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Sabbah M, Olsen NT, Minkkinen M, Holmvang L, Tilsted H, Pedersen F, Joshi FR, Ahtarovski K, Sørensen R, Linde JJ, Søndergaard L, Pijls N, Lønborg J, Engstrøm T. Microcirculatory Function in Nonhypertrophic and Hypertrophic Myocardium in Patients With Aortic Valve Stenosis. J Am Heart Assoc 2022; 11:e025381. [PMID: 35470693 PMCID: PMC9238586 DOI: 10.1161/jaha.122.025381] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Left ventricular hypertrophy (LVH) has often been supposed to be associated with abnormal myocardial blood flow and resistance. The aim of this study was to evaluate and quantify the physiological and pathological changes in myocardial blood flow and microcirculatory resistance in patients with and without LVH attributable to severe aortic stenosis. Methods and Results Absolute coronary blood flow and microvascular resistance were measured using a novel technique with continuous thermodilution and infusion of saline. In addition, myocardial mass was assessed with cardiac magnetic resonance imaging. Fifty-three patients with aortic valve stenosis were enrolled in the study. In 32 patients with LVH, hyperemic blood flow per gram of tissue was significantly decreased compared with 21 patients without LVH (1.26±0.48 versus 1.66±0.65 mL·min-1·g-1; P=0.018), whereas minimal resistance indexed for left ventricular mass was significantly increased in patients with LVH (63 [47-82] versus 43 [35-63] Wood Units·kg; P=0.014). Conclusions Patients with LVH attributable to severe aortic stenosis had lower hyperemic blood flow per gram of myocardium and higher minimal myocardial resistance compared with patients without LVH.
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Affiliation(s)
- Muhammad Sabbah
- Department of CardiologyCopenhagen University Hospital–RigshospitaletCopenhagenDenmark
| | - Niels Thue Olsen
- Department of CardiologyCopenhagen University Hospital–Herlev and GentofteGentofteDenmark
- Department of Clinical MedicineUniversity of CopenhagenDenmark
| | - Mikko Minkkinen
- Department of CardiologyCopenhagen University Hospital–RigshospitaletCopenhagenDenmark
| | - Lene Holmvang
- Department of CardiologyCopenhagen University Hospital–RigshospitaletCopenhagenDenmark
| | - Hans‐Henrik Tilsted
- Department of CardiologyCopenhagen University Hospital–RigshospitaletCopenhagenDenmark
| | - Frants Pedersen
- Department of CardiologyCopenhagen University Hospital–RigshospitaletCopenhagenDenmark
| | - Francis R. Joshi
- Department of CardiologyCopenhagen University Hospital–RigshospitaletCopenhagenDenmark
| | - Kiril Ahtarovski
- Department of CardiologyCopenhagen University Hospital–RigshospitaletCopenhagenDenmark
| | - Rikke Sørensen
- Department of CardiologyCopenhagen University Hospital–RigshospitaletCopenhagenDenmark
| | - Jesper James Linde
- Department of CardiologyCopenhagen University Hospital–RigshospitaletCopenhagenDenmark
| | - Lars Søndergaard
- Department of CardiologyCopenhagen University Hospital–RigshospitaletCopenhagenDenmark
- Department of Clinical MedicineUniversity of CopenhagenDenmark
| | - Nico Pijls
- Department of CardiologyCatharina HospitalEindhoventhe Netherlands
| | - Jacob Lønborg
- Department of CardiologyCopenhagen University Hospital–RigshospitaletCopenhagenDenmark
| | - Thomas Engstrøm
- Department of CardiologyCopenhagen University Hospital–RigshospitaletCopenhagenDenmark
- Department of Clinical MedicineUniversity of CopenhagenDenmark
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2
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Sen J, Chung E, Neil C, Marwick T. Antihypertensive therapies in moderate or severe aortic stenosis: a systematic review and meta-analysis. BMJ Open 2020; 10:e036960. [PMID: 33020089 PMCID: PMC7537451 DOI: 10.1136/bmjopen-2020-036960] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 08/19/2020] [Accepted: 08/25/2020] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Hypertension confers a poor prognosis in moderate or severe aortic stenosis (AS), however, antihypertensive therapy (AHT) is often not prescribed due to the perceived deleterious effects of vasodilation and negative inotropes. OBJECTIVE To assess the efficacy and safety outcomes of AHT in adults with moderate or severe AS. DESIGN Systematic review and meta-analysis. DATA SOURCES The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and grey literature were searched without language restrictions up to 9 September 2019. STUDY ELIGIBILITY CRITERIA, APPRAISAL AND SYNTHESIS METHODS Two independent reviewers performed screening, data extraction and risk of bias assessments from a systematic search of observational studies and randomised controlled trials comparing AHT with a placebo or no AHT in adults with moderate or severe AS for any parameter of efficacy and safety outcomes. Conflicts were resolved by the third reviewer. Meta-analysis with pooled effect sizes using random-effects model, were estimated in R. MAIN OUTCOME MEASURES Mortality, Left Ventricular (LV) Mass Index, systolic blood pressure, diastolic blood pressure and LV ejection fraction RESULTS: From 3025 publications, 31 studies (26 500 patients) were included in the qualitative synthesis and 24 studies in the meta-analysis. AHT was not associated with mortality when all studies were pooled, but heterogeneity was substantial across studies. The effect size of AHT differed according to drug class. Renin-angiotensin-aldosterone system inhibitors (RAASi) were associated with reduced risk of mortality (Pooled HR 0.58, 95% CI 0.43 to 0.80, p=0.006), The differences in changes of haemodynamic or echocardiographic parameters from baseline with and without AHT did not reach statistical significance. CONCLUSION AHT appears safe, is well tolerated. RAASi were associated with clinical benefit in patients with moderate or severe AS.
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Affiliation(s)
- Jonathan Sen
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Erin Chung
- Graduate Department of Pharmaceutical Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Christopher Neil
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Thomas Marwick
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
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3
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Abstract
Aortic stenosis is a heterogeneous disorder. Variations in the pathological and physiological responses to pressure overload are incompletely understood and generate a range of flow and pressure gradient patterns, which ultimately cause varying microvascular effects. The impact of cardiac-coronary coupling depends on these pressure and flow effects. In this article, we explore important concepts concerning cardiac physiology and the coronary microcirculation in aortic stenosis and their impact on myocardial remodeling, aortic valve flow patterns, and clinical progression.
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Affiliation(s)
- Hannah Z.R. McConkey
- Cardiovascular Division, King’s College London British Heart Foundation Centre of Excellence, The Rayne Institute, St. Thomas’ Hospital Campus, London, United Kingdom (H.Z.R.M., M.M., A.C., S.R.R., B.D.P.)
| | - Michael Marber
- Cardiovascular Division, King’s College London British Heart Foundation Centre of Excellence, The Rayne Institute, St. Thomas’ Hospital Campus, London, United Kingdom (H.Z.R.M., M.M., A.C., S.R.R., B.D.P.)
| | - Amedeo Chiribiri
- Cardiovascular Division, King’s College London British Heart Foundation Centre of Excellence, The Rayne Institute, St. Thomas’ Hospital Campus, London, United Kingdom (H.Z.R.M., M.M., A.C., S.R.R., B.D.P.)
| | - Philippe Pibarot
- Department of Medicine, Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, Québec, Canada (P.P.)
| | - Simon R. Redwood
- Cardiovascular Division, King’s College London British Heart Foundation Centre of Excellence, The Rayne Institute, St. Thomas’ Hospital Campus, London, United Kingdom (H.Z.R.M., M.M., A.C., S.R.R., B.D.P.)
| | - Bernard D. Prendergast
- Cardiovascular Division, King’s College London British Heart Foundation Centre of Excellence, The Rayne Institute, St. Thomas’ Hospital Campus, London, United Kingdom (H.Z.R.M., M.M., A.C., S.R.R., B.D.P.)
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4
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Broyd CJ, Rigo F, Nijjer S, Sen S, Petraco R, Al-Lamee R, Foin N, Chukwuemeka A, Anderson J, Parker J, Malik IS, Mikhail GW, Francis DP, Parker K, Hughes AD, Mayet J, Davies JE. Regression of left ventricular hypertrophy provides an additive physiological benefit following treatment of aortic stenosis: Insights from serial coronary wave intensity analysis. Acta Physiol (Oxf) 2018; 224:e13109. [PMID: 29935058 DOI: 10.1111/apha.13109] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 05/28/2018] [Accepted: 05/29/2018] [Indexed: 01/10/2023]
Abstract
AIM Severe aortic stenosis frequently involves the development of left ventricular hypertrophy (LVH) creating a dichotomous haemodynamic state within the coronary circulation. Whilst the increased force of ventricular contraction enhances its resultant relaxation and thus increases the distal diastolic coronary "suction" force, the presence of LVH has a potentially opposing effect on ventricular-coronary interplay. The aim of this study was to use non-invasive coronary wave intensity analysis (WIA) to separate and measure the sequential effects of outflow tract obstruction relief and then LVH regression following intervention for aortic stenosis. METHODS Fifteen patients with unobstructed coronary arteries undergoing aortic valve intervention (11 surgical aortic valve replacement [SAVR], 4 TAVI) were successfully assessed before and after intervention, and at 6 and 12 months post-procedure. Coronary WIA was constructed from simultaneously acquired coronary flow from transthoracic echo and pressure from an oscillometric brachial cuff system. RESULTS Immediately following intervention, a decline in the backward decompression wave (BDW) was noted (9.7 ± 5.7 vs 5.1 ± 3.6 × 103 W/m2 /s, P < 0.01). Over 12 months, LV mass index fell from 114 ± 19 to 82 ± 17 kg/m2 . Accompanying this, the BDW fraction increased to 32.8 ± 7.2% at 6 months (P = 0.01 vs post-procedure) and 34.7 ± 6.7% at 12 months (P < 0.001 vs post-procedure). CONCLUSION In aortic stenosis, both the outflow tract gradient and the presence of LVH impact significantly on coronary haemodynamics that cannot be appreciated by examining resting coronary flow rates alone. An immediate change in coronary wave intensity occurs following intervention with further effects appreciable with hypertrophy regression. The improvement in prognosis with treatment is likely to be attributable to both features.
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Affiliation(s)
| | - Fausto Rigo
- Division of Cardiology; dell'Angelo Hospital; Mestre-Venice Italy
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5
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Sigvardsen PE, Larsen LH, Carstensen HG, Sørgaard M, Hindsø L, Hassager C, Køber L, Møgelvang R, Kofoed KF. Prognostic implications of left ventricular asymmetry in patients with asymptomatic aortic valve stenosis. Eur Heart J Cardiovasc Imaging 2018; 19:168-175. [DOI: 10.1093/ehjci/jew339] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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6
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A numerical study of the hemodynamic effect of the aortic valve on coronary flow. Biomech Model Mechanobiol 2017; 17:319-338. [DOI: 10.1007/s10237-017-0962-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 09/05/2017] [Indexed: 01/09/2023]
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7
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Broyd CJ, Davies JE, Escaned JE, Hughes A, Parker K. Wave intensity analysis and its application to the coronary circulation. Glob Cardiol Sci Pract 2017; 2017:e201705. [PMID: 28971104 PMCID: PMC5621714 DOI: 10.21542/gcsp.2017.5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Wave intensity analysis (WIA) is a technique developed from the field of gas dynamics that is now being applied to assess cardiovascular physiology. It allows quantification of the forces acting to alter flow and pressure within a fluid system, and as such it is highly insightful in ascribing cause to dynamic blood pressure or velocity changes. When co-incident waves arrive at the same spatial location they exert either counteracting or summative effects on flow and pressure. WIA however allows waves of different origins to be measured uninfluenced by other simultaneously arriving waves. It therefore has found particular applicability within the coronary circulation where both proximal (aortic) and distal (myocardial) ends of the coronary artery can markedly influence blood flow. Using these concepts, a repeating pattern of 6 waves has been consistently identified within the coronary arteries, 3 originating proximally and 3 distally. Each has been associated with a particular part of the cardiac cycle. The most clinically relevant wave to date is the backward decompression wave, which causes the marked increase in coronary flow velocity observed at the start of the diastole. It has been proposed that this wave is generated by the elastic re-expansion of the intra-myocardial blood vessels that are compressed during systolic contraction. Particularly by quantifying this wave, WIA has been used to provide mechanistic and prognostic insight into a number of conditions including aortic stenosis, left ventricular hypertrophy, coronary artery disease and heart failure. It has proven itself to be highly sensitive and as such a number of novel research directions are encouraged where further insights would be beneficial.
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Affiliation(s)
- C J Broyd
- Imperial College London, London, UK.,Hospital Clinico San Carlos, Madrid, Spain
| | | | | | - A Hughes
- University College London, London, UK
| | - K Parker
- Imperial College London, London, UK
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8
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Nield LE, Dragulescu A, MacColl C, Manlhiot C, Brun H, McCrindle BW, Kuipers B, Caldarone CA, Miner SES, Mertens L. Coronary artery Doppler patterns are associated with clinical outcomes post-arterial switch operation for transposition of the great arteries. Eur Heart J Cardiovasc Imaging 2017; 19:461-468. [DOI: 10.1093/ehjci/jex050] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 02/27/2017] [Indexed: 11/12/2022] Open
Affiliation(s)
- Lynne E Nield
- Division of Cardiology, The Hospital for Sick Children, Labatt Family Heart Centre, 555 University Avenue, Toronto, ON M5G 1X8, Canada
| | - Andreea Dragulescu
- Division of Cardiology, The Hospital for Sick Children, Labatt Family Heart Centre, 555 University Avenue, Toronto, ON M5G 1X8, Canada
| | - Christine MacColl
- Division of Cardiology, The Hospital for Sick Children, Labatt Family Heart Centre, 555 University Avenue, Toronto, ON M5G 1X8, Canada
| | - Cedric Manlhiot
- Division of Cardiology, The Hospital for Sick Children, Labatt Family Heart Centre, 555 University Avenue, Toronto, ON M5G 1X8, Canada
| | - Henrik Brun
- Division of Cardiology, The Hospital for Sick Children, Labatt Family Heart Centre, 555 University Avenue, Toronto, ON M5G 1X8, Canada
| | - Brian W McCrindle
- Division of Cardiology, The Hospital for Sick Children, Labatt Family Heart Centre, 555 University Avenue, Toronto, ON M5G 1X8, Canada
| | - Bart Kuipers
- Division of Cardiology, The Hospital for Sick Children, Labatt Family Heart Centre, 555 University Avenue, Toronto, ON M5G 1X8, Canada
| | - Christopher A Caldarone
- Division of Cardiology, The Hospital for Sick Children, Labatt Family Heart Centre, 555 University Avenue, Toronto, ON M5G 1X8, Canada
| | - Steven E S Miner
- University of Toronto, 1 King’s College Circle, Toronto, ON M5S 1A8, Canada
| | - Luc Mertens
- Division of Cardiology, The Hospital for Sick Children, Labatt Family Heart Centre, 555 University Avenue, Toronto, ON M5G 1X8, Canada
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9
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Broyd C, Davies J, Escaned J, Hughes A, Parker K. Wave intensity analysis and its application to the coronary circulation. Glob Cardiol Sci Pract 2015. [DOI: 10.5339/gcsp.2015.64] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
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10
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Meimoun P, Czitrom D. [Coronary microvascular dysfunction and aortic stenosis: an update]. Ann Cardiol Angeiol (Paris) 2014; 63:353-361. [PMID: 25261167 DOI: 10.1016/j.ancard.2014.08.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Accepted: 08/24/2014] [Indexed: 06/03/2023]
Abstract
The coronary microcirculatory impairment is a key feature of the pathophysiology of aortic stenosis (AS), the most operated valvular disease over the world. Several studies showed this coronary microcirculatory impairment in AS, using different tools and protocols, in various patient population of AS. This article will review the impairment of the coronary microcirculation in AS underlining its multifactorial origin, its functional part related to the hemodynamic consequences of AS, its complex relationship with left ventricular hypertrophy, and its potential diagnostic and prognostic value.
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Affiliation(s)
- P Meimoun
- Service de cardiologie-USIC, centre hospitalier de Compiègne, 8, rue Henri-Adnot, 60200 Compiègne, France.
| | - D Czitrom
- Service de cardiologie, institut mutualiste Montsouris, 75014 Paris, France
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11
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Jelenc M, Jelenc B, Klokočovnik T, Lakič N, Geršak B, Kneževic I. Understanding coronary artery bypass transit time flow curves: role of bypass graft compliance. Interact Cardiovasc Thorac Surg 2013; 18:164-8. [PMID: 24174121 DOI: 10.1093/icvts/ivt457] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Low mean bypass graft flow (Q) and high pulsatility index (PI) measured by the transit time flow measurement method are not specific for anastomotic stenosis, but occur with competitive flow and poor coronary run-off. We hypothesized that graft compliance is responsible for these changes and that flow measured at the proximal end of the coronary bypass can be viewed as a sum of the graft capacitive flow and flow that passes through the distal anastomosis. METHODS Transit time flow measurements (TTFMs) of 15 left internal thoracic artery (LITA) to LAD bypass grafts and 10 saphenous vein grafts (SVGs) to either the right coronary artery (RCA) or posterior descending artery (PDA) were analysed. The TTFM was performed on the proximal and distal end of the graft, and proximally with distal occlusion of the graft. Low mean bypass graft flow PI and diastolic filling (DF) measured distally and proximally were compared, and graft compliance was estimated. RESULTS Diastolic filling was higher distally in every single case (LITA-LAD: distal DF 76 ± 12% vs proximal 66 ± 13%, P = 0.005; SVG-RCA/PDA: distal 72 ± 15% vs proximal 63 ± 12%, P = 0.018). There were no significant differences in Q and PI. Subtracting the distal from the proximal flow gave a result identical to the proximal TTFM in distally occluded grafts, confirming the presence of graft capacitive flow. Graft compliance estimated from the flow of distally occluded grafts was 0.99 ± 0.47 μl/mmHg for LITA grafts and 0.78 ± 0.42 μl/mmHg for SVG grafts. CONCLUSIONS The study confirmed that the TTFM measured at the proximal end of the coronary bypass could be viewed as a sum of graft capacitive flow and the flow that passes through the distal anastomosis. Graft capacitive flow increases the systolic and decreases the diastolic TTFM when measured at the proximal end of the graft. It explains the higher DF when the TTFM is measured at the distal end of the graft and the increase in the PI at the proximal end when Q decreases. As the influence of graft capacitive flow on the PI in low Q can be eliminated by performing the TTFM at the distal end of the graft, we believe that the value of PI is clinically irrelevant.
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Affiliation(s)
- Matija Jelenc
- Department of Cardiovascular Surgery, University Medical Center Ljubljana, Ljubljana, Slovenia
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12
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Meimoun P, Germain AL, Elmkies F, Benali T, Boulanger J, Espanel C, Clerc J, Zemir H, Luycx-Bore A, Tribouilloy C. Factors Associated with Noninvasive Coronary Flow Reserve in Severe Aortic Stenosis. J Am Soc Echocardiogr 2012; 25:835-41. [DOI: 10.1016/j.echo.2012.05.020] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2011] [Indexed: 01/27/2023]
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13
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Mannacio V, Di Tommaso L, Stassano P, De Amicis V, Vosa C. Myocardial metabolism and diastolic function after aortic valve replacement for aortic stenosis: influence of patient-prosthesis mismatch. Eur J Cardiothorac Surg 2011; 41:316-21. [DOI: 10.1016/j.ejcts.2011.05.039] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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14
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Gaillard E, Garcia D, Kadem L, Pibarot P, Durand LG. In Vitro Investigation of the Impact of Aortic Valve Stenosis Severity on Left Coronary Artery Flow. J Biomech Eng 2010; 132:044502. [DOI: 10.1115/1.4000990] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Patients with aortic valve stenosis (AS) may experience angina pectoris even if they have angiographically normal coronary arteries. Angina is associated with a marked increase in the risk of sudden death in AS patients. Only a few in vitro models describing the interaction between the left ventricular and aortic pressures, and the coronary circulation have been reported. These models were designed for specific research studies and they need to be improved or modified when other specific studies are required. Consequently, we have developed an in vitro model that is able to mimic the coronary circulation in presence of aortic stenosis. First, we have validated the model under physiological conditions. Then, we have examined and quantified the hemodynamic effects of different degrees of AS (from normal to severe AS) on the coronary flow using a model of the normal left coronary artery. In the coronary in vitro model without AS (normal valve), the amplitude and shape of coronary flow were similar to those observed in in vivo measurements obtained under physiological conditions, as described by Hozumi et al. (1998, “Noninvasive Assessment of Significant Left Anterior Descending Coronary Artery Stenosis by Coronary Flow Velocity Reserve With Transthoracic Color Doppler Echocardiography,” Circulation, 97, pp. 1557–1562). The presence of an AS induced an increase in the maximum and mean coronary flow rates (97% and 73%, respectively, for a very severe AS). Furthermore, when AS was very severe, a retrograde flow occurred during systole. This study allowed us to validate our coronary in vitro model under physiological conditions, both in the absence and presence of AS. These changes could explain the fact that even if patients have angiographically normal epicardial coronary arteries, we can observe the occurrence of angina pectoris in these patients in the presence of an AS.
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Affiliation(s)
- E. Gaillard
- Laboratory of Biomedical Engineering, Clinical Research Institute of Montreal, University of Montreal, 110 Avenue des Pins Ouest, Montreal, QC, H2W 1R7, Canada
| | - D. Garcia
- CRCHUM, Research Centre, University of Montreal Hospital, 2099 Alexandre de Seve, Montreal, QC, H2L 2W5, Canada
| | - L. Kadem
- Laboratory of Cardiovascular Fluid Dynamics, Concordia University, 1515 St. Catherine Street West, Montreal, QC, H3G 1M8, Canada
| | - P. Pibarot
- Quebec Heart Institute, Laval Hospital, Laval University, 2725 Chemin Sainte-Foy, Sainte-Foy, QC, G1V 4G5, Canada
| | - L.-G. Durand
- Laboratory of Biomedical Engineering, Clinical Research Institute of Montreal, University of Montreal, 110 Avenue des Pins Quest, Montreal, QC, H2W 1R7, Canada
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15
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The noninvasive estimation of central aortic blood pressure in patients with aortic stenosis. J Hypertens 2008; 26:2381-8. [DOI: 10.1097/hjh.0b013e328313919f] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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16
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Vitarelli A, Morichetti MC, Conde Y, Cimino E, D'Orazio S, Stellato S, Padella V, Caranci F, Battaglia D. Assessment of severity in aortic stenosis-incremental value of endocardial function parameters compared with standard indexes. ULTRASOUND IN MEDICINE & BIOLOGY 2007; 33:1224-35. [PMID: 17466445 DOI: 10.1016/j.ultrasmedbio.2007.02.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/15/2006] [Revised: 02/01/2007] [Accepted: 02/13/2007] [Indexed: 05/15/2023]
Abstract
Several studies have reported that patients (pts) with severe aortic stenosis and similar pressure gradients or even similar aortic valve areas may have quite different symptomatic status and clinical outcomes suggesting that other factors might have a significant impact on the pathophysiology of this disease. Our purpose was to assess the severity of subendocardial wall dysfunction in symptomatic and asymptomatic pts with aortic stenosis using tissue Doppler imaging (TDI), strain rate imaging (SRI) and cyclic variation of integrated backscatter (IB). We studied 68 pts with aortic valvar stenosis and 46 subjects with no signs of heart disease. SRI/IB indexes were calculated in the apical four chambers views at endocardial level. Early diastolic endocardial strain rate showed the best correlation with transvalvar pressure gradients and valve areas. Compared with controls, symptomatic pts showed a more marked decrease in endocardial strain, strain rate and cyclic variation of IB. Receiver operating characteristic (ROC) curves suggested that the thresholds offering an adequate compromise between sensitivity and specificity for the prediction of symptoms were >/=60 mm Hg for the pressure gradient, less than 0.60 cm(2)/m(2) for aortic valve area, less than 20% for strain, less than 2.0 s(-1) for strain rate and less than 3.0 dB for cyclic variation. The combination of pressure gradient, aortic valve area and SRI/IB parameters resulted in an improvement of the overall performance for predicting the symptomatic state. Thus, SRI/IB parameters have an incremental value in differentiating symptomatic and asymptomatic pts with aortic stenosis compared with conventional hemodynamic parameters.
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17
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Affiliation(s)
- Paolo G Camici
- Medical Research Council Clinical Sciences Centre Hammersmith Hospital, and National Heart and Lung Institute, Imperial College, London, United Kingdom.
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18
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Garcia D, Kadem L, Savéry D, Pibarot P, Durand LG. Analytical modeling of the instantaneous maximal transvalvular pressure gradient in aortic stenosis. J Biomech 2006; 39:3036-44. [PMID: 16307750 DOI: 10.1016/j.jbiomech.2005.10.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2005] [Accepted: 10/12/2005] [Indexed: 11/16/2022]
Abstract
In presence of aortic stenosis, a jet is produced downstream of the aortic valve annulus during systole. The vena contracta corresponds to the location where the cross-sectional area of the flow jet is minimal. The maximal transvalvular pressure gradient (TPG(max)) is the difference between the static pressure in the left ventricle and that in the vena contracta. TPG(max) is highly time-dependent over systole and is known to depend upon the transvalvular flow rate, the effective orifice area (EOA) of the aortic valve and the cross-sectional area of the left ventricular outflow tract. However, it is still unclear how these parameters modify the TPG(max) waveform. We thus derived an explicit analytical model to describe the instantaneous TPG(max) across the aortic valve during systole. This theoretical model was validated with in vivo experiments obtained in 19 pigs with supravalvular aortic stenosis. Instantaneous TPG(max) was measured by catheter and its waveform was compared with the one determined from the derived equation. Our results showed a very good concordance between the measured and predicted instantaneous TPG(max). Total relative error and mean absolute error were on average 9.4+/-4.9% and 2.1+/-1.1 mmHg, respectively. The analytical model proposed and validated in this study provides new insight into the behaviour of the TPG(max) and thus of the aortic pressure at the level of vena contracta. Because the static pressure at the coronary inlet is similar to that at the vena contracta, the proposed equation will permit to further examine the impact of aortic stenosis on coronary blood flow.
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Affiliation(s)
- Damien Garcia
- Biomedical Engineering Laboratory, Clinical Research Institute of Montreal, IRCM, 110 Pine West Avenue, Montreal, QC, Canada.
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Kodama-Takahashi K, Ohshima K, Kurata A, Yamamoto K, Uemura S, Watanabe S, Iwata T, Kawachi K. Myocardial infarction in a patient with severe aortic stenosis and normal coronary arteriograms: involvement of the circumferential subendocardial wall of the left ventricle. Circ J 2003; 67:891-4. [PMID: 14578627 DOI: 10.1253/circj.67.891] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
A case of severe aortic stenosis with normal coronary arteriograms was associated with myocardial infarction involving the circumferential subendocardial wall of the left ventricle. The infarct was caused solely by the severe aortic stenosis and resulted from the extreme disparity between myocardial oxygen supply and demand.
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Rajappan K, Rimoldi OE, Camici PG, Bellenger NG, Pennell DJ, Sheridan DJ. Functional changes in coronary microcirculation after valve replacement in patients with aortic stenosis. Circulation 2003; 107:3170-5. [PMID: 12796134 DOI: 10.1161/01.cir.0000074211.28917.31] [Citation(s) in RCA: 165] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Increased extravascular compression and reduced diastolic perfusion time (DPT), rather than vascular remodeling, influence coronary microcirculatory dysfunction in aortic stenosis (AS). However, alterations after aortic valve replacement (AVR) remain unclear. The aim of the present study was to quantify changes in transmural perfusion and coronary vasodilator reserve (CVR), a measure of microcirculatory function, after AVR and determine the relative contribution of left ventricular mass (LVM) regression, change in aortic valve area (AVA), and DPT. METHODS AND RESULTS Twenty-two patients with AS were studied before and 1 year after AVR using echocardiography to measure AVA, cardiovascular magnetic resonance to assess LVM, and positron emission tomography to quantify resting and hyperemic myocardial blood flow (MBF) and CVR. Regression of LVM occurred in all patients (from 129+/-30 to 94+/-24 g/m2; P<0.0001), and there was a significant reduction in resting MBF and increase in CVR corrected for rate-pressure product after AVR, although these changes displayed marked heterogeneity. Regression of LVM was linearly related to change in resting total LV blood flow but not CVR. Increase in hyperemic MBF and CVR transmurally was directly related to the increase in AVA after AVR. A significant relationship existed between the change in hyperemic DPT (1.0+/-4.7 s/min [range, 6.8 to 9.6]) and change in transmural CVR (y=0.08x+0.18; r=0.44; P=0.04). CONCLUSIONS Changes in coronary microcirculatory function in patients with AS after AVR are not directly dependent on regression of LVM. Reduced extravascular compression and increased DPT are proposed as the main mechanisms for improvement in MBF and CVR after AVR.
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Affiliation(s)
- Kim Rajappan
- Academic Cardiology Unit, St Mary's Hospital, London, UK
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Rajappan K, Rimoldi OE, Dutka DP, Ariff B, Pennell DJ, Sheridan DJ, Camici PG. Mechanisms of coronary microcirculatory dysfunction in patients with aortic stenosis and angiographically normal coronary arteries. Circulation 2002; 105:470-6. [PMID: 11815430 DOI: 10.1161/hc0402.102931] [Citation(s) in RCA: 223] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Development of left ventricular hypertrophy in aortic stenosis (AS) is accompanied by coronary microcirculatory dysfunction, demonstrated by an impaired coronary vasodilator reserve (CVR). However, evidence for regional abnormalities in myocardial blood flow (MBF) and the potential mechanisms is limited. The aims of this study were to quantitatively demonstrate differences in subendocardial and subepicardial microcirculation and to investigate the relative contribution of myocyte hypertrophy, hemodynamic load, severity of AS, and coronary perfusion to impairment in microcirculatory function. METHODS AND RESULTS Twenty patients with isolated moderate to severe AS were studied using echocardiography to assess severity of AS, cardiovascular magnetic resonance to measure left ventricular mass (LVM), and PET to quantify resting and hyperemic (dipyridamole 0.56 mg/kg) MBF and CVR in both the subendocardium and subepicardium. In the patients with most severe AS (n=15), the subendocardial to subepicardial MBF ratio decreased from 1.14+/-7 at rest to 0.92+/-7 during hyperemia (P<0.005), and subendocardial CVR (1.43+/-3) was lower than subepicardial CVR (1.78+/-35; P=0.01). Resting total LV blood flow was linearly related to LVM, whereas CVR was not. Increase of total LV blood flow during hyperemia (mean value, 89.6+/-6%; range, 17% to 233%) was linearly related to aortic valve area. The decrease in CVR was related to severity of AS, increase in hemodynamic load, and reduction in diastolic perfusion time, particularly in the subendocardium. CONCLUSIONS CVR was more severely impaired in the subendocardium in patients with LVH attributable to severe AS. Severity of impairment was related to aortic valve area, hemodynamic load imposed, and diastolic perfusion rather than to LVM.
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Affiliation(s)
- Kim Rajappan
- Medical Research Council Clinical Sciences Centre, Hammersmith Hospital, London, UK
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Beyerbacht HP, Lamb HJ, van Der Laarse A, Vliegen HW, Leujes F, Hazekamp MG, de Roos A, van Der Wall EE. Aortic valve replacement in patients with aortic valve stenosis improves myocardial metabolism and diastolic function. Radiology 2001; 219:637-43. [PMID: 11376247 DOI: 10.1148/radiology.219.3.r01jn25637] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To evaluate whether functional and metabolic changes recover after aortic valve replacement (AVR). MATERIALS AND METHODS Eighteen men with aortic valve stenosis (mean pressure gradient +/- SD, 79.9 mm Hg +/- 15.1) underwent magnetic resonance (MR) imaging and phosphorus 31 MR spectroscopy. In nine patients who underwent AVR, MR imaging and spectroscopy were repeated 40 weeks +/- 12 after AVR. Ten age-matched healthy men were control subjects. RESULTS Before AVR, the myocardial phosphocreatine (PCr)-to-adenosine triphosphate (ATP) ratio in the 18 patients was 1.24 +/- 0.17 and 1.43 +/- 0.14 in the control group (P <.01). In nine patients who underwent follow-up MR spectroscopy, the ratio increased from 1.28 +/- 0.17 to 1.47 +/- 0.14 (P <.05) following AVR. Before AVR, early acceleration peak corrected for cardiac output was (0.043 +/- 0.008) x 10(-3) sec(-1) in patients and (0.081 +/- 0.033) x 10(-3) sec(-1) in the control group (P <.05). After 40 weeks +/- 12, the mean early acceleration peak corrected for cardiac output in the nine patients increased significantly to (0.055 +/- 0.006) x 10(-3) sec(-1) (P <.05), although it was still significantly lower than that of the control group (P <.05). Before AVR, a significant correlation was found between the myocardial PCr-ATP ratio and left ventricular diastolic function (n = 18; P <.05). CONCLUSION Severe aortic valve stenosis leads to a decreased myocardial PCr-ATP ratio and impairment of left ventricular diastolic function; following AVR, the ratio normalizes completely, whereas function improves significantly. There is an association between altered myocardial high-energy phosphate metabolism and impaired left ventricular diastolic function.
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Affiliation(s)
- H P Beyerbacht
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 2A Leiden, the Netherlands
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Takeda S, Rimington H, Smeeton N, Chambers J. Long axis excursion in aortic stenosis. BRITISH HEART JOURNAL 2001. [DOI: 10.1136/hrt.86.1.52] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVESTo examine long axis excursion in patients with all grades of aortic stenosis and preserved transverse systolic function, and to compare long axis excursion in symptomatic with that in asymptomatic severe aortic stenosis.DESIGNProspective comparative study.SETTINGRegional cardiothoracic centre.PATIENTS78 patients with all grades of aortic stenosis and normal fractional shortening and ejection fraction were studied. There were two comparison groups, 10 age matched normal subjects and 14 patients with aortic stenosis and fractional shortening < 26%.METHODSAortic valve function and left ventricular mass were assessed echocardiographically. M mode measurements of long axis excursion at the septal and lateral sides of the mitral annulus were taken.RESULTSThere were significant differences between the groups in long axis excursion at both the septal (p < 0.0001) and lateral sides of the mitral annulus (p = 0.002 by analysis of variance). Long axis excursion was independently related to both left ventricular mass index (p = 0.001) and the grade of aortic stenosis (p = 0.002). Comparing patients with severe aortic stenosis with and without symptoms, there were significant differences in effective orifice area (p = 0.02 ) and long axis excursion at the lateral side of the mitral annulus (p = 0.04), but not in fractional shortening, ejection fraction, or peak or mean pressure difference.CONCLUSIONIn patients with aortic stenosis, long axis excursion is reduced even in the presence of normal fractional shortening or ejection fraction. It is lower in patients with symptomatic compared with asymptomatic severe aortic stenosis and may be of use in predicting the onset of symptoms.
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Abstract
OBJECTIVES To examine long axis excursion in patients with all grades of aortic stenosis and preserved transverse systolic function, and to compare long axis excursion in symptomatic with that in asymptomatic severe aortic stenosis. DESIGN Prospective comparative study. SETTING Regional cardiothoracic centre. PATIENTS 78 patients with all grades of aortic stenosis and normal fractional shortening and ejection fraction were studied. There were two comparison groups, 10 age matched normal subjects and 14 patients with aortic stenosis and fractional shortening < 26%. METHODS Aortic valve function and left ventricular mass were assessed echocardiographically. M mode measurements of long axis excursion at the septal and lateral sides of the mitral annulus were taken. RESULTS There were significant differences between the groups in long axis excursion at both the septal (p < 0.0001) and lateral sides of the mitral annulus (p = 0.002 by analysis of variance). Long axis excursion was independently related to both left ventricular mass index (p = 0.001) and the grade of aortic stenosis (p = 0.002). Comparing patients with severe aortic stenosis with and without symptoms, there were significant differences in effective orifice area (p = 0.02 ) and long axis excursion at the lateral side of the mitral annulus (p = 0.04), but not in fractional shortening, ejection fraction, or peak or mean pressure difference. CONCLUSION In patients with aortic stenosis, long axis excursion is reduced even in the presence of normal fractional shortening or ejection fraction. It is lower in patients with symptomatic compared with asymptomatic severe aortic stenosis and may be of use in predicting the onset of symptoms.
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Affiliation(s)
- S Takeda
- Department of Adult Echocardiography, Guy's and St Thomas' Hospitals NHS Trust, Lambeth Palace Road, London SE1 7EH, UK
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Otto CM, Lind BK, Kitzman DW, Gersh BJ, Siscovick DS. Association of aortic-valve sclerosis with cardiovascular mortality and morbidity in the elderly. N Engl J Med 1999; 341:142-7. [PMID: 10403851 DOI: 10.1056/nejm199907153410302] [Citation(s) in RCA: 846] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Although aortic-valve stenosis is clearly associated with adverse cardiovascular outcomes, it is unclear whether valve sclerosis increases the risk of cardiovascular events. METHODS We assessed echocardiograms obtained at base line from 5621 men and women 65 years of age or older who were enrolled in a population-based prospective study. On echocardiography, the aortic valve was normal in 70 percent (3919 subjects), sclerotic without outflow obstruction in 29 percent (1610), and stenotic in 2 percent (92). The subjects were followed for a mean of 5.0 years to assess the risk of death from any cause and of death from cardiovascular causes. Cardiovascular morbidity was defined as new episodes of myocardial infarction, angina pectoris, congestive heart failure, or stroke. RESULTS There was a stepwise increase in deaths from any cause (P for trend, <0.001) and deaths from cardiovascular causes (P for trend, <0.001) with increasing aortic-valve abnormality; the respective rates were 14.9 and 6.1 percent in the group with normal aortic valves, 21.9 and 10.1 percent in the group with aortic sclerosis, and 41.3 and 19.6 percent in the group with aortic stenosis. The relative risk of death from cardiovascular causes among subjects without coronary heart disease at base line was 1.66 (95 percent confidence interval, 1.23 to 2.23) for those with sclerotic valves as compared with those with normal valves, after adjustment for age and sex. The relative risk remained elevated after further adjustment for clinical factors associated with sclerosis (relative risk, 1.52; 95 percent confidence interval, 1.12 to 2.05). The relative risk of myocardial infarction was 1.40 (95 percent confidence interval, 1.07 to 1.83) among subjects with aortic sclerosis, as compared with those with normal aortic valves. CONCLUSIONS Aortic sclerosis is common in the elderly and is associated with an increase of approximately 50 percent in the risk of death from cardiovascular causes and the risk of myocardial infarction, even in the absence of hemodynamically significant obstruction of left ventricular outflow.
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Affiliation(s)
- C M Otto
- Department of Medicine, University of Washington, Seattle 98195-6422, USA
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Abstract
Aortic valve disease is common in the elderly with recent data suggesting that aortic sclerosis and stenosis are the end-stage of an active disease process. Aortic atenosis may be diagnosed at symptom onset (angina, heart failure or syncope) but often the diagnosis is suspected in an asymptomatic patient with a systolic murmur. The diagnosis can be confirmed and disease severity evaluated reliably using Doppler echocardiography. Symptomatic severe aortic stenosis is treated with valve replacement, even in the elderly, due to the extremely poor prognosis without relief of outflow obstruction. Management is controversial when there is coexisting moderate aortic stenosis and left ventricular systolic dysfunction.
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Affiliation(s)
- C M Otto
- Division of Cardiology, University of Washington, Seattle, USA
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Irvine T, Kenny A. Aortic stenosis and angina with normal coronary arteries: the role of coronary flow abnormalities. HEART (BRITISH CARDIAC SOCIETY) 1997; 78:213-4. [PMID: 9391277 PMCID: PMC484917 DOI: 10.1136/hrt.78.3.213] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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