medical therapy is the mainstay therapy and has been shown to reduce the severity of mitral regurgitation in 40-45% of patients. Rapid medication titration protocols reduce heart failure hospitalisation and facilitate earlier referral for device therapy. The pursuit of sinus rhythm in patients with atrial fibrillation has been shown to significantly reduce mitral regurgitation severity, as has the use of cardiac resynchronisation devices in patients who meet guideline-directed criteria. Finally, we highlight the key role of mitral valve intervention, particularly transcatheter edge-to-edge repair (TEER) for management of moderate-severe mitral regurgitation in carefully selected patients with poor left ventricular systolic function, with a number needed to treat of 3.1 to reduce heart failure hospitalisation and 5.9 to reduce all-cause death. To slow the rapid accumulation of morbidity and mortality, we advocate a proactive approach with accelerated medical optimisation, followed by management of atrial fibrillation and cardiac resynchronisation therapy if indicated, then, rapid referral to the Heart Team for consideration of mitral valve intervention in patients with ongoing symptoms and at least moderate-severe mitral regurgitation. Mitral TEER has been shown to be 'reasonably cost-effective' (but not cost-saving) in the UK in selected patients, although TEER remains underused with only 6.5 procedures per million population (pmp) compared with Germany (77 pmp), Switzerland (44 pmp) and the USA (32 pmp).
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Affiliation(s)
- Cara Barnes
- Oxford Heart Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Harish Sharma
- Cardiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - James Gamble
- Oxford Heart Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Sam Dawkins
- Oxford Heart Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Bække PS, Jørgensen TH, Thuraiaiyah J, Gröning M, De Backer O, Sondergaard L. Incidence, predictors, and prognostic impact of rehospitalization after transcatheter aortic valve implantation. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2024; 10:446-455. [PMID: 37950564 DOI: 10.1093/ehjqcco/qcad067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 10/25/2023] [Accepted: 11/07/2023] [Indexed: 11/12/2023]
Abstract
AIMS Despite rehospitalization being common after transcatheter aortic valve implantation (TAVI), an in-depth analysis on this topic is missing. This study sought to report on the incidence, predictors, and prognostic impact of rehospitalization within 1 year following TAVI. METHODS AND RESULTS All consecutive patients treated with TAVI between 2016 and 2020 in East Denmark were included. Medical records of all patients were reviewed to validate rehospitalizations up to 1 year after discharge from the index admission. The study population consisted of 1397 patients, of whom 615 (44%) had an unplanned rehospitalization within the first year post-TAVI. The rehospitalization incidence rate was three-fold higher in the early period (within 30 days) compared with the late period (30 days to 1 year; 2.5 vs. 0.8 per patient-year, respectively; P < 0.001). Predictors of early unplanned rehospitalization were procedure-related complications and prior stroke, whereas late unplanned rehospitalization was associated with preexisting comorbidities. Predictors of heart failure (HF) rehospitalization included ischaemic heart disease, the extent of cardiac damage, atrial fibrillation, and New York Heart Association class at baseline. HF rehospitalization within 30 days and 1 year post-TAVI was associated with a markedly increased 1- and 5-year mortality risk [hazard ratio (HR) of 4.3 and 3.2 for 1-year mortality and HR of 3.2 and 2.9 for 5-year mortality, respectively; P< 0.001]. CONCLUSIONS Rehospitalization after TAVI is frequent in real-world practice. Early rehospitalization is mostly procedure related, whereas late rehospitalization is related to preexisting comorbidities. HF rehospitalization is associated with poor long-term survival and could be validated as a prognostically relevant endpoint for TAVI trials.
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Affiliation(s)
- Pernille Steen Bække
- The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Inge Lehmanns Vej 7, 2100 Coppenhagen, Denmark
| | - Troels Højsgaard Jørgensen
- The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Inge Lehmanns Vej 7, 2100 Coppenhagen, Denmark
| | - Jani Thuraiaiyah
- The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Inge Lehmanns Vej 7, 2100 Coppenhagen, Denmark
| | - Mathis Gröning
- The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Inge Lehmanns Vej 7, 2100 Coppenhagen, Denmark
| | - Ole De Backer
- The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Inge Lehmanns Vej 7, 2100 Coppenhagen, Denmark
| | - Lars Sondergaard
- The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Inge Lehmanns Vej 7, 2100 Coppenhagen, Denmark
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9
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Gilchrist IC, Kort S, Wang TY, Tannous H, Pyo R, Gracia E, Bilfinger T, Skopicki HA, Parikh PB. Impact of left ventricular ejection fraction and aortic valve gradient on mortality following transcatheter aortic valve intervention. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024; 65:32-36. [PMID: 38490937 DOI: 10.1016/j.carrev.2024.03.005] [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: 09/13/2023] [Revised: 02/14/2024] [Accepted: 03/04/2024] [Indexed: 03/17/2024]
Abstract
BACKGROUND Data regarding the impact of reduced left ventricular ejection fraction (LVEF) and/or reduced mean aortic valve gradient (AVG) on outcomes following transcatheter aortic valve intervention (TAVI) have been conflicting. We sought to assess the relationship between LVEF, AVG, and 1-year mortality in patients undergoing TAVI. METHODS We prospectively evaluated 298 consecutive adults undergoing TAVI from 2015 to 2018 at an academic tertiary medical center. Patients were categorized according to LVEF and mean AVG. The primary outcome of interest was all-cause mortality at 1 year. RESULTS Of 298 adults undergoing TAVI, 66 (22.1%) had baseline LVEF ≤45% while 232 (77.9%) had baseline LVEF >45%; 173 (58.1%) had baseline AVG < 40mmHg while 125 (41.9%) had baseline AVG ≥ 40mmHg. Rates of 1-year all-cause mortality were significantly higher in patients with LVEF ≤45% (28.8% vs 12.1%, p = 0.001) and those with AVG < 40mmHg (19.7% vs 10.4%, p = 0.031) compared to those with LVEF >45% and AVG ≥ 40mmHg respectively. In multivariable analysis, higher AVG (per mmHg) (OR 0.97, 95% CI 0.94-0.99, p = 0.026) was noted to be independently associated with lower rates of 1-year mortality, while LVEF was not (OR 0.98, 95% CI 0.96-1.01). CONCLUSIONS In this prospective, contemporary registry of adults undergoing TAVI, while 1-year unadjusted mortality rates are significantly higher in patients with reduced LVEF and reduced AVG, risk-adjusted mortality at 1 year is only higher in those with reduced AVG - not in those with reduced LVEF.
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Affiliation(s)
- Ian C Gilchrist
- Department of Medicine, Renaissance School of Medicine, State University of New York at Stony Brook, Stony Brook, NY, USA
| | - Smadar Kort
- Department of Medicine, Renaissance School of Medicine, State University of New York at Stony Brook, Stony Brook, NY, USA
| | - Ting-Yu Wang
- Department of Medicine, Renaissance School of Medicine, State University of New York at Stony Brook, Stony Brook, NY, USA
| | - Henry Tannous
- Department of Surgery, Renaissance School of Medicine, State University of New York at Stony Brook, Stony Brook, NY, USA
| | - Robert Pyo
- Department of Medicine, Renaissance School of Medicine, State University of New York at Stony Brook, Stony Brook, NY, USA
| | - Ely Gracia
- Department of Medicine, Renaissance School of Medicine, State University of New York at Stony Brook, Stony Brook, NY, USA
| | - Thomas Bilfinger
- Department of Surgery, Renaissance School of Medicine, State University of New York at Stony Brook, Stony Brook, NY, USA
| | - Hal A Skopicki
- Department of Medicine, Renaissance School of Medicine, State University of New York at Stony Brook, Stony Brook, NY, USA
| | - Puja B Parikh
- Department of Medicine, Renaissance School of Medicine, State University of New York at Stony Brook, Stony Brook, NY, USA.
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10
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Benfari G, Springhetti P, Enriquez-Sarano M. Combined tricuspid and left-sided valvular heart disease: A frequent and treatable scenario. Eur J Heart Fail 2024; 26:1861-1862. [PMID: 38957032 DOI: 10.1002/ejhf.3370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 03/05/2024] [Indexed: 07/04/2024] Open
Affiliation(s)
- Giovanni Benfari
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Paolo Springhetti
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
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11
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Onishi H, Izumo M, Watanabe Y, Okutsu M, Hozawa K, Shoji T, Sato Y, Kuwata S, Akashi YJ. Prognostic value of extraaortic-valvular cardiac damage in patients with moderate aortic stenosis and reduced left ventricular ejection fraction. Echocardiography 2024; 41:e15892. [PMID: 39023286 DOI: 10.1111/echo.15892] [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: 04/27/2024] [Revised: 06/26/2024] [Accepted: 07/07/2024] [Indexed: 07/20/2024] Open
Abstract
PURPOSE The extraaortic-valvular cardiac damage (EVCD) Stage has shown potential for risk stratification for patients with aortic stenosis (AS). This study aimed to examine the usefulness of the EVCD Stage in risk stratification of patients with moderate AS and reduced left ventricular ejection fraction (LVEF). METHODS Clinical data from patients with moderate AS (aortic valve area, .60-.85 cm2/m2; peak aortic valve velocity, 2.0-4.0 m/s) and reduced LVEF (LVEF 20%-50%) were analyzed during 2010-2019. Patients were categorized into three groups: EVCD Stages 1 (LV damage), 2 (left atrium and/or mitral valve damage), and 3/4 (pulmonary artery vasculature and/or tricuspid valve damage or right ventricular damage). The primary endpoint included a composite of cardiac death and heart failure hospitalization, with non-cardiac death as a competing risk. RESULTS The study included 130 patients (mean age 76.4 ± 6.8 years; 62.3% men). They were categorized into three groups: 26 (20.0%) in EVCD Stage 1, 66 (50.8%) in Stage 2, and 48 (29.2%) in Stage 3/4. The endpoint occurred in 54 (41.5%) patients during a median follow-up of 3.2 years (interquartile range, 1.4-5.1). Multivariate analysis indicated EVCD Stage 3/4 was significantly associated with the endpoint (hazard ratio 2.784; 95% confidence interval 1.197-6.476; P = .017) compared to Stage 1, while Stage 2 did not (hazard ratio 1.340; 95% confidence interval .577-3.115; P = .500). CONCLUSION The EVCD staging system may aid in the risk stratification of patients with moderate AS and reduced LVEF.
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Affiliation(s)
- Hirokazu Onishi
- Department of Cardiology, New Tokyo Hospital, Chiba, Japan
- Department of Cardiology, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Masaki Izumo
- Department of Cardiology, St. Marianna University School of Medicine, Kanagawa, Japan
| | | | - Masaaki Okutsu
- Department of Cardiology, New Tokyo Hospital, Chiba, Japan
| | - Koji Hozawa
- Department of Cardiology, New Tokyo Hospital, Chiba, Japan
| | - Tatsuro Shoji
- Department of Cardiology, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Yukio Sato
- Department of Cardiology, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Shingo Kuwata
- Department of Cardiology, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Yoshihiro J Akashi
- Department of Cardiology, St. Marianna University School of Medicine, Kanagawa, Japan
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12
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Ishizu K, Shirai S, Isotani A, Hayashi M, Tabata H, Ohno N, Kakumoto S, Ando K, Yashima F, Tada N, Yamawaki M, Naganuma T, Yamanaka F, Ueno H, Tabata M, Mizutani K, Takagi K, Watanabe Y, Yamamoto M, Hayashida K. Long-term prognostic value of the H 2FPEF score in patients undergoing transcatheter aortic valve implantation. ESC Heart Fail 2024; 11:2159-2171. [PMID: 38607328 PMCID: PMC11287290 DOI: 10.1002/ehf2.14773] [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: 11/16/2022] [Revised: 11/23/2023] [Accepted: 03/10/2024] [Indexed: 04/13/2024] Open
Abstract
AIMS A considerable proportion of candidates for transcatheter aortic valve implantation (TAVI) have underlying heart failure (HF) with preserved ejection fraction (HFpEF), which can be challenging for diagnosis because significant valvular heart disease should be excluded before diagnosing HFpEF. This study investigated the long-term prognostic value of the pre-procedural H2FPEF score in patients with preserved ejection fraction (EF) undergoing TAVI. METHODS AND RESULTS Patients who underwent TAVI between October 2013 and May 2017 were enrolled from the Optimized CathEter vAlvular iNtervention-Transcatheter Aortic Valve Implantation Japanese multicentre registry. After excluding 914 patients, 1674 patients with preserved EF ≥ 50% (median age: 85 years, 72% female) were selected for calculation of the H2FPEF score and were dichotomized into two groups: the low H2FPEF score [0-5 points; n = 1399 (83.6%)] group and the high H2FPEF score [6-9 points; n = 275 (16.4%)] group. Patients with high H2FPEF scores were associated with a higher prevalence of New York Heart Association Functional Class III/IV (59.3% vs. 43.7%, P < 0.001), diabetes (24.4% vs. 18.5%, P = 0.03), and paradoxical low-flow, low-gradient aortic stenosis (15.9% vs. 6.2%, P < 0.001). These patients showed worse prognoses than those with low H2FPEF scores regarding the cumulative 2 year all-cause mortality (26.3% vs. 15.5%, log-rank P < 0.001), cardiovascular mortality (10.5% vs. 5.4%, log-rank P < 0.001), HF hospitalization (16.2% vs. 6.7%, log-rank P < 0.001), and the composite endpoint of cardiovascular mortality and HF hospitalization (23.8% vs. 10.8%, log-rank P < 0.001). After adjustment for several confounders, the high H2FPEF scores were independently associated with increased risk for all-cause mortality [adjusted hazard ratio (HR), 1.48; 95% confidence interval (CI), 1.09-2.00; P = 0.011] and for the composite endpoint of cardiovascular mortality and HF hospitalization (adjusted HR, 1.95; 95% CI, 1.38-2.74; P < 0.001). Subgroup analysis confirmed the excess risk of high H2FPEF scores relative to low H2FPEF scores for the composite endpoint of cardiovascular mortality and HF hospitalization increased with a lower Society of Thoracic Surgeons (STS) score (STS score <8%: adjusted HR, 2.40; 95% CI, 1.50-3.85; P < 0.001; STS score ≥8%: adjusted HR, 1.34; 95% CI, 0.79-2.28; P = 0.28; Pinteraction = 0.030). CONCLUSIONS The H2FPEF score is useful for predicting long-term adverse outcomes after TAVI, including all-cause mortality, cardiovascular mortality, and HF hospitalization for patients with preserved EF. More aggressive interventions targeting HFpEF in addition to the TAVI procedure might be relevant in patients with high H2FPEF scores, particularly in those with a lower surgical risk.
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Affiliation(s)
- Kenichi Ishizu
- Department of CardiologyKokura Memorial HospitalKitakyushuJapan
| | - Shinichi Shirai
- Department of CardiologyKokura Memorial HospitalKitakyushuJapan
| | - Akihiro Isotani
- Department of CardiologyKokura Memorial HospitalKitakyushuJapan
| | - Masaomi Hayashi
- Department of CardiologyKokura Memorial HospitalKitakyushuJapan
| | - Hiroyuki Tabata
- Department of CardiologyKokura Memorial HospitalKitakyushuJapan
| | - Nobuhisa Ohno
- Department of Cardiovascular SurgeryKokura Memorial HospitalKitakyushuJapan
| | | | - Kenji Ando
- Department of CardiologyKokura Memorial HospitalKitakyushuJapan
| | - Fumiaki Yashima
- Department of CardiologySaiseikai Utsunomiya HospitalUtsunomiyaJapan
- Department of CardiologyKeio University School of MedicineTokyoJapan
| | - Norio Tada
- Department of CardiologySendai Kosei HospitalSendaiJapan
| | - Masahiro Yamawaki
- Department of CardiologySaiseikai Yokohama City Eastern HospitalYokohamaJapan
| | - Toru Naganuma
- Department of CardiologyNew Tokyo HospitalMatsudoJapan
- Department of Cardiovascular Medicine, Graduate School of Medical SciencesKumamoto UniversityKumamotoJapan
| | - Futoshi Yamanaka
- Department of Cardiovascular Medicine, Graduate School of Medical SciencesKumamoto UniversityKumamotoJapan
- Department of CardiologyShonan Kamakura General HospitalKamakuraJapan
| | - Hiroshi Ueno
- Department of Cardiovascular MedicineToyama University HospitalToyamaJapan
| | - Minoru Tabata
- Department of Cardiovascular SurgeryTokyo Bay Urayasu Ichikawa Medical CenterUrayasuJapan
| | - Kazuki Mizutani
- Division of Cardiology, Department of Medicine, Faculty of MedicineKindai UniversityOsakasayamaJapan
| | - Kensuke Takagi
- Department of Cardiovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Yusuke Watanabe
- Department of CardiologyTeikyo University School of MedicineTokyoJapan
| | - Masanori Yamamoto
- Department of CardiologyToyohashi Heart CenterToyohashiJapan
- Department of CardiologyNagoya Heart CenterNagoyaJapan
| | - Kentaro Hayashida
- Department of CardiologyKeio University School of MedicineTokyoJapan
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13
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Sen J, Wahi S, Vollbon W, Prior M, de Sá AGC, Ascher DB, Huynh Q, Marwick TH. Definition and Validation of Prognostic Phenotypes in Moderate Aortic Stenosis. JACC Cardiovasc Imaging 2024:S1936-878X(24)00251-1. [PMID: 39152961 DOI: 10.1016/j.jcmg.2024.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 05/13/2024] [Accepted: 06/24/2024] [Indexed: 08/19/2024]
Abstract
BACKGROUND Adverse outcomes from moderate aortic stenosis (AS) may be caused by progression to severe AS or by the effects of comorbidities. In the absence of randomized trial evidence favoring aortic valve replacement (AVR) in patients with moderate AS, phenotyping patients according to risk may assist decision making. OBJECTIVES This study sought to identify and validate clusters of moderate AS that may be used to guide patient management. METHODS Unsupervised clustering algorithms were applied to demographics, comorbidities, and echocardiographic parameters in a training data set in patients with moderate AS (n = 2,469). External validation was obtained by assigning the defined clusters to an independent group with moderate AS (n = 1,358). The primary outcome, a composite of cardiac death, heart failure hospitalization, or aortic valve (AV) intervention after 5 years, was assessed between clusters in both data sets. RESULTS Four distinct clusters-cardiovascular (CV)-comorbid, low-flow, calcified AV, and low-risk-with significant outcomes (log-rank P < 0.0001 in both data sets) were identified and replicated. The highest risk was in the CV-comorbid cluster (validation HR: 2.00 [95% CI: 1.54-2.59]; P < 0.001). The effect of AVR on cardiac death differed among the clusters. There was a significantly lower rate of outcomes after AVR in the calcified AV cluster (validation HR: 0.21 [95% CI: 0.08-0.57]; P = 0.002), but no significant effect on outcomes in the other 3 clusters. These analyses were limited by the low rate of AVR. CONCLUSIONS Moderate AS has several phenotypes, and multiple comorbidities are the key drivers of adverse outcomes in patients with moderate AS. Outcomes of patients with noncalcified moderate AS were not altered by AVR in these groups. Careful attention to subgroups of moderate AS may be important to define treatable risk.
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Affiliation(s)
- Jonathan Sen
- Imaging Research laboratory, Baker Heart and Diabetes Institute, Melbourne, Australia; Baker Department of Cardiometabolic Health, University of Melbourne, Melbourne, Australia; Western Health, Melbourne, Australia; Princess Alexandra Hospital, Brisbane, Australia
| | - Sudhir Wahi
- Princess Alexandra Hospital, Brisbane, Australia
| | - William Vollbon
- Statewide Cardiac Clinical Informatics Unit, Queensland Health, Brisbane, Australia
| | - Marcus Prior
- Statewide Cardiac Clinical Informatics Unit, Queensland Health, Brisbane, Australia
| | - Alex G C de Sá
- Baker Department of Cardiometabolic Health, University of Melbourne, Melbourne, Australia; Computational Biology and Clinical Informatics, Baker Heart and Diabetes Institute, Melbourne, Australia; School of Chemistry and Molecular Biosciences, University of Queensland, Brisbane, Australia; Systems and Computational Biology, Bio21 Institute, University of Melbourne, Parkville, Australia
| | - David B Ascher
- Baker Department of Cardiometabolic Health, University of Melbourne, Melbourne, Australia; Computational Biology and Clinical Informatics, Baker Heart and Diabetes Institute, Melbourne, Australia; School of Chemistry and Molecular Biosciences, University of Queensland, Brisbane, Australia; Systems and Computational Biology, Bio21 Institute, University of Melbourne, Parkville, Australia
| | - Quan Huynh
- Imaging Research laboratory, Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Thomas H Marwick
- Imaging Research laboratory, Baker Heart and Diabetes Institute, Melbourne, Australia; Baker Department of Cardiometabolic Health, University of Melbourne, Melbourne, Australia; Western Health, Melbourne, Australia; Menzies Institute of Medical Research, Hobart, Tasmania, Australia.
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14
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Gaznabi S, Miranda J, Lorenzatti D, Piña P, Balasubramanian SS, Desai D, Desai A, Ho EC, Scotti A, Gongora CA, Schenone AL, Garcia MJ, Latib A, Parwani P, Slipczuk L. Multimodality Imaging in Aortic Stenosis: Beyond the Valve - Focusing on the Myocardium. Cardiol Clin 2024; 42:433-446. [PMID: 38910026 DOI: 10.1016/j.ccl.2024.04.002] [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] [Indexed: 06/25/2024]
Abstract
Current guidelines of aortic stenosis (AS) management focus on valve parameters, LV systolic dysfunction, and symptoms; however, emerging data suggest that there may be benefit of aortic valve replacement before it becomes severe by present criteria. Myocardial assessment using novel multimodality imaging techniques exhibits subclinical myocardial injury and remodeling at various stages before guideline-directed interventions, which predicts adverse outcomes. This raises the question of whether implementing serial myocardial assessment should become part of the standard appraisal, thereby identifying high-risk patients aiming to minimize adverse outcomes.
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Affiliation(s)
- Safwan Gaznabi
- Division of Cardiology, Montefiore Medical Center/Albert Einstein College of Medicine, 111 East 210th street, Bronx, NY 10467, USA; Division of Cardiology, University of Chicago at Northshore University Health System, 1000 Central Street, Evanston, IL 60201, USA
| | - Jeirym Miranda
- Division of Cardiology, Montefiore Medical Center/Albert Einstein College of Medicine, 111 East 210th street, Bronx, NY 10467, USA; Division of Cardiology, Mount Sinai Morningside. 419 West 114th Street, NY 10025, USA
| | - Daniel Lorenzatti
- Division of Cardiology, Montefiore Medical Center/Albert Einstein College of Medicine, 111 East 210th street, Bronx, NY 10467, USA
| | - Pamela Piña
- Division of Cardiology, Montefiore Medical Center/Albert Einstein College of Medicine, 111 East 210th street, Bronx, NY 10467, USA; Division of Cardiology, CEDIMAT. Arturo Logroño, Plaza de la Salud, Dr. Juan Manuel Taveras Rodríguez, C. Pepillo Salcedo esq. Santo Domingo, Dominican Republic
| | - Senthil S Balasubramanian
- Division of Cardiology, University of Chicago at Northshore University Health System, 1000 Central Street, Evanston, IL 60201, USA
| | - Darshi Desai
- Department of Internal Medicine, University of California Riverside School of Medicine. 900 University Avenue, Riverside, CA 92521, USA
| | - Aditya Desai
- Department of Internal Medicine, University of California Riverside School of Medicine. 900 University Avenue, Riverside, CA 92521, USA
| | - Edwin C Ho
- Division of Cardiology, Montefiore Medical Center/Albert Einstein College of Medicine, 111 East 210th street, Bronx, NY 10467, USA
| | - Andrea Scotti
- Division of Cardiology, Montefiore Medical Center/Albert Einstein College of Medicine, 111 East 210th street, Bronx, NY 10467, USA
| | - Carlos A Gongora
- Division of Cardiology, Montefiore Medical Center/Albert Einstein College of Medicine, 111 East 210th street, Bronx, NY 10467, USA
| | - Aldo L Schenone
- Division of Cardiology, Montefiore Medical Center/Albert Einstein College of Medicine, 111 East 210th street, Bronx, NY 10467, USA
| | - Mario J Garcia
- Division of Cardiology, Montefiore Medical Center/Albert Einstein College of Medicine, 111 East 210th street, Bronx, NY 10467, USA
| | - Azeem Latib
- Division of Cardiology, Montefiore Medical Center/Albert Einstein College of Medicine, 111 East 210th street, Bronx, NY 10467, USA
| | - Purvi Parwani
- Division of Cardiology, Department of Medicine, Loma Linda University Health, 11234 Anderson Street, Loma Linda, CA 92354, USA
| | - Leandro Slipczuk
- Division of Cardiology, Montefiore Medical Center/Albert Einstein College of Medicine, 111 East 210th street, Bronx, NY 10467, USA.
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15
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Lee CY, Nabeshima Y, Kitano T, Parasca CA, Calin A, Popescu BA, Takeuchi M. Prognostic value of right ventricular free-wall longitudinal strain in aortic stenosis: A systematic review and meta-analysis. J Cardiol 2024; 84:80-85. [PMID: 38043709 DOI: 10.1016/j.jjcc.2023.11.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 11/23/2023] [Accepted: 11/24/2023] [Indexed: 12/05/2023]
Abstract
BACKGROUND Assessment of right ventricular (RV) function in aortic stenosis (AS) may improve risk stratification. However, whether the prognostic value of RV free-wall longitudinal strain (RVfwLS) is better than that of other right heart or pulmonary circulation parameters remains uncertain. This study assessed and compared the prognostic value of RVfwLS with traditional parameters in the AS population using a systematic review and meta-analysis. METHODS We selected studies reporting the hazard ratio (HR) of RVfwLS in patients with AS. We also collected data regarding the HR of systolic pulmonary arterial pressure (SPAP), fractional area change (FAC), and tricuspid annulus plane systolic excursion (TAPSE). To ensure comparability, we standardized the HR using within-study standard deviations. The comparison between the prognostic value of RVfwLS and other parameters was conducted as a ratio of HR. RESULTS This meta-analysis included 9 studies comprising a total of 2547 patients, with 679 events. The pooled HR of RVfwLS was 1.56 (95 % CI: 1.39-1.75, p < 0.001). When examining the ratio of HR between RVfwLS and conventional parameters, all comparisons were statistically non-significant [RVfwLS/SPAP: 1.28 (95 % CI: 0.99-1.65, p = 0.06); RVfwLS/FAC: 1.24 (95 % CI: 0.90-1.72, p = 0.14); and RVfwLS/TAPSE:1.07 (95 % CI: 0.75-1.52, p = 0.60)]. CONCLUSIONS This meta-analysis establishes a substantial association between RVfwLS and adverse outcomes in the AS population. However, comparative analysis between RVfwLS and SPAP, FAC, or TAPSE did not support the prognostic superiority of RVfwLS.
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Affiliation(s)
- Chung-Yen Lee
- School of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yosuke Nabeshima
- Department of Cardiology, Saga University, School of Medicine, Saga, Japan
| | - Tetsuji Kitano
- Second Department of Internal Medicine, University of Occupational and Environmental Health, School of Medicine, Kitakyushu, Japan
| | - Catalina A Parasca
- Cardiothoracic Department, University of Medicine and Pharmacy "Carol Davia", Bucharest, Romania; Cardiology and Cardiovascular Surgery Department, Emergency Institute for Cardiovascular Diseases "Prof. Dr. C. C. Iliescu", Bucharest, Romania
| | - Andreea Calin
- Cardiothoracic Department, University of Medicine and Pharmacy "Carol Davia", Bucharest, Romania; Cardiology and Cardiovascular Surgery Department, Emergency Institute for Cardiovascular Diseases "Prof. Dr. C. C. Iliescu", Bucharest, Romania
| | - Bogdan A Popescu
- Cardiothoracic Department, University of Medicine and Pharmacy "Carol Davia", Bucharest, Romania; Cardiology and Cardiovascular Surgery Department, Emergency Institute for Cardiovascular Diseases "Prof. Dr. C. C. Iliescu", Bucharest, Romania
| | - Masaaki Takeuchi
- Department of Laboratory and Transfusion Medicine, Hospital of University of Occupational and Environmental Health, Kitakyushu, Japan.
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16
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Moya A, de Oliveira EK, Delrue L, Beles M, Buytaert D, Goethals M, Verstreken S, Dierckx R, Bartunek J, Heggermont W, Wyffels E, Vanderheyden M. Myocardial work and risk stratification in patients with severe aortic valve stenosis referred for transcatheter aortic valve replacement. IJC HEART & VASCULATURE 2024; 53:101474. [PMID: 39156917 PMCID: PMC11327593 DOI: 10.1016/j.ijcha.2024.101474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Revised: 07/01/2024] [Accepted: 07/18/2024] [Indexed: 08/20/2024]
Abstract
Background Transcatheter aortic valve replacement(TAVR) has shown clear survival benefits in severe aortic valve stenosis(AS). However, patients unable to recover left ventricle function remain at risk with poor long-term survival. This single-center prospective study aims to analyze the supplementary benefits of myocardial work(MW) assessment for baseline risk stratification in patients with severe AS referred for TAVR. Methods A total of 110 patients with severe AS referred for TAVR were included in the study. Baseline ECG data, transthoracic echocardiographic(TTE) images and blood samples were obtained. The TTE examination was repeated one day and one month after valve replacement. The primary outcome of the study was a composite endpoint consisting of all-cause mortality and HF hospitalization. Results During a mean follow-up period of 521 ± 343 days, 29patients(26.4 %) reached the composite endpoint. Baseline troponins, NT-proBNP, sST2, GWI and GCW showed statistically significant differences between groups. Patients with a baseline GWI<2323 mmHg% (sensitivity 0.63 and specificity 0.76)had significantly worse outcome following TAVR. A basic predictive model included QRS-length, TAPSE, LAVI and E/e'. The addition of biomarkers did not yield any further advantages whereas incorporating the GWI cut-off value of 2323 mmHg% significantly enhanced the predictive value. Although there were no significant changes in LVEF and GLS, all patients exhibited a significant reduction in GWI and GCW immediately after TAVR. Conclusion Our findings provide evidence for the enhanced usefulness of MW analysis in the initial risk stratification of patients with severe AS referred for TAVR. Specifically, a baseline GWI<2323 mmHg% demonstrates an independent predictor associated with increased incidence of all-cause mortality and HF hospitalization following TAVR.
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Affiliation(s)
- Ana Moya
- CardioPath PhD Program, Federico II University Hospital, Naples, Italy
- Cardiovascular Center, OLV Hospital, Aalst, Belgium
| | - Elayne Kelen de Oliveira
- CardioPath PhD Program, Federico II University Hospital, Naples, Italy
- Cardiovascular Center, OLV Hospital, Aalst, Belgium
| | - Leen Delrue
- Cardiovascular Center, OLV Hospital, Aalst, Belgium
| | - Monika Beles
- Cardiovascular Center, OLV Hospital, Aalst, Belgium
| | | | | | | | - Riet Dierckx
- Cardiovascular Center, OLV Hospital, Aalst, Belgium
| | | | | | - Eric Wyffels
- Cardiovascular Center, OLV Hospital, Aalst, Belgium
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17
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Margonato D, Ingallina G, Belli M, Tavernese A, Ricchetti G, Ancona F, Stella S, Biondi F, Fiore G, De Bonis M, Maisano F, Topilsky Y, Agricola E. Tricuspid regurgitation in the context of severe left-sided valvular disease: Patients characteristics and outcome. Heliyon 2024; 10:e34874. [PMID: 39148991 PMCID: PMC11325386 DOI: 10.1016/j.heliyon.2024.e34874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2024] [Revised: 07/17/2024] [Accepted: 07/17/2024] [Indexed: 08/17/2024] Open
Abstract
Background We aimed to assess the characteristics, management and long-term prognosis of a cohort of patients with multiple valvular disease, focusing on the context of severe mitral or aortic disease with concomitant significant tricuspid regurgitation (TR). Methods After using a propensity score matching for age, 975 patients with ≥ moderate TR, diagnosed at our centers from 2012 to 2020, were included and divided in four groups, including isolated TR patients as reference group. Primary endpoint was all-cause death (ACD), secondary endpoint was the composite of heart failure (HF) hospitalization + any valvular intervention. Results Patients with isolated TR (356, 37 %) had more history of atrial fibrillation and were more often asymptomatic and with preserved left-ventricular ejection fraction (LVEF). Patients with severe mitral regurgitation (MR) + TR (466, 48 %) showed higher rates of concomitant coronary artery disease, advanced functional class symptoms and larger left atrial volumes. Severe aortic stenosis (AS) patients (131, 13 %) were older, with more comorbidities and lower LVEF. Patients with severe aortic regurgitation and TR (22, 2 %) were younger, with larger LV dimensions and higher pulmonary arterial pressures.After a median follow-up of 2.8 years, both endpoints were univariably more frequent in patients with severe AS + TR (all p < 0.001), but after comprehensive adjustment difference in the primary endpoint became insignificant, underscoring the serious outcomes of all significant TR groups significantly. Overall, in 44 (5 %) patients tricuspid intervention was performed, with no differences between groups in term of frequency of concomitant or staged tricuspid valve surgical treatment. Conclusions In the context of severe left-sided VD, concomitant significant TR is common, and each subtype presents with different clinical and echocardiographic features: patients with severe AS and TR have considerable worse prognosis, although comprehensive adjustment reflected the poor outcomes affecting all types of patients with significant TR. In this scenario, TR was profoundly undertreated.
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Affiliation(s)
- Davide Margonato
- Cardiovascular Imaging Unit, Cardiothoracic Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giacomo Ingallina
- Cardiovascular Imaging Unit, Cardiothoracic Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Martina Belli
- Cardiovascular Imaging Unit, Cardiothoracic Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Annamaria Tavernese
- Cardiovascular Imaging Unit, Cardiothoracic Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Gianluca Ricchetti
- Cardiovascular Imaging Unit, Cardiothoracic Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Ancona
- Cardiovascular Imaging Unit, Cardiothoracic Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Stefano Stella
- Cardiovascular Imaging Unit, Cardiothoracic Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Federico Biondi
- Cardiovascular Imaging Unit, Cardiothoracic Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giorgio Fiore
- Cardiovascular Imaging Unit, Cardiothoracic Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Michele De Bonis
- Cardiac Surgery Unit, Cardiothoracic Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute University San Raffaele, Milan, Italy
| | - Francesco Maisano
- Cardiac Surgery Unit, Cardiothoracic Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute University San Raffaele, Milan, Italy
| | - Yan Topilsky
- Department of Cardiology, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Eustachio Agricola
- Cardiovascular Imaging Unit, Cardiothoracic Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute University San Raffaele, Milan, Italy
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18
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Boxhammer E, Paar V, Kopp K, Gharibeh SX, Bovenkamp-Aberger E, Rezar R, Lichtenauer M, Hoppe UC, Mirna M. Insulin-like Growth Factor-Binding Protein 2 in Severe Aortic Valve Stenosis and Pulmonary Hypertension: A Gender-Based Perspective. Int J Mol Sci 2024; 25:8220. [PMID: 39125788 PMCID: PMC11312253 DOI: 10.3390/ijms25158220] [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: 06/01/2024] [Revised: 07/23/2024] [Accepted: 07/24/2024] [Indexed: 08/12/2024] Open
Abstract
Severe aortic valve stenosis (AS) and pulmonary hypertension (PH) are life-threatening cardiovascular conditions, necessitating early detection and intervention. Recent studies have explored the role of Insulin-like Growth Factor-Binding Protein 2 (IGF-BP2) in cardiovascular pathophysiology. Understanding its involvement may offer novel insights into disease mechanisms and therapeutic targets for these conditions. A total of 102 patients (46 female, 56 male) with severe AS undergoing a transcatheter aortic valve replacement (TAVR) in a single-center study were classified using echocardiography tests to determine systolic pulmonary artery pressure (sPAP) and the presence (sPAP ≥ 40 mmHg) or absence (sPAP < 40 mmHg) of PH. Additionally, serial laboratory determinations of IGF-BP2 before, and at 24 h, 96 h, and 3 months after intervention were conducted in all study participants. Considering the entire cohort, patients with PH had significant and continuously higher serum IGF-BP2 concentrations over time than patients without PH. After subdivision by sex, it could be demonstrated that the above-mentioned results were only verifiable in males, but not in females. In the male patients, baseline IGF-BP2 levels before the TAVR was an isolated risk factor for premature death after intervention and at 1, 3, and 5 years post-intervention. The same was valid for the combination of male and echocardiographically established PH patients. The predictive role of IGF-BP2 in severe AS and concurrent PH remains unknown. A more profound comprehension of IGF-BP2 mechanisms, particularly in males, could facilitate the earlier consideration of the TAVR as a more effective and successful treatment strategy.
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Affiliation(s)
- Elke Boxhammer
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria
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19
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Tomii D, Okuno T, Nakase M, Praz F, Stortecky S, Reineke D, Windecker S, Lanz J, Pilgrim T. Renin-Angiotensin System Inhibition and Cardiac Damage in Patients Who Have Undergoing Transcatheter Aortic Valve Replacement. Can J Cardiol 2024:S0828-282X(24)00577-4. [PMID: 39067618 DOI: 10.1016/j.cjca.2024.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 06/23/2024] [Accepted: 07/21/2024] [Indexed: 07/30/2024] Open
Abstract
BACKGROUND The optimal medical treatment strategy after transcatheter aortic valve replacement (TAVR) has not been established, and might be affected by the extent of extravalvular cardiac damage. We aimed to investigate the prognostic association of renin-angiotensin system (RAS) inhibitors in TAVR patients stratified according to the extent of extravalvular cardiac damage. METHODS In a prospective TAVR registry, patients were retrospectively evaluated for baseline cardiac damage and classified into 5 stages of cardiac damage (0-4) according to established criteria. Clinical outcomes at 1 year were compared according to RAS inhibitor prescription at discharge. RESULTS Among 2247 eligible patients who underwent TAVR between August 2007 and June 2021, 1634 (72.7%) were prescribed RAS inhibitors at discharge. Eighty-three patients (3.7%) were classified as stage 0, 276 (12.3%) as stage 1, 889 (39.6%) as stage 2, 489 (21.8%) as stage 3, and 510 (22.7%) as stage 4. RAS inhibitor prescription after TAVR was associated with a reduced risk of 1-year mortality (adjusted hazard ratio [HRadjusted], 0.59; 95% confidence interval [CI], 0.45-0.77). The protective association was accentuated among patients with cardiac stages 3 and 4 (HRadjusted, 0.54 [95% CI, 0.32-0.92]; and HRadjusted, 0.58 [95% CI, 0.36-0.92], respectively), but not statistically significant in for those with stage 2 (HRadjusted, 0.70; 95% CI, 0.43-1.14). CONCLUSIONS In patients who underwent TAVR, we found a strong association of RAS inhibitor prescription and improved clinical outcome in the overall population, and there were no signs of heterogeneity across stages of cardiac damage. CLINICAL TRIAL REGISTRATION NCT01368250.
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Affiliation(s)
- Daijiro Tomii
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Taishi Okuno
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Masaaki Nakase
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Fabien Praz
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Stefan Stortecky
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - David Reineke
- Department of Cardiac Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Stephan Windecker
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Jonas Lanz
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Thomas Pilgrim
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland.
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20
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Imamura T, Narang N, Ushijima R, Sobajima M, Fukuda N, Ueno H, Kinugawa K. Impaired Gastrointestinal Motility and Worsening Heart Failure in Patients Receiving Trans-Catheter Aortic Valve Replacement. J Clin Med 2024; 13:4301. [PMID: 39124567 PMCID: PMC11313607 DOI: 10.3390/jcm13154301] [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: 06/02/2024] [Revised: 06/18/2024] [Accepted: 07/20/2024] [Indexed: 08/12/2024] Open
Abstract
Background: Impaired gastric motility in the form of constipation may often occur in elderly patients with chronic heart failure. Candidates for trans-catheter aortic replacement (TAVR) are of old age and have multiple comorbidities, probably including constipation. However, the clinical implication of a history of constipation in patients receiving TAVR remains unknown. Methods: Patients who underwent TAVR at our large academic center between 2015 and 2022 were eligible. The prognostic impact of the prescribed laxative type and number, which was assumed as the severity of constipation, on the incidence of death or heart failure readmission two years after index discharge was investigated. Results: A total of 344 patients were included. Median age was 85 years, and 99 patients were men. Patients with any laxatives (N = 166) had higher systolic blood pressure, higher plasma B-type natriuretic peptide levels, and a lower prescription rate of renin-angiotensin system inhibitors at the time of index discharge after TAVR (p < 0.05 for all). The number of laxative types was independently associated with the composite primary outcome with an adjusted hazard ratio of 1.83 (95% confidence interval 1.27-2.63, p = 0.001) with a cutoff of one type of laxative used, which significantly stratified the 2-year cumulative incidence of the primary outcome (18% versus 7%, p = 0.001). Conclusions: The presence of constipation was associated with worse clinical outcomes following TAVR. The prognostic impact of an aggressive intervention for constipation remains a future concern in this cohort.
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Affiliation(s)
- Teruhiko Imamura
- The Second Department of Internal Medicine, University of Toyama, Toyama 930-0194, Japan
| | - Nikhil Narang
- Advocate Christ Medical Center, Oak Lawn, IL 60453, USA
| | - Ryuichi Ushijima
- The Second Department of Internal Medicine, University of Toyama, Toyama 930-0194, Japan
| | - Mitsuo Sobajima
- The Second Department of Internal Medicine, University of Toyama, Toyama 930-0194, Japan
| | - Nobuyuki Fukuda
- The Second Department of Internal Medicine, University of Toyama, Toyama 930-0194, Japan
| | - Hiroshi Ueno
- The Second Department of Internal Medicine, University of Toyama, Toyama 930-0194, Japan
| | - Koichiro Kinugawa
- The Second Department of Internal Medicine, University of Toyama, Toyama 930-0194, Japan
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21
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Lillo R, Cangemi S, Graziani F, Locorotondo G, Pedicino D, Aurigemma C, Romagnoli E, Malara S, Meucci MC, Iannaccone G, Bianchini F, Nesta M, Bruno P, Lombardo A, Trani C, Burzotta F. Pulmonary congestion assessed by lung ultrasound in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation: Prevalence and prognostic implications. Eur J Heart Fail 2024. [PMID: 39014551 DOI: 10.1002/ejhf.3365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Revised: 05/08/2024] [Accepted: 06/21/2024] [Indexed: 07/18/2024] Open
Abstract
AIMS Lung ultrasound (LUS) is a sensitive tool to assess pulmonary congestion (PC). Few data are available on LUS-PC evaluation in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI). The aim of this study was to assess the prevalence and prognostic impact of LUS-PC in patients with severe AS before and after TAVI. METHODS AND RESULTS We designed a single-centre prospective study in patients referred for TAVI for severe AS (ClinicalTrials.gov identification number: NCT05024942). All patients underwent echocardiography and LUS (according to a simplified 8-zone scanning protocol) the day before and within 72 h after the procedure. The primary endpoint was the composite of all-cause mortality, hospitalization for heart failure and urgent medical visits for worsening dyspnoea at 12-month follow-up. A total of 127 patients were enrolled (mean age 81.1 ± 5.8 years; 54.3% female). Pre-TAVI LUS-PC was documented in 65 patients (51%). After TAVI, the prevalence of LUS-PC significantly decreased as compared to pre-TAVI evaluation, being documented in only 28 patients (22% vs. 51%, p < 0.001) with a median B-lines score of 4 (interquartile range [IQR] 0-11) versus 11 (IQR 6-19) pre-TAVI (p < 0.001). During a median follow-up of 12 (12-17) months, 25 patients (19.6%) met the composite endpoint. On multivariable Cox regression analysis, pre-TAVI LUS-PC was independently associated with cardiovascular events (hazard ratio 2.764, 95% confidence interval 1.114-6.857; p = 0.028). CONCLUSIONS Lung ultrasonography reveals a high prevalence of PC in patients with severe AS undergoing TAVI, which is significantly reduced by the procedure. Pre-TAVI PC, measured by LUS, is an independent predictor of 1-year clinical outcome.
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Affiliation(s)
- Rosa Lillo
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Catholic University of the Sacred Heart, Rome, Italy
| | | | - Francesca Graziani
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Gabriella Locorotondo
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Daniela Pedicino
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Cristina Aurigemma
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Enrico Romagnoli
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Silvia Malara
- Catholic University of the Sacred Heart, Rome, Italy
| | - Maria Chiara Meucci
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giulia Iannaccone
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Catholic University of the Sacred Heart, Rome, Italy
| | - Francesco Bianchini
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Marialisa Nesta
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Piergiorgio Bruno
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Catholic University of the Sacred Heart, Rome, Italy
| | - Antonella Lombardo
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Catholic University of the Sacred Heart, Rome, Italy
| | - Carlo Trani
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Catholic University of the Sacred Heart, Rome, Italy
| | - Francesco Burzotta
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Catholic University of the Sacred Heart, Rome, Italy
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22
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Schofer N, Ludwig S. TAVI in moderate aortic stenosis: the earlier the better? EUROINTERVENTION 2024; 20:e840-e842. [PMID: 39007827 PMCID: PMC11228534 DOI: 10.4244/eij-d-24-00164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 03/07/2024] [Indexed: 07/16/2024]
Affiliation(s)
- Niklas Schofer
- University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Sebastian Ludwig
- University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
- Cardiovascular Research Foundation (CRF), New York, NY, USA
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23
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Lee CY, Tsai CM, Chiang KC, Huang CC, Lin MS, Hung CL, Ho YL, Nkomo VT, Takeuchi M, Yang LT. Prognostic value of left ventricular and left atrial strain imaging in moderate to severe aortic stenosis: Insights from an Asian population. Int J Cardiol 2024; 407:132103. [PMID: 38677333 DOI: 10.1016/j.ijcard.2024.132103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 04/04/2024] [Accepted: 04/24/2024] [Indexed: 04/29/2024]
Abstract
BACKGROUND Data regarding the prognostic value of left atrial (LA) strain in aortic stenosis (AS) is scarce, especially in Asian population and moderate AS. METHOD Left ventricular global longitudinal strain (LVGLS), LA reservoir strain (LASr), conduit strain (LAScd), and contractile strain (LASct) were measured using automated speckle-tracking echocardiography in consecutive patients with moderate or severe AS. The primary endpoint was a composite of all-cause death (ACD) and major adverse cardiovascular events (MACE; myocardial infarction, syncope, and heart failure hospitalization). RESULTS Of 712 patients (mean age, 78 ± 12 years; 370 [52%] moderate AS; 342 [48%] severe AS), average LV ejection fraction (LVEF) was 68 with SD of 12%. At a median follow-up of 18 months (interquartile range, 11-26 months), the primary endpoint occurred in 93 patients (60 deaths and 35 MACEs) and 221 patients underwent surgical or transcatheter aortic valve replacement (AVR). In the entire cohort, separate multivariable models adjusted for age, Charlson index, symptomatic status, time-dependent AVR, AS-severity, LA volume index and LVEF demonstrated that only LASr was associated with MACE+ACD (Hazard ratio, 0.97; P = 0.014). Subgroup analysis for MACE+ACD demonstrated consistent prognostication for LASr in moderate and severe AS; LVGLS was prognostic only in severe AS (all P ≤ 0.023). The optimal MACE+ACD cutoff for LASr from spline curves was 21.3%. Adjusted Kaplan-Meier curves demonstrated better event-free survival in patients with LASr >21.3% versus those with LASr ≤21.3% (P = 0.04). CONCLUSIONS In both moderate and severe AS, only LASr robustly predicted outcomes; thus, including LASr in the AS staging algorithm should be considered.
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Affiliation(s)
- Chung-Yen Lee
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chieh-Mei Tsai
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kuang-Chien Chiang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chi-Ching Huang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Mao-Shin Lin
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chung-Lieh Hung
- Cardiovascular Division, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
| | - Yi-Lwun Ho
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Telehealth Center, National Taiwan University Hospital, Taipei, Taiwan
| | - Vuyisile T Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Masaaki Takeuchi
- Department of Laboratory and Transfusion Medicine, Hospital of University of Occupational and Environmental Health, School of Medicine, Kitakyushu, Japan
| | - Li-Tan Yang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Telehealth Center, National Taiwan University Hospital, Taipei, Taiwan.
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24
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Stolz L, Hausleiter J. Seeing the Bigger Picture: Impact of Extramitral Cardiac Damage in Patients With Mitral Annular Calcification. JACC Cardiovasc Interv 2024; 17:1591-1596. [PMID: 38986658 DOI: 10.1016/j.jcin.2024.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2024] [Accepted: 06/06/2024] [Indexed: 07/12/2024]
Affiliation(s)
- Lukas Stolz
- Medizinische Klinik und Poliklinik I, LMU Klinikum, LMU München, Munich, Germany; German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany
| | - Jörg Hausleiter
- Medizinische Klinik und Poliklinik I, LMU Klinikum, LMU München, Munich, Germany; German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany.
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25
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Al-Abcha A, Abbasi M, El-Am E, Ghorbanzadeh A, Lee A, Scott CG, Thaden JJ, Eleid M, Rihal C, Oh J, Pellikka PA, Guerrero ME. Staging Extramitral Cardiac Damage in Mitral Annular Calcification With Mitral Valve Dysfunction. JACC Cardiovasc Interv 2024; 17:1577-1590. [PMID: 38986657 DOI: 10.1016/j.jcin.2024.05.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 05/09/2024] [Accepted: 05/21/2024] [Indexed: 07/12/2024]
Abstract
BACKGROUND Mitral annular calcification (MAC) is a progressive degenerative process associated with comorbidities and increased mortality. A staging system that considers extramitral cardiac damage in MAC may help improve patient selection for mitral valve interventions. OBJECTIVES This study sought to develop a transthoracic echocardiogram (TTE)-based cardiac staging system in patients with MAC and significant mitral valve dysfunction and assess its prognostic utility. METHODS We retrospectively evaluated all adults who underwent TTE over 1 year at Mayo Clinic with MAC and significant mitral valve dysfunction defined as mitral stenosis and/or at least moderate mitral regurgitation. Patients were categorized into 5 stages according to extramitral cardiac damage by TTE. All-cause mortality and heart failure hospitalization were assessed. RESULTS For the 953 included patients, the mean age was 76.2 ± 10.7 years, and 54.0% were women. Twenty-eight (2.9%) patients were classified in stages 0 to 1, 499 (52.4%) in stage 2, 115 (12.1%) in stage 3, and 311 (32.6%) in stage 4. At the 3.8-year follow-up, mortality was significantly higher in patients in stages 2 to 4 compared to stages 0 to 1 and increased with each stage. Survival differences were maintained after adjustment for age, diabetes mellitus, and glomerular filtration rate. The rate of heart failure hospitalization was significantly higher in stages 3 and 4 compared to stages 0 to 1. Similar results were observed in subgroup analysis in patients with moderate or severe MAC, predominant mitral stenosis, or predominant mitral regurgitation. CONCLUSIONS Using the proposed extramitral cardiac damage staging system in patients with MAC and significant mitral valve dysfunction, more advanced stages are associated with higher mortality.
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Affiliation(s)
- Abdullah Al-Abcha
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Muhannad Abbasi
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Edward El-Am
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Atefeh Ghorbanzadeh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Alexander Lee
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | - Christopher G Scott
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | - Jeremy J Thaden
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Mackram Eleid
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Charanjit Rihal
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jae Oh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Patricia A Pellikka
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Mayra E Guerrero
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.
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Myagmardorj R, Fortuni F, Galloo X, Nabeta T, Meucci MC, Butcher SC, van der Kley F, Bax JJ, Ajmone Marsan N. Changes in Global Longitudinal Strain after TAVI: Additional Prognostic Value over Cardiac Damage in Patients with Severe Aortic Stenosis. J Clin Med 2024; 13:3945. [PMID: 38999514 PMCID: PMC11242647 DOI: 10.3390/jcm13133945] [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: 06/04/2024] [Revised: 06/27/2024] [Accepted: 07/02/2024] [Indexed: 07/14/2024] Open
Abstract
Background: Previous studies demonstrated the prognostic value of baseline cardiac damage staging as well as left ventricular global longitudinal strain (LVGLS) in patients undergoing transcatheter aortic valve implantation (TAVI). The aim of the present study was to evaluate the changes in cardiac damage stage and LVGLS after TAVI and to investigate their prognostic values when integrated into the follow-up assessment. Methods: Patients with severe aortic stenosis undergoing TAVI were hierarchically classified into cardiac damage stages based on echocardiographic criteria before TAVI and at a 6-month follow-up. At the same time, LVGLS was measured. The staging system included stage 0 = no signs of cardiac damage; stage 1 = LV damage; stage 2 = mitral or left atrial damage; stage 3 = pulmonary vasculature or tricuspid damage; and stage 4 = right ventricular damage. The primary endpoint was all-cause mortality. Results: A total of 620 patients were included. At follow-up, LVGLS significantly improved, and the improvement was similar among each baseline cardiac damage stage. Follow-up LVGLS values were divided into quintiles, and each quintile was integrated into the cardiac damage staging, leading to a reclassification of 308 (50%) patients. At the time of a median follow-up at 48 (IQR 31-71) months starting from the 6-month follow-up after TAVI, 262 (38%) patients had died. A multivariable Cox regression model showed that LVGLS-integrated cardiac damage staging at follow-up had an incremental prognostic value over the baseline assessment (HR per 1-stage increase 1.384; 95% CI 1.152-1.663; p < 0.001). Conclusions: The integration of LVGLS with conventional echocardiographic parameters of cardiac damage at a 6-month follow-up after TAVI can improve patient risk-stratification.
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Affiliation(s)
- Rinchyenkhand Myagmardorj
- Department of Cardiology, Heart Lung Centre, Leiden University Medical Centre (LUMC), 2333 ZC Leiden, The Netherlands; (F.F.); (X.G.); (T.N.); (M.C.M.); (S.C.B.); (F.v.d.K.); (J.J.B.); (N.A.M.)
| | - Federico Fortuni
- Department of Cardiology, Heart Lung Centre, Leiden University Medical Centre (LUMC), 2333 ZC Leiden, The Netherlands; (F.F.); (X.G.); (T.N.); (M.C.M.); (S.C.B.); (F.v.d.K.); (J.J.B.); (N.A.M.)
- Department of Cardiology, San Giovanni Battista Hospital, 06034 Foligno, Italy
| | - Xavier Galloo
- Department of Cardiology, Heart Lung Centre, Leiden University Medical Centre (LUMC), 2333 ZC Leiden, The Netherlands; (F.F.); (X.G.); (T.N.); (M.C.M.); (S.C.B.); (F.v.d.K.); (J.J.B.); (N.A.M.)
| | - Takeru Nabeta
- Department of Cardiology, Heart Lung Centre, Leiden University Medical Centre (LUMC), 2333 ZC Leiden, The Netherlands; (F.F.); (X.G.); (T.N.); (M.C.M.); (S.C.B.); (F.v.d.K.); (J.J.B.); (N.A.M.)
| | - Maria Chiara Meucci
- Department of Cardiology, Heart Lung Centre, Leiden University Medical Centre (LUMC), 2333 ZC Leiden, The Netherlands; (F.F.); (X.G.); (T.N.); (M.C.M.); (S.C.B.); (F.v.d.K.); (J.J.B.); (N.A.M.)
| | - Steele C. Butcher
- Department of Cardiology, Heart Lung Centre, Leiden University Medical Centre (LUMC), 2333 ZC Leiden, The Netherlands; (F.F.); (X.G.); (T.N.); (M.C.M.); (S.C.B.); (F.v.d.K.); (J.J.B.); (N.A.M.)
| | - Frank van der Kley
- Department of Cardiology, Heart Lung Centre, Leiden University Medical Centre (LUMC), 2333 ZC Leiden, The Netherlands; (F.F.); (X.G.); (T.N.); (M.C.M.); (S.C.B.); (F.v.d.K.); (J.J.B.); (N.A.M.)
| | - Jeroen J. Bax
- Department of Cardiology, Heart Lung Centre, Leiden University Medical Centre (LUMC), 2333 ZC Leiden, The Netherlands; (F.F.); (X.G.); (T.N.); (M.C.M.); (S.C.B.); (F.v.d.K.); (J.J.B.); (N.A.M.)
- Heart Center, University of Turku and Turku University Hospital, 20520 Turku, Finland
| | - Nina Ajmone Marsan
- Department of Cardiology, Heart Lung Centre, Leiden University Medical Centre (LUMC), 2333 ZC Leiden, The Netherlands; (F.F.); (X.G.); (T.N.); (M.C.M.); (S.C.B.); (F.v.d.K.); (J.J.B.); (N.A.M.)
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Ghannam M, Kovacs B, Liang J, Attili A, Cochet H, Latchamsetty R, Jongnarangsin K, Morady F, Bogun F. Reply to Unique feature of ventricular arrhythmia in patients with bicuspid aortic valve. J Cardiovasc Electrophysiol 2024; 35:1514-1515. [PMID: 38695246 DOI: 10.1111/jce.16297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Accepted: 04/24/2024] [Indexed: 07/12/2024]
Affiliation(s)
- Michael Ghannam
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Boldizsar Kovacs
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Jackson Liang
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Anil Attili
- Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Hubert Cochet
- Department of Radiology, University of Bordeaux, Bordeaux, France
| | - Rakesh Latchamsetty
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Krit Jongnarangsin
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Fred Morady
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Frank Bogun
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
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Basman C, Landers D, Dudiy Y, Yoon SH, Batsides G, Faraz H, Anderson M, Kaple R. Multiple Valvular Heart Disease in the Transcatheter Era: A State-of-the-Art Review. STRUCTURAL HEART : THE JOURNAL OF THE HEART TEAM 2024; 8:100301. [PMID: 39100585 PMCID: PMC11294895 DOI: 10.1016/j.shj.2024.100301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Revised: 03/03/2024] [Accepted: 03/13/2024] [Indexed: 08/06/2024]
Abstract
Although existing guidelines offer strong recommendations for single valvular dysfunction, the growing prevalence of multiple valvular heart disease (MVHD) in our aging population is challenging the clarity of clinical guidance. Traditional diagnostic modalities, such as echocardiography, face inherent constraints in precisely quantifying valvular dysfunction due to the hemodynamic interactions that occur with multiple valve involvement. Therefore, many patients with MVHD present at a later stage in their disease course and with an elevated surgical risk. The expansion of transcatheter therapy for the treatment of valvular heart disease has added new opportunities for higher-risk patients. However, the impact of isolated valve therapies on patients with MVHD is still not well understood. This review focuses on the etiology, diagnostic challenges, and therapeutic considerations for some of the most common concomitant valvular abnormalities that occur in our daily clinic population.
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Affiliation(s)
- Craig Basman
- Department of Cardiology and Cardiothoracic Surgery, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - David Landers
- Department of Cardiology and Cardiothoracic Surgery, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Yuriy Dudiy
- Department of Cardiology and Cardiothoracic Surgery, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Sung-Han Yoon
- Department of Cardiology and Cardiothoracic Surgery, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - George Batsides
- Department of Cardiology and Cardiothoracic Surgery, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Haroon Faraz
- Department of Cardiology and Cardiothoracic Surgery, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Mark Anderson
- Department of Cardiology and Cardiothoracic Surgery, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Ryan Kaple
- Department of Cardiology and Cardiothoracic Surgery, Hackensack University Medical Center, Hackensack, New Jersey, USA
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Bolaji O, Oriaifo O, Adabale O, Dilibe A, Kuruvada K, Ouedraogo F, Ezeh E, Nair A, Olanipekun T, Mazimba S, Alraies C. A meta-analysis of left ventricular dysfunction in ankylosing spondylitis. J Clin Hypertens (Greenwich) 2024; 26:772-788. [PMID: 38708932 PMCID: PMC11232451 DOI: 10.1111/jch.14827] [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: 12/26/2023] [Revised: 04/03/2024] [Accepted: 04/12/2024] [Indexed: 05/07/2024]
Abstract
Ankylosing spondylitis (AS) is a chronic inflammatory arthritis affecting the spine, presenting a considerable morbidity risk. Although evidence consistently indicates an elevated risk of ischemic heart disease among AS patients, debates persist regarding the likelihood of these patients developing left ventricular dysfunction (LVD). Our investigation aimed to determine whether individuals with AS face a greater risk of LVD compared to the general population. To accomplish this, we identified studies exploring LVD in AS patients across five major databases and Google Scholar. Initially, 431 studies were identified, of which 30 met the inclusion criteria, collectively involving 2933 participants. Results show that AS patients had: (1) poorer Ejection Fraction (EF) [mean difference (MD): -0.92% (95% CI: -1.25 to -0.59)], (2) impaired Early (E) and Late (atrial-A) ventricular filling velocity (E/A) ratio [MD: -0.10 m/s (95% CI: -0.13 to -0.08)], (3) prolonged deceleration time (DT) [MD: 12.30 ms (95% CI: 9.23-15.36)] and, (4) a longer mean isovolumetric relaxation time (IVRT) [MD: 8.14 ms (95% CI: 6.58-9.70)] compared to controls. Though AS patients show increased risks of both systolic and diastolic LVD, we found no significant differences were observed in systolic blood pressure [MD: 0.32 mmHg (95% Confidence Interval (CI): -2.09 to 2.73)] or diastolic blood pressure [MD: 0.30 mmHg (95% CI: -0.40 to 1.01)] compared to the general population. This study reinforces AS patients' susceptibility to LVD without a notable difference in HTN risk.
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Affiliation(s)
- Olayiwola Bolaji
- Department of Internal Medicine, Rutgers University New Jersey Medical School, Newark, New Jersey, USA
| | - Osejie Oriaifo
- Department of Internal Medicine, ECU Health Medical Center, Greenville, North Carolina, USA
| | - Olanrewaju Adabale
- Department of Internal Medicine, ECU Health Medical Center, Greenville, North Carolina, USA
| | - Arthur Dilibe
- Department of Internal Medicine, ECU Health Medical Center, Greenville, North Carolina, USA
| | - Krishna Kuruvada
- Department of Internal Medicine, University of Maryland Capital Region Health, Largo, Maryland, USA
| | - Faizal Ouedraogo
- Department of Internal Medicine, University of Maryland Capital Region Health, Largo, Maryland, USA
| | - Ebubechukwu Ezeh
- Department of Cardiovascular Disease, The University Of Kansas Medical Center, Kansas City, Kansas, USA
| | - Ambica Nair
- Ocean Medical Center Brick, Brick, New Jersey, USA
| | - Titilope Olanipekun
- Brigham and Women's Hospital Department of Medicine Boston, Boston, Massachusetts, USA
| | - Sula Mazimba
- Advanced Heart Failure and Transplant Cardiology, AdventHealth Medical Group Transplant Institute, Orlando, Florida, USA
| | - Chadi Alraies
- Cardiovascular Institute, Detroit Medical Center, DMC Heart Hospital, Detroit, Michigan, USA
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Springhetti P, Tomaselli M, Benfari G, Milazzo S, Ciceri L, Penso M, Pilan M, Clement A, Rota A, Del Sole PA, Nistri S, Muraru D, Ribichini F, Badano L. Peak atrial longitudinal strain and risk stratification in moderate and severe aortic stenosis. Eur Heart J Cardiovasc Imaging 2024; 25:947-957. [PMID: 38319610 DOI: 10.1093/ehjci/jeae040] [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: 10/26/2023] [Accepted: 01/29/2024] [Indexed: 02/07/2024] Open
Abstract
AIMS We sought to investigate the association of left atrial strain with the outcome in a large cohort of patients with at least moderate aortic stenosis (AS). METHODS AND RESULTS We analysed 467 patients (mean age 80.6 ± 8.2 years; 51% men) with at least moderate AS and sinus rhythm. The primary study endpoint was the composite of all-cause mortality and hospitalizations for heart failure. After a median follow-up of 19.2 (inter-quartile range 12.5-24.4) months, 96 events occurred. Using the receiver operator characteristic curve analysis, the cut-off value of peak atrial longitudinal strain (PALS) more strongly associated with outcome was <16% {area under the curve (AUC) 0.70 [95% confidence interval (CI): 0.63-0.78], P < 0.001}. The Kaplan-Meier curves demonstrated a higher rate of events for patients with PALS < 16% (log-rank P < 0.001). On multivariable analysis, PALS [adjusted HR (aHR) 0.95 (95% CI 0.91-0.99), P = 0.017] and age were the only variables independently associated with the combined endpoint. PALS provided incremental prognostic value over left ventricular (LV) global longitudinal strain, LV ejection fraction, and right ventricular function. Subgroup analysis revealed that impaired PALS was also independently associated with outcome in the subgroups of paucisymptomatic patients [aHR 0.98 (95% CI 0.97-0.98), P = 0.048], moderate AS [aHR 0.92, (95% CI 0.86-0.98), P = 0.016], and low-flow AS [aHR 0.90 (95% CI 0.83-0.98), P = 0.020]. CONCLUSION In our patients with at least moderate AS, PALS was independently associated with outcome. In asymptomatic patients, PALS could be a potential marker of sub-clinical damage, leading to better risk stratification and, potentially, earlier treatment.
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Affiliation(s)
- Paolo Springhetti
- Department of Medicine, Division of Cardiology, University of Verona, Piazzale Aristide Stefani 1, 37100 Verona, Italy
| | - Michele Tomaselli
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Giovanni Benfari
- Department of Medicine, Division of Cardiology, University of Verona, Piazzale Aristide Stefani 1, 37100 Verona, Italy
| | - Salvatore Milazzo
- Division of Cardiology, University Hospital Paolo Giaccone, Palermo, Italy
| | - Luca Ciceri
- Department of Medicine, Division of Cardiology, University of Verona, Piazzale Aristide Stefani 1, 37100 Verona, Italy
| | - Marco Penso
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Matteo Pilan
- Department of Medicine, Division of Cardiology, University of Verona, Piazzale Aristide Stefani 1, 37100 Verona, Italy
| | - Alexandra Clement
- Internal Medicine Department, 'Grigore T. Popa' University of Medicine and Pharmacy, Iasi, Romania
| | - Alessandra Rota
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Paolo Alberto Del Sole
- Department of Medicine, Division of Cardiology, University of Verona, Piazzale Aristide Stefani 1, 37100 Verona, Italy
| | | | - Denisa Muraru
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Flavio Ribichini
- Department of Medicine, Division of Cardiology, University of Verona, Piazzale Aristide Stefani 1, 37100 Verona, Italy
| | - Luigi Badano
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
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Reichl JJ, Stolte T, Tang S, Boeddinghaus J, Wagener M, Leibundgut G, Kaiser CA, Nestelberger T. Prognostic Impact of Left Ventricular Ejection Fraction Improvement after Transcatheter Aortic Valve Replacement. J Clin Med 2024; 13:3639. [PMID: 38999205 PMCID: PMC11242474 DOI: 10.3390/jcm13133639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2024] [Revised: 06/12/2024] [Accepted: 06/19/2024] [Indexed: 07/14/2024] Open
Abstract
Introduction: Transcatheter aortic valve replacement (TAVR) has become an efficient and safe alternative to surgical aortic valve replacement (SAVR). While severe aortic stenosis as well as severe aortic regurgitation (AR) are known to negatively impact left ventricular ejection fraction (LVEF), prior studies have shown that TAVR can lead to an improvement in LVEF. Thus far, little is known about the prognostic implication of LVEF improvement as a sole predictor of outcomes. Therefore, the aim of this study was to assess the prognostic impact of LVEF impairment before TAVR, as well as early LVEF improvement in patients undergoing TAVR. Materials and Methods: Patients undergoing TAVR in a large tertiary university hospital were consecutively included in a prospective registry. Transthoracic echocardiography (TTE) was performed at baseline, after 1 month and annually thereafter. Significant LVEF improvement was defined as a relative increase of ≥10% in LVEF at 30 days compared to baseline LVEF. The primary outcome was all-cause mortality at 1 year. Secondary outcomes were major adverse cardiovascular events (MACEs) including cardiovascular death, non-fatal myocardial infarction, stroke, bleeding and unplanned re-interventions of the aortic valve at 5 years. Results: Among 1655 patients who underwent TAVR between September 2011 and April 2024, the LVEF at baseline was available for 1556 patients. Of these, 1031 patients (66.2%) had preserved LVEF at baseline (LVEF ≥ 53%), whereas 303 patients (19.5%) had moderately reduced LVEF (40-52%) and 222 patients (14.3%) had severely reduced LVEF (<40%). Out of the patients with impaired LVEF, 155 (40.4%) patients showed a significant improvement in LVEF ≥10% after 30 days, while 229 (60.6%) patients showed no significant LVEF improvement (<10%). Patients with preserved LVEF at baseline had significantly better mortality outcomes than those with severely reduced LVEF (p < 0.001). LVEF improvement was associated with a survival benefit after 1 year (p = 0.009, HR 2.68, 0.95 CI 1.23-5.85) which diminished after 5 years (p = 0.058), but patients with LVEF improvement showed lower MACE rates at 5 years (p < 0.001). Conclusions: Preserved LVEF before TAVR is an independent predictor for improved outcomes. Additionally, early improvement in LVEF is associated with beneficial outcomes in patients undergoing TAVR.
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Affiliation(s)
- Jakob Johannes Reichl
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, 4031 Basel, Switzerland; (J.J.R.); (T.S.); (S.T.); (J.B.); (M.W.); (G.L.); (C.A.K.)
- Department of General Internal Medicine, University Hospital Basel, 4031 Basel, Switzerland
| | - Thorald Stolte
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, 4031 Basel, Switzerland; (J.J.R.); (T.S.); (S.T.); (J.B.); (M.W.); (G.L.); (C.A.K.)
- Department of Health Sciences and Technology, Swiss Federal Institute of Technology, 8093 Zurich, Switzerland
| | - Shihui Tang
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, 4031 Basel, Switzerland; (J.J.R.); (T.S.); (S.T.); (J.B.); (M.W.); (G.L.); (C.A.K.)
| | - Jasper Boeddinghaus
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, 4031 Basel, Switzerland; (J.J.R.); (T.S.); (S.T.); (J.B.); (M.W.); (G.L.); (C.A.K.)
| | - Max Wagener
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, 4031 Basel, Switzerland; (J.J.R.); (T.S.); (S.T.); (J.B.); (M.W.); (G.L.); (C.A.K.)
| | - Gregor Leibundgut
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, 4031 Basel, Switzerland; (J.J.R.); (T.S.); (S.T.); (J.B.); (M.W.); (G.L.); (C.A.K.)
| | - Christoph Ado Kaiser
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, 4031 Basel, Switzerland; (J.J.R.); (T.S.); (S.T.); (J.B.); (M.W.); (G.L.); (C.A.K.)
| | - Thomas Nestelberger
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, 4031 Basel, Switzerland; (J.J.R.); (T.S.); (S.T.); (J.B.); (M.W.); (G.L.); (C.A.K.)
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Islas F, O’Neill-González P, Jiménez-Quevedo P, Nombela-Franco L, Gil-Abizanda S, Mahía-Casado P, Rivadeneira-Ruiz M, Pozo-Osinalde E, Carbone A, Olmos C. Aortic Stenosis and the Evolution of Cardiac Damage after Transcatheter Aortic Valve Replacement. J Clin Med 2024; 13:3539. [PMID: 38930068 PMCID: PMC11204698 DOI: 10.3390/jcm13123539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Revised: 06/02/2024] [Accepted: 06/07/2024] [Indexed: 06/28/2024] Open
Abstract
Background/Objectives: Severe aortic stenosis (AS) is the most frequent valvular heart disease. Models for stratifying cardiac damage associated with aortic stenosis have been developed to predict outcomes following valve replacement. However, evidence regarding morphological and functional evolution, as well as potential changes in the degree of cardiac damage, is limited. We aim to provide information on the evolution of cardiac morphology and the function of patients undergoing transcatheter aortic valve replacement (TAVR) who have been classified using a cardiac damage staging system. Methods: In total, 496 patients were included in the analysis, and were classified into four stages based on the extent of cardiac damage as follows: Stage 0, no cardiac damage: left ventricle global longitudinal strain (LV-GLS) < -17%; right ventricular-arterial coupling (RVAc) ≥ 0.35), and absence of significant mitral regurgitation (MR). Stage 1, left-sided subclinical damage: LV-GLS ≥ -17%. Stage 2, left-sided damage: significant MR. Stage 3, right-sided damage: RVAc < 0.35. Results: The mean age was 82.1 ± 5.9 years, and 53.0% were female. In total, 24.5% of patients met the criteria for Stage 0, and Stage 1 included 42.8% of patients, Stage 2 included 16.5%, and Stage 3 comprised 16.2% of patients. Mortality was 8.4% for stage 0, 17.4% for stage 1, 25.6% for stage 2, and 28.6% for stage 3 patients (p = 0.004). Diabetes mellitus (DM) (p = 0.047) and chronic kidney disease (CKD) (p = 0.024) were the only clinical predictors of no change or worsening in the stage of cardiac damage. Regarding echocardiographic variables, concomitant tricuspid, and mitral regurgitation, ≥ 2 were both significantly associated with no change or worsening, also (p < 0.001). Conclusions: Cardiac damage that is secondary to severe aortic stenosis has morphological and functional repercussions that, even after valve replacement, persist and might worsen the prognosis.
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Affiliation(s)
- Fabián Islas
- Instituto Cardiovascular, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), 28040 Madrid, Spain; (F.I.); (P.O.-G.)
- Unidad de Imagen Cardiaca, Hospital Universitario Nuestra Señora del Prado, 45600 Talavera de la Reina, Spain
| | - Patrick O’Neill-González
- Instituto Cardiovascular, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), 28040 Madrid, Spain; (F.I.); (P.O.-G.)
| | - Pilar Jiménez-Quevedo
- Instituto Cardiovascular, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), 28040 Madrid, Spain; (F.I.); (P.O.-G.)
| | - Luis Nombela-Franco
- Instituto Cardiovascular, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), 28040 Madrid, Spain; (F.I.); (P.O.-G.)
| | - Sandra Gil-Abizanda
- Instituto Cardiovascular, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), 28040 Madrid, Spain; (F.I.); (P.O.-G.)
| | - Patricia Mahía-Casado
- Instituto Cardiovascular, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), 28040 Madrid, Spain; (F.I.); (P.O.-G.)
| | - María Rivadeneira-Ruiz
- Instituto Cardiovascular, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), 28040 Madrid, Spain; (F.I.); (P.O.-G.)
| | - Eduardo Pozo-Osinalde
- Instituto Cardiovascular, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), 28040 Madrid, Spain; (F.I.); (P.O.-G.)
| | - Andreina Carbone
- Cardiology Unit, University of Campania Luigi Vanvitelli, 81100 Naples, Italy
| | - Carmen Olmos
- Instituto Cardiovascular, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), 28040 Madrid, Spain; (F.I.); (P.O.-G.)
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Akintoye E, El Dahdah J, Dabbagh MM, Patel H, Badwan O, Braghieri L, Chedid El Helou M, Kassab J, Jellis CL, Desai MY, Rodriguez LL, Grimm RA, Roselli EE, Griffin BP, Popovic ZB. Longitudinal Assessment of Left Atrial Remodeling in Patients With Chronic Severe Aortic Regurgitation. JACC Cardiovasc Imaging 2024:S1936-878X(24)00156-6. [PMID: 38878040 DOI: 10.1016/j.jcmg.2024.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 03/14/2024] [Accepted: 04/05/2024] [Indexed: 06/19/2024]
Abstract
BACKGROUND There are significant sex and age differences in left ventricular (LV) remodeling that may lead to disparity in outcomes when used to inform the timing of aortic regurgitation (AR) intervention. OBJECTIVES The aim of this study was to examine whether left atrial (LA) parameters might represent better criteria than LV parameters to inform the timing of AR intervention. METHODS Using data on patients with moderate to severe or severe AR with serial echocardiography (2010-2016), the longitudinal trends in left atrial volume index (LAVI) and left atrial reservoir strain (LAr) were evaluated by sex and age. The incremental utility of these parameters in predicting adverse events over LV parameters was also determined. RESULTS In 525 patients (25.7% women) with 1,687 echocardiograms over a median follow-up period of 2.0 years (Q1-Q3: 1.0-3.6 years), there was significant increase in LAVI (1.0 mL/m2 per year [95% CI: 0.76-1.2 mL/m2 per year]) and decrease in LAr (-1.3% per year [95% CI: -1.6% to -0.92%]), without a significant interaction by sex or age category (P for interaction ≥ 0.17). In addition, both LAVI and LAr were significant predictors of adverse events independent of LV parameters. The optimal discriminatory thresholds were 37 mL/m2 for LAVI and 35% for LAr. These thresholds were similar across categories of sex and age. Within the relatively short-term follow-up, surgery was associated with survival benefit among patients with LAVI ≥37 mL/m2 (HR: 0.33 [95% CI: 0.15-0.72]; P = 0.006) but was not statistically significant among patients with LAVI <37 mL/m2 (HR: 0.46 [95% CI: 0.18-1.17]; P = 0.09). Similarly, surgery was associated with survival for the subgroup with LAr ≤35% but not among those with LAr >35%. CONCLUSIONS Unlike LV remodeling, LA remodeling demonstrates a similar rate of progression between categories of sex and age among patients with AR. In addition, LA parameters provide incremental prognostic value over LV parameters.
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Affiliation(s)
- Emmanuel Akintoye
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA; Section of Cardiovascular Imaging, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA.
| | - Joseph El Dahdah
- Section of Cardiovascular Imaging, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - M Marwan Dabbagh
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Hardik Patel
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Osamah Badwan
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Lorenzo Braghieri
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Michel Chedid El Helou
- Section of Cardiovascular Imaging, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Joseph Kassab
- Section of Cardiovascular Imaging, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Christine L Jellis
- Section of Cardiovascular Imaging, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA. https://twitter.com/ChrisJellisMD
| | - Milind Y Desai
- Section of Cardiovascular Imaging, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA. https://twitter.com/DesaiMilindY
| | - L Leonardo Rodriguez
- Section of Cardiovascular Imaging, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Richard A Grimm
- Section of Cardiovascular Imaging, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Brian P Griffin
- Section of Cardiovascular Imaging, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA. https://twitter.com/BrianGriffinMD
| | - Zoran B Popovic
- Section of Cardiovascular Imaging, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA.
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Alahdab F, Ahmed AI, Nayfeh M, Han Y, Abdelkarim O, Alfawara MS, Little SH, Reardon MJ, Faza NN, Goel SS, Alkhouli M, Zoghbi W, Al‐Mallah MH. Myocardial Blood Flow Reserve, Microvascular Coronary Health, and Myocardial Remodeling in Patients With Aortic Stenosis. J Am Heart Assoc 2024; 13:e033447. [PMID: 38780160 PMCID: PMC11255635 DOI: 10.1161/jaha.123.033447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 04/18/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Coronary microvascular function and hemodynamics may play a role in coronary circulation and myocardial remodeling in patients with aortic stenosis (AS). We aimed to evaluate the relationship between myocardial blood flow and myocardial function in patients with AS, no AS, and aortic valve sclerosis. METHODS AND RESULTS We included consecutive patients who had resting transthoracic echocardiography and clinically indicated positron emission tomography myocardial perfusion imaging to capture their left ventricular ejection fraction, global longitudinal strain (GLS), and myocardial flow reserve (MFR). The primary outcome was major adverse cardiovascular event (all-cause mortality, myocardial infarction, or late revascularization). There were 2778 patients (208 with aortic sclerosis, 39 with prosthetic aortic valve, 2406 with no AS, and 54, 49, and 22 with mild, moderate, and severe AS, respectively). Increasing AS severity was associated with impaired MFR (P<0.001) and GLS (P<0.001), even when perfusion was normal. Statistically significant associations were noted between MFR and GLS, MFR and left ventricular ejection fraction, and MFR and left ventricular ejection fraction reserve. After a median follow-up of 349 (interquartile range, 116-662) days, 4 (7.4%), 5 (10.2%), and 6 (27.3%) patients experienced a major adverse cardiovascular event in the mild, moderate, and severe AS groups, respectively. In a matched-control analysis, patients with mild-to-moderate AS had higher rates of impaired MFR (52.9% versus 39.9%; P=0.048) and major adverse cardiovascular event (11.8% versus 3.0%; P=0.002). CONCLUSIONS Despite lack of ischemia, as severity of AS increased, MFR decreased and GLS worsened, reflecting worse coronary microvascular health and myocardial remodeling. Positron emission tomography-derived MFR showed a significant independent correlation with left ventricular ejection fraction and GLS. Patients with prosthetic aortic valve showed a high prevalence of impaired MFR.
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Affiliation(s)
- Fares Alahdab
- Houston Methodist DeBakey Heart and Vascular CenterHoustonTX
| | - Ahmed I. Ahmed
- Houston Methodist DeBakey Heart and Vascular CenterHoustonTX
| | - Malek Nayfeh
- Houston Methodist DeBakey Heart and Vascular CenterHoustonTX
| | - Yushui Han
- Houston Methodist DeBakey Heart and Vascular CenterHoustonTX
| | - Ola Abdelkarim
- Department of Cardiology, Faculty of MedicineAlexandria UniversityAlexandriaEgypt
| | | | | | | | - Nadeen N. Faza
- Houston Methodist DeBakey Heart and Vascular CenterHoustonTX
| | - Sachin S. Goel
- Houston Methodist DeBakey Heart and Vascular CenterHoustonTX
| | | | - William Zoghbi
- Houston Methodist DeBakey Heart and Vascular CenterHoustonTX
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Sugiura A, Yamamoto M, Saji M, Asami M, Enta Y, Nakashima M, Shirai S, Izumo M, Mizuno S, Watanabe Y, Amaki M, Kodama K, Yamaguchi J, Nakajima Y, Naganuma T, Bota H, Ohno Y, Yamawaki M, Ueno H, Mizutani K, Adachi Y, Otsuka T, Kubo S, Nickenig G, Hayashida K. Cardiac Damage in Degenerative Mitral Regurgitation Treated With Transcatheter Mitral Edge-to-Edge Repair. Circ Cardiovasc Interv 2024; 17:e013794. [PMID: 38629311 PMCID: PMC11177598 DOI: 10.1161/circinterventions.123.013794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 02/27/2024] [Indexed: 06/16/2024]
Abstract
BACKGROUND The extent of cardiac damage and its association with clinical outcomes in patients undergoing transcatheter edge-to-edge repair (TEER) for degenerative mitral regurgitation remains unclear. This study was aimed to investigate cardiac damage in patients with degenerative mitral regurgitation treated with TEER and its association with outcomes. METHODS We analyzed patients with degenerative mitral regurgitation treated with TEER in the Optimized Catheter Valvular Intervention-Mitral registry, which is a prospective, multicenter observational data collection in Japan. The study subjects were classified according to the extent of cardiac damage at baseline: no extravalvular cardiac damage (stage 0), mild left ventricular or left atrial damage (stage 1), moderate left ventricular or left atrial damage (stage 2), or right heart damage (stage 3). Two-year mortality after TEER was compared using Kaplan-Meier analysis. RESULTS Out of 579 study participants, 8 (1.4%) were classified as stage 0, 76 (13.1%) as stage 1, 319 (55.1%) as stage 2, and 176 (30.4%) as stage 3. Two-year survival was 100% in stage 0, 89.5% in stage 1, 78.9% in stage 2, and 75.3% in stage 3 (P=0.013). Compared with stage 0 to 1, stage 2 (hazard ratio, 3.34 [95% CI, 1.03-10.81]; P=0.044) and stage 3 (hazard ratio, 4.51 [95% CI, 1.37-14.85]; P=0.013) were associated with increased risk of 2-year mortality after TEER. Significant reductions in heart failure rehospitalization rate and New York Heart Association functional scale were observed following TEER (both, P<0.001), irrespective of the stage of cardiac damage. CONCLUSIONS Advanced cardiac damage is associated with an increased risk of mortality in patients undergoing TEER for degenerative mitral regurgitation. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: UMIN000023653.
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Affiliation(s)
- Atsushi Sugiura
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Germany (A.S., G.N.)
| | - Masanori Yamamoto
- Department of Cardiology, Toyohashi Heart Center, Japan (M. Yamamoto, Y.A.)
- Department of Cardiology, Nagoya Heart Center, Japan (M. Yamamoto, Y.A.)
- Department of Cardiology, Gifu Heart Center, Japan (M. Yamamoto)
| | - Mike Saji
- Department of Cardiology, Sakakibara Heart Institute, Tokyo, Japan (M.S.)
- Division of Cardiovascular Medicine, Department of Internal Medicine, Toho University Faculty of Medicine, Tokyo, Japan (M.S.)
| | - Masahiko Asami
- Division of Cardiology, Mitsui Memorial Hospital, Tokyo, Japan (M. Asami)
| | - Yusuke Enta
- Department of Cardiology, Sendai Kosei Hospital, Japan (Y.E., M.N.)
| | - Masaki Nakashima
- Department of Cardiology, Sendai Kosei Hospital, Japan (Y.E., M.N.)
| | - Shinichi Shirai
- Division of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan (S.S.)
| | - Masaki Izumo
- Division of Cardiology, St. Marianna University School of Medicine Hospital, Kawasaki, Japan (M.I.)
| | - Shingo Mizuno
- Department of Cardiology, Shonan Kamakura General Hospital, Kanagawa, Japan (S.M.)
| | - Yusuke Watanabe
- Department of Cardiology, Teikyo University School of Medicine, Tokyo, Japan (Y.W.)
| | - Makoto Amaki
- Department of Cardiology, National Cerebral and Cardiovascular Center, Suita, Japan (M. Amaki)
| | - Kazuhisa Kodama
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Japan (K.K.)
| | - Junichi Yamaguchi
- Department of Cardiology Tokyo Woman’s Medical University, Japan (J.Y.)
| | - Yoshifumi Nakajima
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University, Japan (Y.N.)
| | - Toru Naganuma
- Department of Cardiology, New Tokyo Hospital, Chiba, Japan (T.N.)
| | - Hiroki Bota
- Department of Cardiology, Sapporo Higashi Tokushukai Hospital, Japan (H.B.)
| | - Yohei Ohno
- Department of Cardiology, Tokai University School of Medicine, Isehara, Japan. Department of Cardiology (Y.O.)
| | - Masahiro Yamawaki
- Saiseikai Yokohama City Eastern Hospital, Kanagawa, Japan (M. Yamawaki)
| | - Hiroshi Ueno
- Second Department of Internal Medicine, Toyama University Hospital, Japan (H.U.)
| | - Kazuki Mizutani
- Division of Cardiology, Department of Medicine, Kindai University Faculty of Medicine, Osaka, Japan (K.M.)
| | - Yuya Adachi
- Department of Cardiology, Toyohashi Heart Center, Japan (M. Yamamoto, Y.A.)
- Department of Cardiology, Nagoya Heart Center, Japan (M. Yamamoto, Y.A.)
| | - Toshiaki Otsuka
- Department of Hygiene and Public Health, Nippon Medical School, Tokyo, Japan (T.O.)
| | - Shunsuke Kubo
- Department of Cardiology, Kurashiki Central Hospital, Japan (S.K.)
| | - Georg Nickenig
- Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Germany (A.S., G.N.)
| | - Kentaro Hayashida
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan (K.H.)
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Martinsson A, Rasalingam R, Jeppsson A. Stable incidence and outcomes for patients with incident aortic stenosis: how can we translate excellent trial data into improved clinical outcomes in the population? Eur Heart J 2024; 45:1887-1889. [PMID: 38446140 DOI: 10.1093/eurheartj/ehae078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2024] Open
Affiliation(s)
- Andreas Martinsson
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ravi Rasalingam
- Department of Cardiology, Boston Veteran Affairs Healthcare, West Roxbury, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Anders Jeppsson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
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37
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Chong A, Stanton T, Taylor A, Prior D, La Gerche A, Anderson B, Scalia G, Cooke J, Dahiya A, To A, Davis M, Mottram P, Moir S, Playford D, Mahadavan D, Thomas L, Wahi S. 2024 CSANZ Position Statement on Indications, Assessment and Monitoring of Structural and Valvular Heart Disease With Transthoracic Echocardiography in Adults. Heart Lung Circ 2024; 33:773-827. [PMID: 38749800 DOI: 10.1016/j.hlc.2023.11.028] [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: 11/24/2022] [Revised: 08/22/2023] [Accepted: 11/01/2023] [Indexed: 06/25/2024]
Abstract
Transthoracic echocardiography (TTE) is the most widely available and utilised imaging modality for the screening, diagnosis, and serial monitoring of all abnormalities related to cardiac structure or function. The primary objectives of this document are to provide (1) a guiding framework for treating clinicians of the acceptable indications for the initial and serial TTE assessments of the commonly encountered cardiovascular conditions in adults, and (2) the minimum required standard for TTE examinations and reporting for imaging service providers. The main areas covered within this Position Statement pertain to the TTE assessment of the left and right ventricles, valvular heart diseases, pericardial diseases, aortic diseases, infective endocarditis, cardiac masses, pulmonary hypertension, and cardiovascular diseases associated with cancer treatments or cardio-oncology. Facilitating the optimal use and performance of high quality TTEs will prevent the over or under-utilisation of this resource and unnecessary downstream testing due to suboptimal or incomplete studies.
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Affiliation(s)
- Adrian Chong
- Department of Cardiology, Princess Alexandra Hospital, Mater Hospital Brisbane, University of Queensland, Brisbane, Qld, Australia
| | - Tony Stanton
- Sunshine Coast University Hospital, School of Health University of Sunshine Coast, School of Medicine and Dentistry Griffith University, Birtinya, Qld, Australia
| | - Andrew Taylor
- Department of Cardiology, Royal Melbourne Hospital, Alfred Hospital, Melbourne, Vic, Australia
| | - David Prior
- Albury Wodonga Health, Albury, NSW, Australia
| | - Andre La Gerche
- St Vincent's Hospital, Baker Heart and Diabetes Institute, University of Melbourne, Melbourne, Vic, Australia
| | - Bonita Anderson
- Cardiac Sciences Unit, The Prince Charles Hospital, Queensland University of Technology, Brisbane, Qld, Australia
| | - Gregory Scalia
- The Prince Charles Hospital, University of Queensland, Brisbane, Qld, Australia
| | - Jennifer Cooke
- Department of Cardiology, Eastern Health, Monash University, Melbourne, Vic, Australia
| | - Arun Dahiya
- Department of Cardiology, Princess Alexandra Hospital, Logan Hospital, Griffith University, Brisbane, Qld, Australia
| | - Andrew To
- Department of Cardiology, Health New Zealand Waitemata, Auckland, New Zealand
| | | | - Philip Mottram
- Victorian Heart Institute, Monash University, Melbourne, Vic, Australia
| | - Stuart Moir
- Victorian Heart Institute, Monash University, Melbourne, Vic, Australia
| | | | - Devan Mahadavan
- Department of Cardiology, Queen Elizabeth Hospital, Lyell McEwin Hospital, Adelaide, SA, Australia
| | - Liza Thomas
- Department of Cardiology, Westmead Hospital, Westmead Clinical School University of Sydney, South West Clinical School University of New South Wales, Sydney, NSW, Australia
| | - Sudhir Wahi
- Department of Cardiology, Princess Alexandra Hospital, University of Queensland, Brisbane, Qld, Australia.
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Costa G, Giannini C. The Sooner, The Better! JACC Cardiovasc Interv 2024; 17:1265-1266. [PMID: 38811108 DOI: 10.1016/j.jcin.2024.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Accepted: 04/15/2024] [Indexed: 05/31/2024]
Affiliation(s)
- Giulia Costa
- Cardiac Catheterization Laboratory, Cardiac Thoracic and Vascular Department, Azienda Ospedaliero-Unversitaria Pisana, Pisa, Italy.
| | - Cristina Giannini
- Cardiac Catheterization Laboratory, Cardiac Thoracic and Vascular Department, Azienda Ospedaliero-Unversitaria Pisana, Pisa, Italy
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Nakase M, Tomii D, Maznyczka A, Samim D, Lanz J, Praz F, Stortecky S, Reineke D, Windecker S, Pilgrim T. Sex-Specific Differences in Upstream Cardiac Damage in Patients With Aortic Stenosis Undergoing TAVR. JACC Cardiovasc Interv 2024; 17:1252-1264. [PMID: 38811107 DOI: 10.1016/j.jcin.2024.03.031] [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: 01/17/2024] [Revised: 03/22/2024] [Accepted: 03/26/2024] [Indexed: 05/31/2024]
Abstract
BACKGROUND Cardiac damage caused by aortic stenosis (AS) can be categorized into stages, which are associated with a progressively increasing risk of death after transcatheter aortic valve replacement (TAVR). OBJECTIVES The authors investigated sex-related differences in cardiac damage among patients with symptomatic AS and the prognostic value of cardiac damage classification in women and men undergoing TAVR. METHODS In a prospective registry, pre-TAVR echocardiograms were used to categorize patients into 5 stages of cardiac damage caused by AS. Differences in the extent of cardiac damage were compared according to sex, and its implications on clinical outcomes after TAVR were explored. RESULTS Among 2,026 patients undergoing TAVR between August 2007 and June 2022 (995 [49.1%] women and 1,031 [50.9%] men), we observed sex-specific differences in the pattern of cardiac damage (women vs men; stage 0: 2.6% vs 3.1%, stage 1: 13.4% vs 10.1%, stage 2: 37.1% vs 39.5%, stage 3: 27.5% vs 15.6%, and stage 4: 19.4% vs 31.7%). There was a stepwise increase in 5-year all-cause mortality according to stage in women (HRadjusted: 1.43; 95% CI: 1.28-1.60, for linear trend) and men (HRadjusted: 1.26; 95% CI: 1.14-1.38, for linear trend). Female sex was associated with a lower 5-year mortality in early stages (stage 0, 1, or 2) but not in advanced stages (stage 3 or 4). CONCLUSIONS The pattern of cardiac damage secondary to AS differed by sex. In early stages of cardiac damage, women had a lower 5-year mortality than men, whereas in more advanced stages, mortality was comparable between sexes. (SwissTAVI Registry; NCT01368250).
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Affiliation(s)
- Masaaki Nakase
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland. https://twitter.com/masaaki0825
| | - Daijiro Tomii
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Annette Maznyczka
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Daryoush Samim
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jonas Lanz
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Fabien Praz
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stefan Stortecky
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - David Reineke
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stephan Windecker
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thomas Pilgrim
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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40
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Nakase M, Tomii D, Stortecky S, Lanz J, Windecker S, Pilgrim T. Relationship of Upstream Cardiac Damage With Myocardial Injury in Patients With Aortic Stenosis Who Underwent Transcatheter Aortic Valve Implantation. Can J Cardiol 2024:S0828-282X(24)00405-7. [PMID: 38795843 DOI: 10.1016/j.cjca.2024.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 05/02/2024] [Accepted: 05/16/2024] [Indexed: 05/28/2024] Open
Affiliation(s)
- Masaaki Nakase
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Daijiro Tomii
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stefan Stortecky
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jonas Lanz
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stephan Windecker
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thomas Pilgrim
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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Nakase M, Tomii D, Heg D, Praz F, Stortecky S, Lanz J, Reineke D, Windecker S, Pilgrim T. Association of atrial fibrillation with survival in patients with low-flow low-gradient aortic stenosis with preserved ejection fraction undergoing TAVI. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2024; 10:246-255. [PMID: 37491693 DOI: 10.1093/ehjqcco/qcad045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 06/13/2023] [Accepted: 07/24/2023] [Indexed: 07/27/2023]
Abstract
AIMS There is limited evidence on the prognostic significance of atrial fibrillation (AF) in patients with low flow, low-gradient aortic stenosis with preserved ejection fraction (LFLG-pEF AS). We aimed to evaluate the recovery of stroke volume after transcatheter aortic valve implantation (TAVI) and clinical outcomes in patients with LFLG-pEF AS stratified by presence or absence of AF. METHODS AND RESULTS In a prospective TAVI registry, patients with preserved left ventricular ejection fraction (LVEF ≥ 50%) were stratified according to flow-gradient status and presence of AF. Among 2259 TAVI patients with preserved LVEF between August 2007 and June 2021, 765 had high-gradient AS (HG AS) and 444 had LFLG-pEF AS. AF was observed in 199 patients with HG AS (26.0%) and 190 patients with LFLG-pEF AS (42.8%). At 1 year, stroke volume index (SVi) was significantly improved in LFLG-pEF AS patients without AF, while SVi remained low in patients with AF (from 25.9 ± 8.5 mL/m2 to 37.2 ± 9.9 mL/m2 and from 26.8 ± 5.1 mL/m2 to 26.1 ± 9.1 mL/m2, respectively). LFLG-pEF AS patients with AF had an increased risk of 1-year all-cause mortality compared with those without AF (adjusted hazard ratio (HRadjusted) 2.57; 95% confidence interval [CI] 1.44-4.59). LFLG-pEF AS patients without AF had similar mortality compared with HG AS patients without AF (HRadjusted 0.85; 95% CI 0.49-1.46). CONCLUSION Patients with LFLG-pEF AS and AF experienced no relevant recovery of stroke volume after TAVI, but a more than two-fold increased risk of death compared to patients with HG AS or LFLG-pEF AS without AF. CLINICAL TRIAL REGISTRATION https://www.clinicaltrials.gov. NCT01368250.
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Affiliation(s)
- Masaaki Nakase
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern 3010, Switzerland
| | - Daijiro Tomii
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern 3010, Switzerland
| | - Dik Heg
- CTU Bern, University of Bern, Bern 3010, Switzerland
| | - Fabien Praz
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern 3010, Switzerland
| | - Stefan Stortecky
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern 3010, Switzerland
| | - Jonas Lanz
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern 3010, Switzerland
| | - David Reineke
- Department of Cardiac Surgery, Inselspital, Bern University Hospital, University of Bern, Bern 3010, Switzerland
| | - Stephan Windecker
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern 3010, Switzerland
| | - Thomas Pilgrim
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern 3010, Switzerland
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Esposito A, Foffa I, Vecoli C, Bastiani L, Berti S, Mazzone A. The Impact of Acute Heart Failure on Frailty Degree and Outcomes in Elderly Patients with Severe Aortic Stenosis and Chronic Heart Failure with Preserved Ejection Fraction. J Cardiovasc Dev Dis 2024; 11:150. [PMID: 38786972 PMCID: PMC11122270 DOI: 10.3390/jcdd11050150] [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: 03/22/2024] [Revised: 04/24/2024] [Accepted: 05/09/2024] [Indexed: 05/25/2024] Open
Abstract
Frailty degree plays a critical role in the decision-making and outcomes of elderly patients with severe aortic stenosis (AS). Acute heart failure (AHF) results in a severely worse clinical hemodynamic status in this population. This study aimed to evaluate the impact of AHF on frailty degree and outcomes in older patients referred for tailored interventional treatment due to AS. A total of 109 patients (68% female; mean age 83.3 ± 5.4), evaluated by a multidisciplinary path for "frailty-based management" of valve disease, were divided into two groups, one with (AHF+) and one without AHF (AHF-) and preserved ejection fraction (mean value EF: 57.4 ± 8.6). AHF occurred a mean value of 55 days before geriatric, clinical, and surgical assessment. A follow-up for all-cause mortality and readmission was conducted at 20 months. AHF+ patients showed a higher frequency of advanced frailty (53.3% vs. 46.7%, respectively), rehospitalization (35.5% vs. 12.8; p = 0.007), and death (41.9% vs. 12.8%; p < 0.001). In stepwise logistic regression analysis, AHF emerged as an independent risk factor for advanced frailty (OR: 3.8 CI 1.3-10.7; p = 0.01) and hospital readmission (OR: 3.6 CI 1.1-11.6; p = 0.03). In addition, preceding AHF was an independent determinant associated with a higher risk of mortality (HR 2.65; CI 95% 1.04-6.74; p-value 0.04). AHF is independently associated with advanced frailty and poor outcomes in elderly patients with severe AS. So, this population needs careful clinical and geriatric monitoring and the implementation of interventional therapy for AS in the early stages of frailty to avoid the occurrence of AHF and poor outcomes.
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Affiliation(s)
- Augusto Esposito
- Fondazione Toscana Gabriele Monasterio, 54100 Massa, Italy; (A.E.); (C.V.); (L.B.); (S.B.); (A.M.)
| | - Ilenia Foffa
- Fondazione Toscana Gabriele Monasterio, 54100 Massa, Italy; (A.E.); (C.V.); (L.B.); (S.B.); (A.M.)
- CNR Institute of Clinical Physiology, 54100 Massa, Italy
| | - Cecilia Vecoli
- Fondazione Toscana Gabriele Monasterio, 54100 Massa, Italy; (A.E.); (C.V.); (L.B.); (S.B.); (A.M.)
- CNR Institute of Clinical Physiology, 54100 Massa, Italy
| | - Luca Bastiani
- Fondazione Toscana Gabriele Monasterio, 54100 Massa, Italy; (A.E.); (C.V.); (L.B.); (S.B.); (A.M.)
- CNR Institute of Clinical Physiology, 54100 Massa, Italy
| | - Sergio Berti
- Fondazione Toscana Gabriele Monasterio, 54100 Massa, Italy; (A.E.); (C.V.); (L.B.); (S.B.); (A.M.)
- CNR Institute of Clinical Physiology, 54100 Massa, Italy
| | - Annamaria Mazzone
- Fondazione Toscana Gabriele Monasterio, 54100 Massa, Italy; (A.E.); (C.V.); (L.B.); (S.B.); (A.M.)
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Nuche J, Soliman F, Chavarría J, Okoh AK, Alvarado Mora H, Nault I, Natarajan MK, Russo M, Philippon F, Rodés-Cabau J. New-onset atrial fibrillation detected by ambulatory ECG monitoring after transcatheter aortic valve implantation. EUROINTERVENTION 2024; 20:591-601. [PMID: 38726722 PMCID: PMC11067725 DOI: 10.4244/eij-d-23-01014] [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: 11/24/2023] [Accepted: 03/01/2024] [Indexed: 05/14/2024]
Abstract
BACKGROUND Little is known about the occurrence of subclinical new-onset atrial fibrillation (NOAF) after transcatheter aortic valve implantation (TAVI). AIMS We aimed to evaluate the incidence, predictors, and clinical impact of subclinical NOAF after TAVI. METHODS This was a multicentre study, including patients with aortic stenosis (AS) and no previous atrial fibrillation undergoing TAVI, with continuous ambulatory electrocardiogram (AECG) monitoring after TAVI. RESULTS A total of 700 patients (79±8 years, 49% female, Society of Thoracic Surgeons score 2.9% [1.9-4.0]) undergoing transarterial TAVI were included (85% balloon-expandable valves). AECG was started 1 (0-1) day after TAVI (monitoring time: 14121314 days). NOAF was detected in 49 patients (7%), with a median duration of 185 (43-421) minutes (atrial fibrillation burden of 0.7% [0.3-2.8]). Anticoagulation was started in 25 NOAF patients (51%). No differences were found in baseline or procedural characteristics, except for a higher AS severity in the NOAF group (peak gradient: no NOAF: 71.9±23.5 mmHg vs NOAF: 85.2±23.8 mmHg; p=0.024; mean gradient: no NOAF: 44.4±14.7 mmHg vs NOAF: 53.8±16.8 mmHg; p=0.004). In the multivariable analysis, the baseline mean transaortic gradient was associated with a higher risk of NOAF after TAVI (odds ratio 1.04, 95% confidence interval: 1.01-1.06 for each mmHg; p=0.006). There were no differences between groups in all-cause mortality (no NOAF: 4.7% vs NOAF: 0%; p=0.122), stroke (no NOAF: 1.4% vs NOAF: 2.0%; p=0.723), or bleeding (no NOAF: 1.9% vs NOAF: 4.1%; p=0.288) from the 30-day to 1-year follow-up. CONCLUSIONS NOAF detected with AECG occurred in 7% of TAVI recipients and was associated with a higher AS severity. NOAF detection determined the start of anticoagulation therapy in about half of the patients, and it was not associated with an increased risk of clinical events at 1-year follow-up.
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Affiliation(s)
- Jorge Nuche
- Quebec Heart and Lung Institute, Laval University, Quebec City, QC, Canada
| | - Fady Soliman
- Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Jorge Chavarría
- McMaster University, Hamilton, ON, Canada and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Alexis K Okoh
- Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA
- Division of Cardiology, Emory University, Atlanta, GA, USA
| | - Hugo Alvarado Mora
- McMaster University, Hamilton, ON, Canada and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Isabelle Nault
- Quebec Heart and Lung Institute, Laval University, Quebec City, QC, Canada
| | - Madhu K Natarajan
- McMaster University, Hamilton, ON, Canada and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Mark Russo
- Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - François Philippon
- Quebec Heart and Lung Institute, Laval University, Quebec City, QC, Canada
| | - Josep Rodés-Cabau
- Quebec Heart and Lung Institute, Laval University, Quebec City, QC, Canada
- Clínic Barcelona, Barcelona, Spain
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Jacquemyn X, Strom JB, Strange G, Playford D, Stewart S, Kutty S, Bhatt DL, Bleiziffer S, Grubb KJ, Pellikka PA, Clavel MA, Pibarot P, Mentias A, Serna-Gallegos D, Sá MP, Sultan I. Moderate Aortic Valve Stenosis Is Associated With Increased Mortality Rate and Lifetime Loss: Systematic Review and Meta-Analysis of Reconstructed Time-to-Event Data of 409 680 Patients. J Am Heart Assoc 2024; 13:e033872. [PMID: 38700000 PMCID: PMC11179918 DOI: 10.1161/jaha.123.033872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 04/03/2024] [Indexed: 05/05/2024]
Abstract
BACKGROUND The mortality risk attributable to moderate aortic stenosis (AS) remains incompletely characterized and has historically been underestimated. We aim to evaluate the association between moderate AS and all-cause death, comparing it with no/mild AS (in a general referral population and in patients with heart failure with reduced ejection fraction). METHODS AND RESULTS A systematic review and pooled meta-analysis of Kaplan-Meier-derived reconstructed time-to-event data of studies published by June 2023 was conducted to evaluate survival outcomes among patients with moderate AS in comparison with individuals with no/mild AS. Ten studies were included, encompassing a total of 409 680 patients (11 527 with moderate AS and 398 153 with no/mild AS). In the overall population, the 15-year overall survival rate was 23.3% (95% CI, 19.1%-28.3%) in patients with moderate AS and 58.9% (95% CI, 58.1%-59.7%) in patients with no/mild aortic stenosis (hazard ratio [HR], 2.55 [95% CI, 2.46-2.64]; P<0.001). In patients with heart failure with reduced ejection fraction, the 10-year overall survival rate was 15.5% (95% CI, 10.0%-24.0%) in patients with moderate AS and 37.3% (95% CI, 36.2%-38.5%) in patients with no/mild AS (HR, 1.83 [95% CI, 1.69-2.0]; P<0.001). In both populations (overall and heart failure with reduced ejection fraction), these differences correspond to significant lifetime loss associated with moderate AS during follow-up (4.4 years, P<0.001; and 1.9 years, P<0.001, respectively). A consistent pattern of elevated mortality rate associated with moderate AS in sensitivity analyses of matched studies was observed. CONCLUSIONS Moderate AS was associated with higher risk of death and lifetime loss compared with patients with no/mild AS.
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Affiliation(s)
- Xander Jacquemyn
- Department of Cardiovascular Sciences KU Leuven Leuven Belgium
- The Blalock-Taussig-Thomas Pediatric and Congenital Heart Center, Department of Pediatrics, Johns Hopkins School of Medicine Johns Hopkins University Baltimore MD USA
| | - Jordan B Strom
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Department of Medicine, Cardiovascular Division Beth Israel Deaconess Medical Center Boston MA USA
| | - Geoff Strange
- School of Medicine University of Notre Dame Fremantle Western Australia Australia
| | - David Playford
- School of Medicine University of Notre Dame Fremantle Western Australia Australia
| | - Simon Stewart
- Institute for Health Research University of Notre Dame Fremantle Western Australia Australia
| | - Shelby Kutty
- The Blalock-Taussig-Thomas Pediatric and Congenital Heart Center, Department of Pediatrics, Johns Hopkins School of Medicine Johns Hopkins University Baltimore MD USA
| | - Deepak L Bhatt
- Mount Sinai Heart Icahn School of Medicine at Mount Sinai Health System New York NY USA
| | - Sabine Bleiziffer
- Department of Thoracic and Cardiovascular Surgery, Heart and Diabetes Center North Rhine-Westphalia University Hospital Ruhr-University Bochum Bad Oeynhausen Germany
| | - Kendra J Grubb
- Division of Cardiothoracic Surgery Emory University Atlanta GA USA
- Structural Heart and Valve Center Emory University Atlanta GA USA
| | | | | | - Philippe Pibarot
- Quebec Heart and Lung Institute Laval University Quebec City Quebec Canada
| | - Amgad Mentias
- Heart, Vascular and Thoracic Institute Cleveland Clinic Cleveland OH USA
| | - Derek Serna-Gallegos
- Department of Cardiothoracic Surgery University of Pittsburgh Pittsburgh PA USA
- UPMC Heart and Vascular Institute Pittsburgh PA USA
| | - Michel Pompeu Sá
- Department of Cardiothoracic Surgery University of Pittsburgh Pittsburgh PA USA
- UPMC Heart and Vascular Institute Pittsburgh PA USA
| | - Ibrahim Sultan
- Department of Cardiothoracic Surgery University of Pittsburgh Pittsburgh PA USA
- UPMC Heart and Vascular Institute Pittsburgh PA USA
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Bak M, Lee SH, Park SJ, Park J, Kim J, Kim D, Kim EK, Chang SA, Lee SC, Park SW. Perioperative Risk of Noncardiac Surgery in Patients With Asymptomatic Significant Aortic Stenosis: A 10-Year Retrospective Study. J Am Heart Assoc 2024; 13:e032675. [PMID: 38686895 PMCID: PMC11179948 DOI: 10.1161/jaha.123.032675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 03/25/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND Aortic stenosis (AS) is a representative geriatric disease, and there is an anticipated rise in the number of patients requiring noncardiac surgeries in patients with AS. However, there is still a lack of research on the primary predictors of noncardiac perioperative complications in patients with asymptomatic significant AS. METHODS AND RESULTS Among the cohort of noncardiac surgeries under general anesthesia, with an intermediate to high risk of surgery from 2011 to 2019, at Samsung Medical Center, 221 patients were identified to have asymptomatic significant AS. First, to examine the impact of significant AS on perioperative adverse events, the occurrences of major adverse cardiovascular events and perioperative adverse cardiovascular events were compared between patients with asymptomatic significant AS and the control group. Second, to identify the factors influencing the perioperative adverse events in patients with asymptomatic significant AS, a least absolute shrinkage and selection operator regression model was used. There was no significant difference between the control group and the asymptomatic significant AS group in the event rate of major adverse cardiovascular events (4.6% at control group versus 5.5% at asymptomatic significant AS group; P=0.608) and perioperative adverse cardiovascular events (13.8% at control group versus 18.3% at asymptomatic significant AS group; P=0.130). Cardiac damage stage was a significant risk factor of major adverse cardiovascular events and perioperative adverse cardiovascular events. CONCLUSIONS There was no significant difference in major postoperative cardiovascular events between patients with asymptomatic significant AS and the control group. Advanced cardiac damage stage in significant AS is an important factor in perioperative risk of noncardiac surgery.
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Affiliation(s)
- Minjung Bak
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Korea
| | - Seung-Hwa Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Korea
| | - Sung-Ji Park
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Korea
| | - Jungchan Park
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Korea
| | - Jihoon Kim
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Korea
| | - Darae Kim
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Korea
| | - Eun Kyoung Kim
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Korea
| | - Sung-A Chang
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Korea
| | - Sang-Chol Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Korea
| | - Seung Woo Park
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Korea
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Lachmann M, Hesse A, Trenkwalder T, Xhepa E, Rheude T, von Scheidt M, Covarrubias HAA, Rippen E, Hramiak O, Pellegrini C, Schuster T, Yuasa S, Schunkert H, Kastrati A, Kupatt C, Laugwitz KL, Joner M. Invasive Assessment of Right Ventricular to Pulmonary Artery Coupling Improves 1-year Mortality Prediction After Transcatheter Aortic Valve Replacement and Anticipates the Persistence of Extra-Aortic Valve Cardiac Damage. STRUCTURAL HEART : THE JOURNAL OF THE HEART TEAM 2024; 8:100282. [PMID: 38799808 PMCID: PMC11121747 DOI: 10.1016/j.shj.2024.100282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 12/04/2023] [Accepted: 01/03/2024] [Indexed: 05/29/2024]
Abstract
Background The interplay between the right ventricle and the pulmonary artery, known as right ventricular to pulmonary artery (RV-PA) coupling, is crucial for assessing right ventricular systolic function against the afterload from the pulmonary circulation. Pulmonary artery pressure levels are ideally measured by right heart catheterization. Yet, echocardiography represents the most utilized method for evaluating pulmonary artery pressure levels, albeit with limitations in accuracy. This study therefore aims to evaluate the prognostic significance of right ventricular to pulmonary artery (RV-PA) coupling expressed as tricuspid annular plane systolic excursion (TAPSE) related to systolic pulmonary artery pressure (sPAP) levels measured by right heart catheterization (TAPSE/sPAPinvasive) or estimated by transthoracic echocardiography (TAPSE/sPAPechocardiography) in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement (TAVR). Methods Using data from a bicentric registry, this study compares TAPSE/sPAPinvasive vs. TAPSE/sPAPechocardiography in predicting 1-year all-cause mortality after TAVR. Results Among 333 patients with complete echocardiography and right heart catheterization data obtained before TAVR, their mean age was 79.8 ± 6.74 years, 39.6% were female, and general 1-year survival was 89.8%. sPAPinvasive and sPAPechocardiography showed only moderate correlation (Pearson correlation coefficient R: 0.53, p value: <0.0001). TAPSE/sPAPinvasive was superior to TAPSE/sPAPechocardiography in predicting 1-year all-cause mortality after TAVR (area under the curve: 0.662 vs. 0.569, p value: 0.025). Patients with reduced TAPSE/sPAPinvasive levels (< 0.365 mm/mmHg) evidenced significantly lower 1-year survival rates than patients with preserved TAPSE/sPAPinvasive levels (81.8 vs. 93.6%, p value: 0.001; hazard ratio for 1-year mortality: 3.09 [95% confidence interval: 1.55-6.17]). Echocardiographic follow-up data revealed that patients with reduced RV-PA coupling suffer from persistent right ventricular dysfunction (TAPSE: 16.6 ± 4.05 mm vs. 21.6 ± 4.81 mm in patients with preserved RV-PA coupling) and severe tricuspid regurgitation (diagnosed in 19.7 vs. 6.58% in patients with preserved RV-PA coupling). Conclusions RV-PA coupling expressed as TAPSE/sPAPinvasive can refine stratification of severe aortic stenosis patients into low-risk and high-risk cohorts for mortality after TAVR. Moreover, it can help to anticipate persistent extra-aortic valve cardiac damage, which will demand further treatment.
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Affiliation(s)
- Mark Lachmann
- First Department of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Amelie Hesse
- First Department of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Teresa Trenkwalder
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
- Department of Cardiology, Deutsches Herzzentrum München, Technical University of Munich, Munich, Germany
| | - Erion Xhepa
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
- Department of Cardiology, Deutsches Herzzentrum München, Technical University of Munich, Munich, Germany
| | - Tobias Rheude
- Department of Cardiology, Deutsches Herzzentrum München, Technical University of Munich, Munich, Germany
| | - Moritz von Scheidt
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
- Department of Cardiology, Deutsches Herzzentrum München, Technical University of Munich, Munich, Germany
| | | | - Elena Rippen
- First Department of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Oksana Hramiak
- First Department of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- Specialized Department of Cardiology, Ternopil City Communal Hospital №2, Ternopil National Medical University, Ternopil, Ukraine
| | - Costanza Pellegrini
- Department of Cardiology, Deutsches Herzzentrum München, Technical University of Munich, Munich, Germany
| | - Tibor Schuster
- Department of Family Medicine, McGill University, Montreal, Canada
| | - Shinsuke Yuasa
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Heribert Schunkert
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
- Department of Cardiology, Deutsches Herzzentrum München, Technical University of Munich, Munich, Germany
| | - Adnan Kastrati
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
- Department of Cardiology, Deutsches Herzzentrum München, Technical University of Munich, Munich, Germany
| | - Christian Kupatt
- First Department of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Karl-Ludwig Laugwitz
- First Department of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Michael Joner
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
- Department of Cardiology, Deutsches Herzzentrum München, Technical University of Munich, Munich, Germany
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Hopfgarten J, James S, Lindhagen L, Baron T, Ståhle E, Christersson C. Medical treatment of heart failure with renin-angiotensin-aldosterone system inhibitors and beta-blockers in aortic stenosis: association with long-term outcome after aortic valve replacement. EUROPEAN HEART JOURNAL OPEN 2024; 4:oeae039. [PMID: 38812477 PMCID: PMC11135942 DOI: 10.1093/ehjopen/oeae039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Revised: 04/04/2024] [Accepted: 05/03/2024] [Indexed: 05/31/2024]
Abstract
Aims There is a lack of robust data on the optimal medical treatment of heart failure in patients with severe aortic stenosis, with no randomized controlled trials guiding treatment. The study aimed to study the association between exposure to renin-angiotensin-aldosterone system (RAS) inhibitors or beta-blockers and outcome after aortic valve replacement in patients with aortic stenosis and heart failure. Methods and results The study included all patients with heart failure undergoing aortic valve replacement for aortic stenosis in Sweden between 2008 and 2016 (n = 4668 patients). Exposure to treatment was assessed by a continuous tracking of drug dispensations, and outcome events were all-cause mortality and hospitalization for heart failure collected from national patient registries. After adjustment for age, sex, atrial fibrillation, hypertension, diabetes mellitus, and prior myocardial infarction, Cox regression analysis showed that RAS inhibition was associated with a lower risk of all-cause mortality in patients with reduced left ventricular ejection fraction (LV-EF) [hazard ratio (HR) 0.58, 95% confidence interval (CI) 0.51-0.65] and preserved LV-EF (HR 0.69, 95% CI 0.56-0.85). Beta-blockade was associated with a lower risk of all-cause mortality in patients with reduced LV-EF (HR 0.81, 95% CI 0.71-0.92), but not in preserved LV-EF (HR 0.87, 95% CI 0.69-1.10). There was no association between RAS inhibition or beta-blockade and the risk of hospitalization for heart failure. Conclusion The RAS inhibition was associated with a lower all-cause mortality after valve replacement in patients with both reduced and preserved LV-EF. Beta-blockade was associated with lower all-cause mortality only in patients with reduced LV-EF.
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Affiliation(s)
- Johan Hopfgarten
- Department of Medical Sciences, Uppsala University, Akademiska sjukhuset, 751 85, Uppsala, Sweden
| | - Stefan James
- Department of Medical Sciences, Uppsala University, Akademiska sjukhuset, 751 85, Uppsala, Sweden
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Lars Lindhagen
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Tomasz Baron
- Department of Medical Sciences, Uppsala University, Akademiska sjukhuset, 751 85, Uppsala, Sweden
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Elisabeth Ståhle
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Christina Christersson
- Department of Medical Sciences, Uppsala University, Akademiska sjukhuset, 751 85, Uppsala, Sweden
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Banovic M, Iung B, Putnik S, Mahendiran T, Vanderheyden M, Barbato E, Bartunek J. Asymptomatic Aortic Stenosis: From Risk Stratification to Treatment. Am J Cardiol 2024; 218:51-62. [PMID: 38432341 DOI: 10.1016/j.amjcard.2024.02.034] [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: 10/02/2023] [Revised: 02/05/2024] [Accepted: 02/23/2024] [Indexed: 03/05/2024]
Abstract
Our understanding of the natural history of aortic stenosis has significantly increased over the last decade. There have been considerable advances in the diagnosis and risk stratification of patients with aortic stenosis and in surgical and anesthetic techniques. In addition, transcatheter aortic valve replacement has established itself as a viable alternative to surgical management. Inevitably, these developments have raised questions regarding the merits of waiting for symptom onset in asymptomatic patients with severe aortic stenosis before offering treatment. Recent observational and randomized trial data suggest that early intervention in asymptomatic patients with severe aortic stenosis and normal left ventricular function may confer a prognostic advantage to a watchful waiting strategy. In this review, we highlight advances in the management and risk stratification of patients with asymptomatic severe aortic stenosis with particular consideration of recent findings supporting early valvular intervention.
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Affiliation(s)
- Marko Banovic
- Cardiology Department, University Clinical Center of Serbia, Belgrade, Serbia; Belgrade Medical Faculty, University of Belgrade, Serbia.
| | - Bernard Iung
- Cardiology Department, Bichat Hospital APHP and Université Paris Cité, France
| | - Svetozar Putnik
- Belgrade Medical Faculty, University of Belgrade, Serbia; Cardiac-Surgery Department, University Clinical Center of Serbia, Belgrade, Serbia
| | - Thabo Mahendiran
- Cardiovascular Center, OLV Hospital, Aalst, Belgium; Cardiology Department, Lausanne University Hospital, Lausanne, Switzerland
| | | | - Emanuele Barbato
- Cardiovascular Center, OLV Hospital, Aalst, Belgium; Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
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Leitman M, Daoud M, Tyomkin V, Fuchs S. The Flow Rate in Patients With Low-Gradient Aortic Stenosis. Cureus 2024; 16:e60776. [PMID: 38903309 PMCID: PMC11188971 DOI: 10.7759/cureus.60776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/19/2024] [Indexed: 06/22/2024] Open
Abstract
PURPOSE The decision to assess the severity and determine the ideal timing of intervention for low-gradient aortic stenosis poses a greater challenge. Recently, a novel method for determining the flow status of patients with aortic stenosis has been introduced, utilizing flow rate measurements. In this study, we investigated whether the flow status of patients with low-gradient aortic stenosis is linked to mortality within a three-year timeframe. METHODS Twenty-nine patients diagnosed with low-gradient aortic stenosis and valve area ≤ 1 cm were identified during 2010-2015. Each patient's flow rate across the aortic valve was computed, and the study scrutinized echocardiographic parameters to ascertain their correlation with mortality over a three-year timeframe. RESULTS We observed that among patients with low-gradient aortic stenosis and a valve area of ≤1 cm, a decreased flow rate across the aortic valve emerged as an independent predictor of mortality. A flow rate < 210 ml/s was linked with a three-year mortality rate of 66.7%, whereas a low stroke volume index < 35 ml/m² did not show an association with three-year mortality. This observation might be attributed to the smaller body sizes prevalent among these older patients, particularly females, which could influence the calculation of the stroke volume index. CONCLUSION In older patients with low-gradient aortic stenosis, the flow rate can better reflect flow status than the stroke volume index, and it also suggests a prognostic significance in predicting mortality. Additional studies are warranted to validate these findings across broader patient populations and to assess the potential efficacy of early intervention strategies in this particular patient cohort.
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Affiliation(s)
- Marina Leitman
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, ISR
- Cardiology, Shamir Medical Center, Zerifin, ISR
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Patel KP, Scully PR, Saberwal B, Sinha A, Yap-Sanderson JJL, Cheasty E, Mullen M, Menezes LJ, Moon JC, Pugliese F, Klotz E, Treibel TA. Regional Distribution of Extracellular Volume Quantified by Cardiac CT in Aortic Stenosis: Insights Into Disease Mechanisms and Impact on Outcomes. Circ Cardiovasc Imaging 2024; 17:e015996. [PMID: 38771906 DOI: 10.1161/circimaging.123.015996] [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: 08/10/2023] [Accepted: 03/19/2024] [Indexed: 05/23/2024]
Abstract
BACKGROUND Extracellular volume fraction (ECV) is a marker for myocardial fibrosis and infiltration, can be quantified using cardiac computed tomography (ECVCT), and has prognostic utility in several diseases. This study aims to map out regional differences in ECVCT to obtain greater insights into the pathophysiological mechanisms of ECV expansion and its clinical implications. METHODS Three prospective cohorts were included: patients with aortic stenosis (AS) and coexisting AS and transthyretin cardiac amyloidosis were referred for a transcatheter aortic valve replacement and had ECG-gated CT angiography and Technetium-99m-labelled 3,3-diphosphono-1,2-propanodicarboxylic acid scintigraphy to differentiate between the 2 cohorts. Controls had CT angiography and cardiac magnetic resonance demonstrating no significant coronary artery disease or infarction. Global and regional ECVCT was analyzed, and its association with mortality was assessed for patients with AS. RESULTS In 199 patients, controls (n=65; 66% male), AS (n=115), and coexisting AS and transthyretin cardiac amyloidosis (n=19) had a global ECVCT of 26.1 (25.0-27.8%) versus 29.1 (27.5-31.1%) versus 37.4 (32.5-46.6%), respectively; P<0.001. Across cohorts, ECVCT was higher at the base (versus apex), the inferoseptum (versus anterolateral wall), and the subendocardium (versus subepicardium); P<0.05 for all. Among patients with AS, epicardial ECVCT, rather than any other regional value or global ECVCT, was the strongest predictor of mortality at a median of 3.9 (max 6.3) years (adjusted hazard ratio, 1.21 [95% CI, 1.08-1.36]; P=0.002). CONCLUSIONS Regional differences in ECVCT suggest a predilection for fibrosis and amyloid infiltration at the base, subendocardium, inferior wall, and septum more than the anterior and lateral myocardium. ECVCT can predict long-term mortality with the subepicardium demonstrating the strongest discriminatory power. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifiers: NCT03029026 and NCT03094143.
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Affiliation(s)
- Kush P Patel
- Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom (K.P.P., P.R.S., B.S., A.S., J.J.L.Y.-S., E.C., M.M., L.J.M., J.C.M., F.P., T.A.T.)
- Institute of Cardiovascular Sciences, University College London, United Kingdom (K.P.P., P.R.S., J.C.M., T.A.T.)
| | - Paul R Scully
- Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom (K.P.P., P.R.S., B.S., A.S., J.J.L.Y.-S., E.C., M.M., L.J.M., J.C.M., F.P., T.A.T.)
| | - Bunny Saberwal
- Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom (K.P.P., P.R.S., B.S., A.S., J.J.L.Y.-S., E.C., M.M., L.J.M., J.C.M., F.P., T.A.T.)
- William Harvey Research Institute, Queen Mary University of London, United Kingdom (B.S., F.P., T.A.T.)
| | - Apurva Sinha
- Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom (K.P.P., P.R.S., B.S., A.S., J.J.L.Y.-S., E.C., M.M., L.J.M., J.C.M., F.P., T.A.T.)
| | - Joanna J L Yap-Sanderson
- Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom (K.P.P., P.R.S., B.S., A.S., J.J.L.Y.-S., E.C., M.M., L.J.M., J.C.M., F.P., T.A.T.)
| | - Emma Cheasty
- Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom (K.P.P., P.R.S., B.S., A.S., J.J.L.Y.-S., E.C., M.M., L.J.M., J.C.M., F.P., T.A.T.)
| | - Michael Mullen
- Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom (K.P.P., P.R.S., B.S., A.S., J.J.L.Y.-S., E.C., M.M., L.J.M., J.C.M., F.P., T.A.T.)
| | - Leon J Menezes
- Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom (K.P.P., P.R.S., B.S., A.S., J.J.L.Y.-S., E.C., M.M., L.J.M., J.C.M., F.P., T.A.T.)
- Institute of Nuclear Medicine, University College London, United Kingdom (L.J.M.)
- NIHR University College London Hospitals Biomedical Research Centre, United Kingdom (L.J.M.)
| | - James C Moon
- Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom (K.P.P., P.R.S., B.S., A.S., J.J.L.Y.-S., E.C., M.M., L.J.M., J.C.M., F.P., T.A.T.)
| | - Francesca Pugliese
- Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom (K.P.P., P.R.S., B.S., A.S., J.J.L.Y.-S., E.C., M.M., L.J.M., J.C.M., F.P., T.A.T.)
- William Harvey Research Institute, Queen Mary University of London, United Kingdom (B.S., F.P., T.A.T.)
| | - Ernst Klotz
- Siemens Healthineers, Forchheim, Germany (E.K.)
| | - Thomas A Treibel
- Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom (K.P.P., P.R.S., B.S., A.S., J.J.L.Y.-S., E.C., M.M., L.J.M., J.C.M., F.P., T.A.T.)
- Institute of Cardiovascular Sciences, University College London, United Kingdom (K.P.P., P.R.S., J.C.M., T.A.T.)
- William Harvey Research Institute, Queen Mary University of London, United Kingdom (B.S., F.P., T.A.T.)
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