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Lancellotti P, Go YY, Vannan MA. Unveiling sex differences in valvular disease care and outcomes. Eur Heart J 2024; 45:3834-3836. [PMID: 39212414 DOI: 10.1093/eurheartj/ehae524] [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: 09/04/2024] Open
Affiliation(s)
- Patrizio Lancellotti
- Departments of Cardiology, Heart Valve Clinic, University of Liège Hospital, GIGA Institute, CHU Sart Tilman, Domaine Universitaire du Sart Tilman-B.35, 4000 Liège, Belgium
| | - Yun Yun Go
- National Heart Research Institute Singapore, National Heart Centre Singapore, Singapore
| | - Mani A Vannan
- Marcus Heart Valve Center, Piedmont Heart Institute, Atlanta, GA 30309, USA
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2
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Avierinos JF, Tribouilloy C, Bursi F, Grigioni F, Vanoverschelde JL, Resseguier N, Théron A, Pasquet A, Pradier J, Biagini E, Barbieri A, Michelena H, Benfari G, Rusinaru D, Zaffran S, Vancraeynest D, Collart F, Bohbot Y, Essayagh B, Enriquez-Sarano M. Degenerative mitral regurgitation due to flail leaflet: sex-related differences in presentation, management, and outcomes. Eur Heart J 2024; 45:2306-2316. [PMID: 38751052 DOI: 10.1093/eurheartj/ehae265] [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: 07/21/2023] [Revised: 02/26/2024] [Accepted: 04/15/2024] [Indexed: 07/10/2024] Open
Abstract
BACKGROUND AND AIMS Presentation, outcome, and management of females with degenerative mitral regurgitation (DMR) are undefined. We analysed sex-specific baseline clinical and echocardiographic characteristics at referral for DMR due to flail leaflets and subsequent management and outcomes. METHODS In the Mitral Regurgitation International Database (MIDA) international registry, females were compared with males regarding presentation at referral, management, and outcome (survival/heart failure), under medical treatment, post-operatively, and encompassing all follow-up. RESULTS At referral, females (n = 650) vs. males (n = 1660) were older with more severe symptoms and higher MIDA score. Smaller cavity diameters belied higher cardiac dimension indexed to body surface area. Under conservative management, excess mortality vs. expected was observed in males [standardized mortality ratio (SMR) 1.45 (1.27-1.65), P < .001] but was higher in females [SMR 2.00 (1.67-2.38), P < .001]. Female sex was independently associated with mortality [adjusted hazard ratio (HR) 1.29 (1.04-1.61), P = .02], cardiovascular mortality [adjusted HR 1.58 (1.14-2.18), P = .007], and heart failure [adjusted HR 1.36 (1.02-1.81), P = .04] under medical management. Females vs. males were less offered surgical correction (72% vs. 80%, P < .001); however, surgical outcome, adjusted for more severe presentation in females, was similar (P ≥ .09). Ultimately, overall outcome throughout follow-up was worse in females who displayed persistent excess mortality vs. expected [SMR 1.31 (1.16-1.47), P < .001], whereas males enjoyed normal life expectancy restoration [SMR 0.92 (0.85-0.99), P = .036]. CONCLUSIONS Females with severe DMR were referred to tertiary centers at a more advanced stage, incurred higher mortality and morbidity under conservative management, and were offered surgery less and later after referral. Ultimately, these sex-related differences yielded persistent excess mortality despite surgery in females with DMR, while males enjoyed restoration of life expectancy, warranting imperative re-evaluation of sex-specific DMR management.
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Affiliation(s)
- Jean-Fançois Avierinos
- Département de Cardiologie, Centre Hospitalier Universitaire Timone, Assistance Publique Hôpitaux de Marseille, Aix-Marseille Université, 264 rue Saint-Pierre, 13005 Marseille, France
- U1251 INSERM, Marseille Medical Genetics, Aix-Marseille Université, 27 Bd Jean Moulin, 13385 Marseille, France
| | - Christophe Tribouilloy
- Département de Cardiologie, Centre Hospitalier Universitaire d'Amiens, Amiens, France
- EA 7517, Jules Verne University of Picardie, Amiens, France
| | - Francesca Bursi
- Department of Health Sciences, University of Milan, Milano, Italy
| | - Francesco Grigioni
- Research Unit of Cardiovascular Science, Università e Fondazione Policlinico Universitario Campus Bio-Medico, Roma, Italy
| | - Jean-Louis Vanoverschelde
- Service de Cardiologie, Clinique Universitaire Saint-Luc, Brussels, Belgium
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Noémie Resseguier
- Methodological Support Unit for Clinical and Epidemiological Research, University Hospital of Marseille (APHM), Marseille, France
- CEReSS-Health Services and Quality of Life Research, Aix Marseille Université, Marseille, France
| | - Alexis Théron
- U1251 INSERM, Marseille Medical Genetics, Aix-Marseille Université, 27 Bd Jean Moulin, 13385 Marseille, France
- Service de Chirurgie Cardiaque, Centre Hospitalier Universitaire Timone, Assistance Publique Hôpitaux de Marseille, Aix-Marseille Université, Marseille, France
| | - Agnes Pasquet
- Service de Cardiologie, Clinique Universitaire Saint-Luc, Brussels, Belgium
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Julie Pradier
- Département de Cardiologie, Centre Hospitalier Universitaire Timone, Assistance Publique Hôpitaux de Marseille, Aix-Marseille Université, 264 rue Saint-Pierre, 13005 Marseille, France
| | - Elena Biagini
- Cardiology Unit, St Orsola Hospital, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Andrea Barbieri
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Hector Michelena
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Giovanni Benfari
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Dan Rusinaru
- Département de Cardiologie, Centre Hospitalier Universitaire d'Amiens, Amiens, France
- EA 7517, Jules Verne University of Picardie, Amiens, France
| | - Stéphane Zaffran
- U1251 INSERM, Marseille Medical Genetics, Aix-Marseille Université, 27 Bd Jean Moulin, 13385 Marseille, France
| | - David Vancraeynest
- Service de Cardiologie, Clinique Universitaire Saint-Luc, Brussels, Belgium
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Fréderic Collart
- Service de Chirurgie Cardiaque, Centre Hospitalier Universitaire Timone, Assistance Publique Hôpitaux de Marseille, Aix-Marseille Université, Marseille, France
| | - Yohann Bohbot
- Département de Cardiologie, Centre Hospitalier Universitaire d'Amiens, Amiens, France
- EA 7517, Jules Verne University of Picardie, Amiens, France
| | - Benjamin Essayagh
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
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3
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Ranard LS, Bonow RO, Nishimura R, Mack MJ, Thourani VH, Bavaria J, O'Gara PT, Bax JJ, Blanke P, Delgado V, Leipsic J, Lang RM, Michelena HI, Cavalcante JL, Vahl TP, Leon MB, Rigolin VH. Imaging Methods for Evaluation of Chronic Aortic Regurgitation in Adults: JACC State-of-the-Art Review. J Am Coll Cardiol 2023; 82:1953-1966. [PMID: 37940233 DOI: 10.1016/j.jacc.2023.08.051] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 08/21/2023] [Indexed: 11/10/2023]
Abstract
A global multidisciplinary workshop was convened to discuss the multimodality diagnostic evaluation of aortic regurgitation (AR). Specifically, the focus was on assessment tools for AR severity and analyzing evolving data on the optimal timing of aortic valve intervention. The key concepts from this expert panel are summarized as: 1) echocardiography is the primary imaging modality for assessment of AR severity; however, when data is incongruent or incomplete, cardiac magnetic resonance may be helpful; 2) assessment of left ventricular size and function is crucial in determining the timing of intervention; 3) recent evidence suggests current cutpoints for intervention in asymptomatic severe AR patients requires further scrutiny; 4) left ventricular end-systolic volume index has emerged as an additional parameter that has promise in guiding timing of intervention; and 5) the role of additional factors (including global longitudinal strain, regurgitant fraction, and myocardial extracellular volume) is worthy of future investigation.
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Affiliation(s)
- Lauren S Ranard
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Robert O Bonow
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Northwestern Memorial Hospital, Chicago, Illinois, USA
| | - Rick Nishimura
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael J Mack
- Division of Cardiothoracic Surgery, Heart Hospital Baylor Plano, Baylor Healthcare System, Plano, Texas, USA
| | - Vinod H Thourani
- Department of Cardiovascular Surgery, Marcus Valve Center, Piedmont Heart Institute, Atlanta, Georgia, USA
| | - Joseph Bavaria
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Patrick T O'Gara
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Philipp Blanke
- Department of Radiology, St Paul's Hospital & University of British Columbia, Vancouver, British Columbia, Canada
| | - Victoria Delgado
- Department of Cardiology, Hospital University Germans Trias i Pujol, Badalona, Spain
| | - Jonathon Leipsic
- Department of Radiology, St Paul's Hospital & University of British Columbia, Vancouver, British Columbia, Canada
| | - Roberto M Lang
- Section of Cardiology, Heart and Vascular Center, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Hector I Michelena
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - João L Cavalcante
- Division of Cardiology, Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Torsten P Vahl
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Martin B Leon
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Vera H Rigolin
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Northwestern Memorial Hospital, Chicago, Illinois, USA.
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4
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Malahfji M, Senapati A, Debs D, Saeed M, Tayal B, Nguyen DT, Graviss EA, Shah DJ. Sex differences in myocardial remodeling and extracellular volume in aortic regurgitation. Sci Rep 2023; 13:11334. [PMID: 37443191 PMCID: PMC10344872 DOI: 10.1038/s41598-023-37444-y] [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: 08/15/2022] [Accepted: 06/21/2023] [Indexed: 07/15/2023] Open
Abstract
Whether sex differences exist in the cardiac remodeling related to aortic regurgitation (AR) is unclear. Cardiac magnetic resonance (CMR) is the current non-invasive reference standard for cardiac remodeling assessment and can evaluate tissue characteristics. This prospective cohort included patients with AR undergoing CMR between 2011 and 2020. We excluded patients with confounding causes of remodeling. We quantified left ventricular (LV) volume, mass, AR severity, replacement fibrosis by late Gadolinium enhancement (LGE), and extracellular expansion by extracellular volume fraction (ECV). We studied 280 patients (109 women), median age 59.5 (47.2, 68.6) years (P for age = 0.25 between sexes). Women had smaller absolute LV volume and mass than men across the spectrum of regurgitation volume (RVol) (P ≤ 0.01). In patients with ≥ moderate AR and with adjustment for body surface area, indexed LV end-diastolic volume and mass were not significantly different between sexes (all P > 0.5) but men had larger indexed LV end systolic volume and lower LV ejection fraction (P ≥ 0.01). Women were more likely to have NYHA class II or greater symptoms than men but underwent surgery at a similar rate. Prevalence and extent of LGE was not significantly different between sexes or across RVol. Increasing RVol was independently associated with increasing ECV in women, but not in men (adjusted P for interaction = 0.03). In conclusion, women had lower LV volumes and mass than men across AR severity but their ECV increased with higher regurgitant volume, while ECV did not change in men. Indexing to body surface area did not fully correct for the cardiac remodeling differences between men and women. Women were more likely to have symptoms but underwent surgery at a similar rate to men. Further research is needed to determine if differences in ECV would translate to differences in the course of AR and outcomes.
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Affiliation(s)
- Maan Malahfji
- Cardiovascular MRI Laboratory, Division of Cardiovascular Imaging, Houston Methodist DeBakey Heart & Vascular Center, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA
| | - Alpana Senapati
- Cardiovascular MRI Laboratory, Division of Cardiovascular Imaging, Houston Methodist DeBakey Heart & Vascular Center, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA
| | - Dany Debs
- Cardiovascular MRI Laboratory, Division of Cardiovascular Imaging, Houston Methodist DeBakey Heart & Vascular Center, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA
| | - Mujtaba Saeed
- Cardiovascular MRI Laboratory, Division of Cardiovascular Imaging, Houston Methodist DeBakey Heart & Vascular Center, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA
| | - Bhupendar Tayal
- Cardiovascular MRI Laboratory, Division of Cardiovascular Imaging, Houston Methodist DeBakey Heart & Vascular Center, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA
| | - Duc T Nguyen
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital Research Institute, Houston, TX, USA
| | - Edward A Graviss
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital Research Institute, Houston, TX, USA
| | - Dipan J Shah
- Cardiovascular MRI Laboratory, Division of Cardiovascular Imaging, Houston Methodist DeBakey Heart & Vascular Center, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA.
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5
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Malahfji M, Crudo V, Kaolawanich Y, Nguyen DT, Telmesani A, Saeed M, Reardon MJ, Zoghbi WA, Polsani V, Elliott M, Bonow RO, Graviss EA, Kim R, Shah DJ. Influence of Cardiac Remodeling on Clinical Outcomes in Patients With Aortic Regurgitation. J Am Coll Cardiol 2023; 81:1885-1898. [PMID: 36882135 DOI: 10.1016/j.jacc.2023.03.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 03/02/2023] [Indexed: 03/07/2023]
Abstract
BACKGROUND Quantitative cardiac magnetic resonance (CMR) outcome studies in aortic regurgitation (AR) are few. It is unclear if volume measurements are beneficial over diameters. OBJECTIVES This study sought to evaluate the association of CMR quantitative thresholds and outcomes in AR patients. METHODS In a multicenter study, asymptomatic patients with moderate or severe AR on CMR with preserved left ventricular ejection fraction (LVEF) were evaluated. Primary outcome was development of symptoms or decrease in LVEF to <50%, development of guideline indications for surgery based on LV dimensions, or death under medical management. Secondary outcome was the same as the primary outcome, excluding surgery for remodeling indications. We excluded patients who underwent surgery within 30 days of CMR. Receiver-operating characteristic analyses for the association with outcomes were performed. RESULTS We studied 458 patients (median age: 60 years; IQR: 46-70 years). During a median follow-up of 2.4 years (IQR: 0.9-5.3 years), 133 events occurred. Optimal thresholds were regurgitant volume of 47 mL and regurgitant fraction of 43%, indexed LV end-systolic (iLVES) volume of 43 mL/m2, indexed LV end-diastolic volume of 109 mL/m2, and iLVES diameter of 2 cm/m2. In multivariable regression analysis, iLVES volume of ≥43 mL/m2 (HR: 2.53; 95% CI: 1.75-3.66; P < 0.001) and indexed LV end-diastolic volume of ≥109 mL/m2 were independently associated with the outcomes and provided additional discrimination improvement over iLVES diameter, whereas iLVES diameter was independently associated with the primary outcome but not the secondary outcome. CONCLUSIONS In asymptomatic AR patients with preserved LVEF, CMR findings can be used to guide management. CMR-based LVES volume assessment performed favorably compared to LV diameters.
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Affiliation(s)
- Maan Malahfji
- Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas, USA
| | - Valentina Crudo
- Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas, USA
| | - Yodying Kaolawanich
- Division of Cardiology, Department of Internal Medicine, Duke University, Durham, North Carolina, USA
| | - Duc T Nguyen
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital Research Institute, Houston, Texas, USA
| | - Amr Telmesani
- Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas, USA
| | - Mujtaba Saeed
- Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas, USA
| | - Michael J Reardon
- Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas, USA
| | - William A Zoghbi
- Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas, USA
| | | | - Michael Elliott
- Sanger Heart & Vascular Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Robert O Bonow
- Division of Cardiology, Department of Internal Medicine, Northwestern University, Chicago, Illinois, USA
| | - Edward A Graviss
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital Research Institute, Houston, Texas, USA
| | - Raymond Kim
- Division of Cardiology, Department of Internal Medicine, Duke University, Durham, North Carolina, USA
| | - Dipan J Shah
- Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas, USA.
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6
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Enriquez-Sarano M, Grapsa J. Valvular heart diseases in women: facts vs. incantations. Eur Heart J 2023; 44:833-835. [PMID: 36610069 DOI: 10.1093/eurheartj/ehac774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Affiliation(s)
| | - Julia Grapsa
- Department of Cardiology, Guys and St Thomas NHS Trust, London, UK
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7
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Long-term outcomes after aortic valve surgery in patients with aortic regurgitation with preserved ejection fraction and left ventricular dilation. Gen Thorac Cardiovasc Surg 2023; 71:51-58. [PMID: 35852755 DOI: 10.1007/s11748-022-01849-9] [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: 04/17/2022] [Accepted: 06/22/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVES This study aims to assess the long-term outcomes and prognostic predictors of asymptomatic patients with severe aortic regurgitation (AR) accompanied by left ventricular ejection fraction (LVEF) ≥ 55% and left ventricular end-diastolic diameter (LVEDD) > 65 mm undergoing aortic valve replacement (AVR). METHODS We retrospectively studied 291 consecutive asymptomatic patients with severe AR accompanied by LVEF ≥ 55% and LVEDD > 65 mm undergoing AVR from January 2000 to December 2013. The long-term outcomes and prognostic predictors were evaluated. RESULTS There were 2 (0.7%) in-hospital deaths caused by multiple organ failure. The overall survival rate was 95.2% at 5 years, 89.9% at 10 years, 85.9% at 15 years, and 85.9% at 20 years. The left ventricular end-systolic volume index (LVESVi) was an independent predictor of overall mortality, with 59 ml/m2 being the best cut-off value. The left ventricular (LV) dimension decreased within 1 year after surgery and sustained thereafter. There were 15.5% of patients had incomplete LV reverse remodeling. LVESVi was an independent predictor of incomplete LV reverse remodeling, with 56 ml/m2 being the best cut-off value. CONCLUSIONS AVR can be performed with an acceptable outcome in patients with severe AR accompanied by LVEF ≥ 55% and LVEDD > 65 mm. The LVESVi has the best predictive value for prognosis and the cut-off value is 59 ml/m2, and has the best predictive value for incomplete LV reverse remodeling and the cut-off value is 56 ml/m2.
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8
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Hashimoto G, Enriquez-Sarano M, Stanberry LI, Oh F, Wang M, Acosta K, Sato H, Lopes BBC, Fukui M, Garcia S, Goessl M, Sorajja P, Bapat VN, Lesser J, Cavalcante JL. Association of Left Ventricular Remodeling Assessment by Cardiac Magnetic Resonance With Outcomes in Patients With Chronic Aortic Regurgitation. JAMA Cardiol 2022; 7:924-933. [PMID: 35857306 DOI: 10.1001/jamacardio.2022.2108] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Importance Chronic aortic regurgitation (AR) causes left ventricular (LV) volume overload, which results in progressive LV remodeling negatively affecting outcomes. Whether cardiac magnetic resonance (CMR) volumetric quantification can provide incremental risk stratification over standard clinical and echocardiographic evaluation in patients with chronic moderate or severe AR is unknown. Objective To compare LV remodeling measurements by CMR and echocardiography between patients with and without heart failure symptoms and to verify the association of remodeling measurements of patients with chronic moderate or severe AR but no or minimal symptoms with clinical outcomes receiving medical management. Design, Setting, and Participants This multicenter retrospective cohort study included consecutive patients with at least moderate chronic native AR evaluated by 2-dimensional transthoracic echocardiography and CMR examination within 90 days from each other between January 2012 and February 2020 at Allina Health System. Data were analyzed from June 2021 to January 2022. Exposures Clinical evaluation and risk stratification by CMR. Main Outcomes and Measures The end point was a composite of death, heart failure hospitalization, or progression of New York Heart Association functional class while receiving medical management, censoring patients at the time of aortic valve replacement (when performed) or at the end of follow-up. Results Of the 178 included patients, 119 (66.9%) were male, 158 (88.8%) presented with no or minimal symptoms (New York Heart Association class I or II), and the median (IQR) age was 58 (44-69) years. Compared with patients with no or minimal symptoms, symptomatic patients had greater LV end-systolic volume index (LVESVi) by CMR (median [IQR], 66 [46-85] mL/m2 vs 42 [30-58] mL/m2; P < .001), while there were no significant differences by echocardiography (LVESVi: median [IQR], 38 [30-58] mL/m2 vs 27 [20-42] mL/m2; P = .07; LV end-systolic diameter index: median [IQR], 21 [17-25] mm/m2 vs 18 [15-22] mm/m2; P = .17). During the median (IQR) follow-up of 3.3 (1.6-5.8) years, 50 patients with no or minimal symptoms receiving medical management developed the composite end point, which, in multivariate analysis adjusted for age and EuroSCORE II, was independently associated with LVESVi of 45 mL/m2 or greater and aortic regurgitant fraction of 32% or greater, the latter adding incremental prognostic value to CMR volumetric assessment. Conclusions and Relevance In patients with chronic moderate or severe AR, patients presenting with heart failure symptoms have greater LVESVi by CMR than those with no or minimal symptoms. In patients with no or minimal symptoms, CMR quantification of LVESVi and AR severity may identify those at risk of death or incident heart failure and therefore should be considered in the clinical evaluation and decision-making of these patients.
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Affiliation(s)
- Go Hashimoto
- Cardiovascular Imaging Research Center and Core Lab, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Maurice Enriquez-Sarano
- Valve Science Center, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota.,Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Larissa I Stanberry
- Cardiovascular Imaging Research Center and Core Lab, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Felix Oh
- Cardiovascular Imaging Research Center and Core Lab, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Matthew Wang
- Cardiovascular Imaging Research Center and Core Lab, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Keith Acosta
- Cardiovascular Imaging Research Center and Core Lab, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Hirotomo Sato
- Cardiovascular Imaging Research Center and Core Lab, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Bernardo B C Lopes
- Cardiovascular Imaging Research Center and Core Lab, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Miho Fukui
- Cardiovascular Imaging Research Center and Core Lab, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Santiago Garcia
- Valve Science Center, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota.,Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Mario Goessl
- Valve Science Center, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota.,Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Paul Sorajja
- Valve Science Center, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota.,Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Vinayak N Bapat
- Valve Science Center, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota.,Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - John Lesser
- Valve Science Center, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota.,Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - João L Cavalcante
- Cardiovascular Imaging Research Center and Core Lab, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota.,Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
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9
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Tower-Rader A, Mathias IS, Obuchowski NA, Kocyigit D, Kumar Y, Donnellan E, Bolen M, Phelan D, Flamm S, Griffin B, Cho L, Svensson LG, Pettersson G, Popovic Z, Kwon D. Sex-based differences in left ventricular remodeling in patients with chronic aortic regurgitation: a multi-modality study. J Cardiovasc Magn Reson 2022; 24:12. [PMID: 35193584 PMCID: PMC8862390 DOI: 10.1186/s12968-022-00845-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 01/16/2022] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Significant aortic regurgitation (AR) leads to left ventricular (LV) remodeling; however, little data exist regarding sex-based differences in LV remodeling in this setting. We sought to compare LV remodeling and AR severity, assessed by echocardiography and cardiovascular magnetic resonance (CMR), to discern sex-based differences. METHODS Patients with ≥ moderate chronic AR by echocardiography who underwent CMR within 90 days between December 2005 and October 2015 were included. Nonlinear regression models were built to assess the effect of AR regurgitant fraction (RF) on LV remodeling. A generalized linear model and Bland Altman analyses were constructed to evaluate differences between CMR and echocardiography. Referral for surgical intervention based on symptoms and LV remodeling was evaluated. RESULTS Of the 243 patients (48.3 ± 16.6 years, 58 (24%) female), 119 (49%) underwent surgical intervention with a primary indication of severe AR, 97 (82%) men, 22 (18%) women. Significant sex differences in LV remodeling emerged on CMR. Women demonstrated significantly smaller LV end-diastolic volume index (LVEDVI) (96.8 ml/m2 vs 125.6 ml/m2, p < 0.001), LV end-systolic volume index (LVESVI) (41.1 vs 54.5 ml/m2, p < 0.001), blunted LV dilation in the setting of increasing AR severity (LVEDVI p value < 0.001, LVESVI p value 0.011), and LV length indexed (8.32 vs 9.69 cm, p < 0.001). On Bland Altman analysis, a significant interaction with sex and LV diameters was evident, demonstrating a significant increase in the difference between CMR and echocardiography measurements as the LV enlarged in women: LVEDVI (p = 0.006), LVESVI (p < 0.001), such that echocardiographic measurements increasingly underestimated LV diameters in women as the LV enlarged. LV length was higher for males with a linear effect from RF (p < 0.001), with LV length increasing at a higher rate with increasing RF for males compared to females (two-way interaction with sex p = 0.005). Sphericity volume index was higher for men after adjusting for a relative wall thickness (p = 0.033). CONCLUSIONS CMR assessment of chronic AR revealed significant sex differences in LV remodeling and significant echocardiographic underestimation of LV dilation, particularly in women. Defining optimal sex-based CMR thresholds for surgical referral should be further developed. TRIAL REGISTRATION NA.
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Affiliation(s)
- Albree Tower-Rader
- Department of Cardiology, Harvard Medical School, Massachusetts General Hospital, 55 Fruit St, Yawkey 5B, Boston, MA, 02114, USA
| | - Isadora Sande Mathias
- Department of Cardiology, Houston Methodist Hospital, Weill Cornell Medical College, 6565 Fannin St., Houston, TX, 77030, USA
| | - Nancy A Obuchowski
- Quantitative Health Sciences, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
| | - Duygu Kocyigit
- Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
| | - Yash Kumar
- Case Western University, 10900 Euclid Ave, Cleveland, OH, 44106-7017, USA
| | - Eoin Donnellan
- Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
| | - Michael Bolen
- Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
| | - Dermot Phelan
- Sanger Heart & Vascular Institute, Atrium Health, 1237 Harding Place, MOB1 Suite 5000, Charlotte, NC, 28204, USA
| | - Scott Flamm
- Imaging Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
| | - Brian Griffin
- Imaging Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
| | - Leslie Cho
- Imaging Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
| | - Lars G Svensson
- Imaging Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
| | - Gosta Pettersson
- Imaging Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
| | - Zoran Popovic
- Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
- Imaging Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
| | - Deborah Kwon
- Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA.
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OUP accepted manuscript. Eur J Cardiothorac Surg 2022; 62:6521322. [DOI: 10.1093/ejcts/ezac040] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 01/09/2022] [Accepted: 01/27/2022] [Indexed: 11/14/2022] Open
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11
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Voigt KR, Gökalp AL, Papageorgiou G, Bogers AJ, Takkenberg JJ, Mokhles MM, Bekkers JA. Male-Female Differences In Ascending Aortic Aneurysm Surgery: 25-Year Single Center Results. Semin Thorac Cardiovasc Surg 2022; 35:300-308. [DOI: 10.1053/j.semtcvs.2022.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 01/19/2022] [Indexed: 01/15/2023]
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12
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Crousillat DR, Wood MJ. Echocardiography in Women: How Are Mars and Venus Different? Curr Cardiol Rep 2021; 23:149. [PMID: 34427784 DOI: 10.1007/s11886-021-01562-8] [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] [Accepted: 04/14/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE OF REVIEW Sex is an important determinant of cardiac structure and function. We review key sex differences in universal echocardiographic parameters and discuss the clinical implications of using sex-specific algorithms to increase the diagnostic accuracy of echocardiography and improve the timely treatment of common cardiovascular disorders, and the unique role of echocardiography in pregnancy and the evaluation of ischemic heart disease. RECENT FINDINGS Emerging echocardiographic findings have begun to define important sex-based differences in chamber size and ventricular function. We advocate for additional research and the consideration of sex-specific algorithms in future expert consensus guidelines for the diagnosis and treatment of valvular heart disease, heart failure, and thoracic aortic disease. Echocardiography is an essential diagnostic tool in our armamentarium of imaging modalities for the sex-specific diagnosis and guidance of treatment for a broad spectrum of cardiovascular disorders.
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Affiliation(s)
- Daniela R Crousillat
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street Blake 256, Boston, MA, 02114, USA
| | - Malissa J Wood
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street Blake 256, Boston, MA, 02114, USA.
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13
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Yang LT, Enriquez-Sarano M, Pellikka PA, Thapa P, Scott CG, Hung JW, Michelena HI. Sex Differences in Outcomes of Patients With Chronic Aortic Regurgitation: Closing the Mortality Gap. Mayo Clin Proc 2021; 96:2145-2156. [PMID: 34353469 DOI: 10.1016/j.mayocp.2020.11.033] [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: 09/04/2020] [Revised: 11/23/2020] [Accepted: 11/24/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To examine contemporary clinical differences between men and women with hemodynamically significant chronic aortic regurgitation (AR). PATIENTS AND METHODS We retrospectively identified 1072 consecutive patients with moderate to severe or severe AR diagnosed between February 21, 2004, and April 29, 2019. Echocardiographic data, aortic valve surgical intervention (AVS), and all-cause death were analyzed. RESULTS At baseline, the 189 women in the study group were older than the 883 men (mean ± SD age, 64±18 years vs 58±17 years), had more advanced symptoms, and had larger left ventricular end-systolic dimension index (LVESDi) (all P<.001) despite similar AR severity. An LVESDi of greater than 20 mm/m2 was noted in 60 of 92 asymptomatic women (65%) vs 225 of 559 asymptomatic men (40%) (P<.001). Median follow-up was 5.6 years (interquartile range, 2.5 to 10.0 years). Female sex was associated with less AVS (P=.009), and overall 10-year survival was better in men (76%±2%) than in women (64%±5%) (P=.004). However, 10-year post-AVS survival was similar between the sexes (P=.86), and women had better left ventricular reverse remodeling than men regarding end-diastolic dimension (P=.02). Multivariable independent predictors of death were age, advanced symptoms, LVESDi, ejection fraction, and AVS (all P≤.03) but not female sex. When compared with the age-matched US population, women exhibited a 1.3-fold increased relative risk of death (P=.0383) while men had similar survival (P=.11). CONCLUSION In contemporary practice, women with AR continue to exhibit an overall survival penalty not related to female sex but to late referral markers, including more advanced symptoms, larger LVESDi, and less AVS. Nonetheless, women in our study exhibited outstanding post-AVS left ventricular remodeling and had good post-AVS survival, a step forward toward closing the sex-related mortality gap. The high percentage of LVESDi of 20 mm/m2 or greater in asymptomatic women represents a window of opportunity for advanced-symptom prevention and timely AR surgical correction that may close the mortality gap.
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Affiliation(s)
- Li-Tan Yang
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN; Department of Internal Medicine, Division of Cardiology, National Taiwan University Hospital, Taipei, Taiwan
| | | | | | - Prabin Thapa
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Christopher G Scott
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Judy W Hung
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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14
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Preventza O, Cekmecelioglu D, Chatterjee S, Green SY, Amarasekara H, Zhang Q, LeMaire SA, Coselli JS. Sex Differences in Ascending Aortic and Arch Surgery: A Propensity-matched Comparison of 1153 Pairs. Ann Thorac Surg 2021; 113:1153-1158. [PMID: 33971171 DOI: 10.1016/j.athoracsur.2021.04.069] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 04/01/2021] [Accepted: 04/27/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND We investigated the relationship of sex with clinical outcomes after proximal aortic (ascending and arch) operations, and whether sex-specific preoperative factors are associated with mortality. METHODS Of 3745 patients who underwent elective, urgent, and emergency proximal aortic operations over a 20-year period, 1153 pairs of men and women were propensity-matched, and their early and long-term outcomes were compared. Kaplan-Meier survival analysis was used to estimate late survival. RESULTS Women and men had similar operative mortality (9.1% vs 8.8%, P=0.8), stroke (5.7% vs 5.6%, P=0.9), and renal failure rates (7.0% vs 6.6%, P=0.7). Thirty-day mortality was 7.5% versus 5.6% (P=0.06), respectively. Results were less favorable for women than for men regarding respiratory failure (34.3% vs 29.2%, P=0.008) and intensive care unit length of stay (9.11±11.9 vs 7.87±12.48 days; P=0.023). Long-term survival was not significantly different between women and men: 66.3% (95%CI 62.8-69.5) versus 67.1% (95%CI 63.6-70.4) at 5 years, and 45.9% (95%CI 41.76-50.0) versus 46.2% (95%CI 41.7-50.6) at 10 years (P=0.4). Preoperative factors including diabetes, prior stroke, prior renal insufficiency, and peripheral vascular disease were associated with operative mortality in men, whereas chronic obstructive pulmonary disease was the main risk factor in women. CONCLUSIONS No differences were seen between the sexes in life-changing adverse outcomes after ascending aortic and arch procedures, although specific preoperative variables were associated with specific adverse events. Recognizing differences in preoperative risk factors for mortality between the sexes may facilitate targeted preoperative assessment, preparation, and counseling.
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Affiliation(s)
- Ourania Preventza
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine; Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute; Department of Cardiovascular Surgery, CHI St Luke's Health-Baylor St Luke's Medical Center.
| | - Davut Cekmecelioglu
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine; Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute
| | - Subhasis Chatterjee
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine; Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute; Division of General Surgery, Michael E. DeBakey Department of Surgery, Baylor College Medicine, Houston, Texas
| | - Susan Y Green
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine; Office of Surgical Research, Michael E. DeBakey Department of Surgery, Baylor College of Medicine
| | - Hiruni Amarasekara
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine; Office of Surgical Research, Michael E. DeBakey Department of Surgery, Baylor College of Medicine
| | - Qianzi Zhang
- Office of Surgical Research, Michael E. DeBakey Department of Surgery, Baylor College of Medicine
| | - Scott A LeMaire
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine; Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute; Department of Cardiovascular Surgery, CHI St Luke's Health-Baylor St Luke's Medical Center; Office of Surgical Research, Michael E. DeBakey Department of Surgery, Baylor College of Medicine; Cardiovascular Research Institute, Baylor College of Medicine, Houston, Texas
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine; Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute; Department of Cardiovascular Surgery, CHI St Luke's Health-Baylor St Luke's Medical Center; Cardiovascular Research Institute, Baylor College of Medicine, Houston, Texas
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15
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Kammerlander AA, Donà C, Nitsche C, Koschutnik M, Zafar A, Eslami P, Duca F, Aschauer S, Schönbauer R, Beitzke D, Loewe C, Hoffmann U, Gebhard C, Hengstenberg C, Mascherbauer J. Sex Differences in Left Ventricular Remodeling and Outcomes in Chronic Aortic Regurgitation. J Clin Med 2020; 9:E4100. [PMID: 33353247 PMCID: PMC7767247 DOI: 10.3390/jcm9124100] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 12/05/2020] [Accepted: 12/15/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Left ventricular (LV) dilatation is a key compensatory feature in patients with chronic aortic regurgitation (AR). However, sex-differences in LV remodeling and outcomes in chronic AR have been poorly investigated so far. METHODS We performed cardiovascular magnetic resonance imaging (CMR) including phase-contrast velocity-encoded imaging for the measurement of regurgitant fraction (RegF) at the sinotubular junction, in consecutive patients with at least mild AR on echocardiography. We assessed LV size (end-diastolic volume indexed to body surface area, LVEDV/BSA) and investigated sex differences between LV remodeling and increasing degrees of AR severity. Cox-regression models were used to test differences in outcomes between men and women using a composite of heart failure hospitalization, unscheduled AR intervention, and cardiovascular death. RESULTS 270 consecutive patients (59.6% male, 59.8 ± 20.8 y/o, 59.6% with at least moderate AR on echocardiography) were included. On CMR, mean RegF was 18.1 ± 17.9% and a total of 65 (24.1%) had a RegF ≥ 30%. LVEDV/BSA was markedly closer related with AR severity (RegF) in men compared to women. Each 1-SD increase in LVEDV/BSA (mL/m2) was associated with a 9.7% increase in RegF in men and 5.9% in women, respectively (p-value for sex-interaction < 0.001). Based on previously published reference values, women-in contrast to men-frequently had a normal LV size despite severe AR (e.g., for LVEDV/BSA on CMR: 35.3% versus 8.7%, p < 0.001). In a Cox-regression model adjusted for age, LVEDV/BSA and RegF, women were at significantly higher risk for the composite endpoint when compared to men (adj. HR 1.81 (95%CI 1.09-3.03), p = 0.022). CONCLUSION In patients with chronic AR, LV remodeling is a hallmark feature in men but not in women. Severity of AR may be underdiagnosed in female patients in the absence of LV dilatation. Future studies need to address the dismal prognosis in female patients with chronic AR.
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Affiliation(s)
- Andreas A Kammerlander
- Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Carolina Donà
- Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria
| | - Christian Nitsche
- Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria
| | | | - Amna Zafar
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Parastou Eslami
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Franz Duca
- Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria
| | - Stefan Aschauer
- Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria
| | - Robert Schönbauer
- Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria
| | - Dietrich Beitzke
- Section of Cardiovascular and Interventional Radiology, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, 1090 Vienna, Austria
| | - Christian Loewe
- Section of Cardiovascular and Interventional Radiology, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, 1090 Vienna, Austria
| | - Udo Hoffmann
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Cathérine Gebhard
- Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria
- Department of Nuclear Medicine, University Hospital Zurich and Center for Molecular Cardiology, University of Zurich, 8091 Zurich, Switzerland
| | | | - Julia Mascherbauer
- Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria
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16
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Martin J, Coffey S, Whalley GA. Sex Disparity in Cardiovascular Disease Outcomes: Do Our Current Echocardiographic Reference Ranges Measure Up? Heart Lung Circ 2020; 30:e1-e5. [PMID: 33176982 DOI: 10.1016/j.hlc.2020.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 09/29/2020] [Accepted: 10/07/2020] [Indexed: 11/19/2022]
Abstract
Reducing inequity in access to health care and disparity in health outcomes remain key objectives in cardiovascular medicine. Echocardiography is often the primary diagnostic tool used to detect cardiovascular disease (CVD), and relies on comparison with published reference ranges to appropriately detect pathology. Our understanding of the contribution of age, sex and ethnicity to quantification of cardiac size is improving, but cardiovascular disease management guidelines have yet to evolve. While recently, sex, age and ethnicity-specific reference values have been produced, treatment thresholds in many clinical guidelines do not differentiate between sexes. As a result, in order to reach management thresholds, women are often required to have more severe pathology. In order to reduce potential disadvantage to women, future research efforts should be directed to develop more personalised treatment approaches by identification of sex-appropriate management thresholds.
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Affiliation(s)
- Josh Martin
- Department of Cardiology, Sunshine Coast University Hospital, Sunshine Coast, QLD, Australia.
| | - Sean Coffey
- Department of Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Gillian A Whalley
- Department of Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
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17
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Grandi A, Carta N, Cambiaghi T, Bilman V, Melissano G, Chiesa R, Bertoglio L. Sex-Related Anatomical Feasibility Differences in Endovascular Repair of Thoracoabdominal Aortic Aneurysms With a Multibranched Stent-Graft. J Endovasc Ther 2020; 28:283-294. [DOI: 10.1177/1526602820964916] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Purpose: To evaluate the potential anatomical feasibility of using the off-the-shelf multibranched Zenith t-Branch for the treatment of thoracoabdominal aortic aneurysms (TAAAs) in female patients. Materials and Methods: A total of 268 patients (median age 68 years; 69 women) with degenerative TAAA treated at a single institution by means of open or endovascular repair between 2007 and 2019 were retrospectively analyzed to determine the feasibility of using the Zenith t-Branch based on the manufacturer’s instructions for use. The factors determining overall anatomical feasibility were divided into vascular access, aortic anatomy, and visceral vessels. The results were stratified by sex and compared. A logistic regression model was constructed to determine any association between feasibility and clinical factors or potential confounding variables; results are expressed as the odds ratio (OR) with 95% confidence interval (CI). Results: The overall anatomical feasibility was 39% (22% women vs 45% men, p=0.001). The feasibility was negatively influenced by female sex (p<0.001) in multivariable analysis (OR 2.9, 95% CI 1.5 to 5.4, p=0.001). Vascular access feasibility was 82% (61% women vs 89% men, p<0.001). Aorta feasibility was 65% (52% women vs 69% men, p<0.001), and visceral vessel feasibility was 74% (78% women vs 73% men, p=0.260). An access diameter ≤8.5 mm excluded 17% of the patients (39% women vs 9% men, p<0.001). The aortic feasibility was limited by the infrarenal aortic diameter in 16% of patients (45% women vs 6% men, p<0.001) and the aortic lumen at the visceral vessels in 17% patients (19% women vs 17% men, p=0.741). The visceral vessel feasibility was mainly limited by inadequate numbers or diameters of target vessels. Location and orientation of the target vessels were adequate in 96% of patients. Conclusion: A little more than a third of an all-comers cohort of patients with degenerative TAAA could have been treated with on-label use of the Zenith t-Branch. However, only 22% of women could have been treated because of sex-related anatomical limitations. New generations of multibranched devices should address these differences.
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Affiliation(s)
- Alessandro Grandi
- Division of Vascular Surgery, “Vita-Salute” San Raffaele University, Milan, Italy
| | - Niccolò Carta
- Division of Vascular Surgery, “Vita-Salute” San Raffaele University, Milan, Italy
| | - Tommaso Cambiaghi
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, TX, USA
| | - Victor Bilman
- Cirurgia Vascular e Endovascular, Pontifícia Universidade Católica do Rio de Janeiro, Brazil
| | - Germano Melissano
- Division of Vascular Surgery, “Vita-Salute” San Raffaele University, Milan, Italy
| | - Roberto Chiesa
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Luca Bertoglio
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
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18
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Baumgartner H, Iung B, Otto CM. Timing of intervention in asymptomatic patients with valvular heart disease. Eur Heart J 2020; 41:4349-4356. [DOI: 10.1093/eurheartj/ehaa485] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 04/08/2020] [Accepted: 05/24/2020] [Indexed: 01/12/2023] Open
Abstract
Abstract
Current management of valvular heart disease (VHD) seeks to optimize long-term outcome by timely intervention. Recommendations for treatment of patients with symptoms due to severe valvular disease are based on a foundation of solid evidence. However, when to intervene in asymptomatic patients remains controversial and decision requires careful individual weighing of the potential benefits against the risk of intervention and its long-term consequences. The primary rationale for earlier intervention is prevention of irreversible left ventricular (LV) myocardial changes that might result in later clinical symptoms and adverse cardiac events. A number of outcome predictors have been identified that facilitate decision-making. This review summarizes current recommendations and discusses recently published data that challenge them suggesting even earlier intervention. In adults with asymptomatic aortic stenosis (AS), emerging risk markers include very severe valve obstruction, elevated serum natriuretic peptide levels, and imaging evidence of myocardial fibrosis or increased extracellular myocardial volume. Currently, transcatheter aortic valve implantation (TAVI) is not recommended for treatment of asymptomatic severe AS although this may change in the future. In patients with aortic regurgitation (AR), the potential benefit of early intervention in preventing LV dilation and dysfunction must be balanced against the long-term risk of a prosthetic valve, a particular concern because severe AR often occurs in younger patients with a congenital bicuspid valve. In patients with mitral stenosis, the option of transcatheter mitral balloon valvotomy tilts the balance towards earlier intervention to prevent atrial fibrillation, embolic events, and pulmonary hypertension. When chronic severe mitral regurgitation is due to mitral valve prolapse, anatomic features consistent with a high likelihood of a successful and durable valve repair favour early intervention. The optimal timing of intervention in adults with VHD is a constantly changing threshold that depends not only on the severity of valve disease but also on the safety, efficacy, and long-term durability of our treatment options.
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Affiliation(s)
- Helmut Baumgartner
- Department of Cardiology III – Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building A1, 48149 Muenster, Germany
| | - Bernard Iung
- Cardiology Department, Bichat Hospital, APHP, Université de Paris, 46 Rue Henri Huchard, 75018 Paris, France
| | - Catherine M Otto
- Cardiology, University of Washington Medical Center, 1959 NE Pacific St, Seattle, WA 98195, USA
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Barbieri A, Benfari G, Giubertoni E, Manicardi M, Bursi F, Rossi A, Maritan L, Venturi G, Boriani G. Degree of left ventricular dilatation at end-diastole: Correlation and prognostic utility of quantitative volumes by 2D-echocardiography versus linear dimensions in patients with asymptomatic aortic regurgitation. Echocardiography 2020; 37:1336-1344. [PMID: 32757465 DOI: 10.1111/echo.14815] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 07/19/2020] [Accepted: 07/19/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Guideline recommendations for aortic valve replacement (AVR) in asymptomatic patients with chronic aortic regurgitation (AR) have historically focused on linear dimensions without normalization for the body surface area (BSA). Values for grading the severity of end-diastolic volume dilatation by 2D echocardiography remain to be established. METHODS AND RESULTS We retrospectively analyzed 543 consecutive asymptomatic patients with pure chronic moderate/severe AR (mean age 66 ± 17 years, 37.7% males). Applying the ASE/EACVI guidelines, BSA-indexed LV end-diastolic volume (LVEDVi) and indexed LV end-diastolic diameter (LVEDDi) were assessed. Then, we identified 192 patients with at least mild LV end-diastolic dilatation by volumetric or linear measurements. The outcome endpoint was the combination of cardiac death, hospitalization for acute heart failure or AVR during a median follow-up of 4.5 ± 3.6 years. Multivariable Cox regression analyses including age, LV ejection fraction (EF) and AR severity showed an independent prognostic value of the LVEDDi and LVEDVi (P < .001 and P < .01, respectively). Congruent severe LVEDDi and LVEDVi dilatation was associated with a higher event rate compared to discordant severe LV end-diastolic dilatation or nonsevere LV dilatation (P = .001) even after landmark analysis (P = .02). In patients with EF > 50%, only the LVEDVi showed and independent prognostic value (P < .001). CONCLUSIONS In a cohort of asymptomatic patients with AR, the presence of severe LV volume and diameter dilatation on the basis of the cutoff values proposed by current recommendations and normalized for BSA may be instrumental in the identification of patients at increased risk of clinical progression regardless of EF.
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Affiliation(s)
- Andrea Barbieri
- Division of Cardiology, Department of Diagnostics, Clinical and Public Health Medicine, Policlinico University Hospital of Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Giovanni Benfari
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Elisa Giubertoni
- Division of Cardiology, Department of Diagnostics, Clinical and Public Health Medicine, Policlinico University Hospital of Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Marcella Manicardi
- Division of Cardiology, Department of Diagnostics, Clinical and Public Health Medicine, Policlinico University Hospital of Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Francesca Bursi
- Division of Cardiology, Department of Diagnostics, Clinical and Public Health Medicine, Policlinico University Hospital of Modena, University of Modena and Reggio Emilia, Modena, Italy.,Division of Cardiology, Heart and Lung Department, San Paolo Hospital, ASST Santi Paolo and Carlo, University of Milan, Milan, Italy
| | - Andrea Rossi
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Luca Maritan
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Gabriele Venturi
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Giuseppe Boriani
- Division of Cardiology, Department of Diagnostics, Clinical and Public Health Medicine, Policlinico University Hospital of Modena, University of Modena and Reggio Emilia, Modena, Italy
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20
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Nitsche C, Koschutnik M, Kammerlander A, Hengstenberg C, Mascherbauer J. Gender-specific differences in valvular heart disease. Wien Klin Wochenschr 2020; 132:61-68. [PMID: 31997064 PMCID: PMC7035223 DOI: 10.1007/s00508-019-01603-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Accepted: 12/18/2019] [Indexed: 11/29/2022]
Abstract
The development of new devices and treatment options has greatly increased the interest in heart valve diseases. In this context, the consideration of gender differences in diagnosis, treatment success, and prognosis is of great importance. Available data show that women and men with heart valve disease have different risk profiles, which have a significant impact on treatment outcomes and prognosis. It is the purpose of this review article to give an overview of gender-related differences in patients with valvular heart disease, regarding clinical presentation, treatment, and outcomes. In light of the emerging treatment possibilities, future research should emphasize the role of gender since both sexes benefit from tailored management.
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Affiliation(s)
- Christian Nitsche
- Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Matthias Koschutnik
- Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Andreas Kammerlander
- Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Christian Hengstenberg
- Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Julia Mascherbauer
- Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
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Kočková R, Línková H, Hlubocká Z, Pravečková A, Polednová A, Súkupová L, Bláha M, Malý J, Honsová E, Sedmera D, Pěnička M. New Imaging Markers of Clinical Outcome in Asymptomatic Patients with Severe Aortic Regurgitation. J Clin Med 2019; 8:jcm8101654. [PMID: 31614523 PMCID: PMC6832544 DOI: 10.3390/jcm8101654] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 10/03/2019] [Accepted: 10/06/2019] [Indexed: 01/19/2023] Open
Abstract
Background: Determining the value of new imaging markers to predict aortic valve (AV) surgery in asymptomatic patients with severe aortic regurgitation (AR) in a prospective, observational, multicenter study. Methods: Consecutive patients with chronic severe AR were enrolled between 2015–2018. Baseline examination included echocardiography (ECHO) with 2- and 3-dimensional (2D and 3D) vena contracta area (VCA), and magnetic resonance imaging (MRI) with regurgitant volume (RV) and fraction (RF) analyzed in CoreLab. Results: The mean follow-up was 587 days (interquartile range (IQR) 296–901) in a total of 104 patients. Twenty patients underwent AV surgery. Baseline clinical and laboratory data did not differ between surgically and medically treated patients. Surgically treated patients had larger left ventricular (LV) dimension, end-diastolic volume (all p < 0.05), and the LV ejection fraction was similar. The surgical group showed higher prevalence of severe AR (70% vs. 40%, p = 0.02). Out of all imaging markers 3D VCA, MRI-derived RV and RF were identified as the strongest independent predictors of AV surgery (all p < 0.001). Conclusions: Parameters related to LV morphology and function showed moderate accuracy to identify patients in need of early AV surgery at the early stage of the disease. 3D ECHO-derived VCA and MRI-derived RV and RF showed high accuracy and excellent sensitivity to identify patients in need of early surgery.
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Affiliation(s)
- Radka Kočková
- Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague 14021, Czech Republic.
- Faculty of Medicine in Hradec Králové, Charles University, Šimkova 870, Hradec Králové 500 03, Czech Republic.
| | - Hana Línková
- Department of Cardiology, Royal Vinohrady University Hospital, Prague 10034, Czech Republic.
| | - Zuzana Hlubocká
- Department of Cardiology, General University Hospital, Prague 12808, Czech Republic.
| | - Alena Pravečková
- Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague 14021, Czech Republic.
| | - Andrea Polednová
- Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague 14021, Czech Republic.
| | - Lucie Súkupová
- Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague 14021, Czech Republic.
| | - Martin Bláha
- Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague 14021, Czech Republic.
| | - Jiří Malý
- Department of Cardiothoracic surgery, Institute for Clinical and Experimental Medicine, Prague 14021, Czech Republic.
| | - Eva Honsová
- Institute for Clinical and Experimental Medicine, Clinical and Transplant Pathology Centre, Prague 14021, Czech Republic.
| | - David Sedmera
- First Faculty of Medicine, Institute of Anatomy, Charles University in Prague, Prague 12800, Czech Republic.
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Yang LT, Michelena HI, Scott CG, Enriquez-Sarano M, Pislaru SV, Schaff HV, Pellikka PA. Outcomes in Chronic Hemodynamically Significant Aortic Regurgitation and Limitations of Current Guidelines. J Am Coll Cardiol 2019; 73:1741-1752. [DOI: 10.1016/j.jacc.2019.01.024] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 12/18/2018] [Accepted: 01/07/2019] [Indexed: 12/19/2022]
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23
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Girardi LN, Leonard JR, Lau C, Ohmes LB, Gambardella I, Iannacone EM, Munjal M, Schwann AN, Gaudino MF. Gender-related outcomes after open repair of descending thoracic and thoracoabdominal aortic aneurysms. J Vasc Surg 2019; 69:1028-1035.e1. [DOI: 10.1016/j.jvs.2018.06.213] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 06/13/2018] [Indexed: 11/17/2022]
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24
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Kislitsina ON, Zareba KM, Bonow RO, Andrei AC, Kruse J, Puthumana J, Akhter N, Chris Malaisrie S, McCarthy PM, Rigolin VH. Is mitral valve disease treated differently in men and women? Eur J Prev Cardiol 2019; 26:1433-1443. [PMID: 30832507 DOI: 10.1177/2047487319833307] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE This study was performed to determine if there is a sex-based bias in referral practices, complexity of disease, surgical treatment, or outcomes in patients undergoing mitral valve surgery at our institution. METHODS Data were collected from the Cardiovascular Research Database of the Clinical Trial Unit of the Bluhm Cardiovascular Institute at Northwestern Memorial Hospital and they were defined according to the Society of Thoracic Surgeons National Database ( www.sts.org ). All patients who had mitral valve replacement, mitral valve repair with annuloplasty ring placement, and mitral valve annuloplasty alone were evaluated, including patients who underwent concomitant tricuspid valve surgery, atrial fibrillation ablation, patent foramen ovale closure, and coronary artery bypass grafting. An unmatched comparison was made between the 836 men and 600 women in the entire cohort (N = 1436) and propensity score-matching was performed in 423 pairs of men and women. Additional propensity score-matching for 219 pairs of men and women with Type II mitral valve functional class and no coronary artery disease and for 68 pairs of men and women with Type 1 or Type IIIb mitral valve functional class. Propensity score matching was used to compare sex differences involving a greedy algorithm with a caliper of size 0.1 logit propensity score standard deviation units. RESULTS Between 1 April 2004 and 30 June 2017, 1436 patients (41.8% women, mean age 61.1 ± 12.6 years (men), 62.9 ± 13.3 years (women)) underwent mitral valve surgery. The unmatched comparison for the entire cohort showed that, on average, at the time of surgery, women had higher Society of Thoracic Surgery risk scores, were older and had more heart failure, coronary artery disease, and mitral stenosis than men. Women received proportionately fewer mitral repairs and more atrial fibrillation ablation, and tricuspid valve surgery. Women had longer intensive care unit and hospital stays, required more dialysis, and suffered more transient ischemic attacks and cardiac arrests postoperatively, and 30-day mortality rate was higher for women. However, propensity score-matching of 846 of the patients (423 men; 423 women) indicated that both the surgical approaches and surgical outcomes were comparable for men and women who had similar levels of disease and co-morbidities. Additional propensity score-matching of only those patients with degenerative mitral regurgitation (DMR) (219 men; 219 women) and those with Type 1 or Type III mitral valve disease showed no differences in the surgical procedures performed or in 30-day mortality rates. CONCLUSIONS Women appear to be referred for mitral valve surgery later in the course of their disease, which could possibly be on the basis of sex bias, but they may also have a more aggressive form of mitral valve disease than men. Regardless of the reasons for the later referral of women for mitral valve surgery, the clinical outcomes are dependent upon the severity of the mitral disease and associated co-morbidities at the time of surgery, not on the basis of sex bias.
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Affiliation(s)
- Olga N Kislitsina
- Northwestern University Feinberg School of Medicine, Bluhm Cardiovascular Institute, Chicago, IL, USA
| | - Karolina M Zareba
- Northwestern University Feinberg School of Medicine, Bluhm Cardiovascular Institute, Chicago, IL, USA
| | - Robert O Bonow
- Northwestern University Feinberg School of Medicine, Bluhm Cardiovascular Institute, Chicago, IL, USA
| | - Adin-Cristian Andrei
- Northwestern University Feinberg School of Medicine, Bluhm Cardiovascular Institute, Chicago, IL, USA
| | - Jane Kruse
- Northwestern University Feinberg School of Medicine, Bluhm Cardiovascular Institute, Chicago, IL, USA
| | - Jyothy Puthumana
- Northwestern University Feinberg School of Medicine, Bluhm Cardiovascular Institute, Chicago, IL, USA
| | - Nausheen Akhter
- Northwestern University Feinberg School of Medicine, Bluhm Cardiovascular Institute, Chicago, IL, USA
| | - S Chris Malaisrie
- Northwestern University Feinberg School of Medicine, Bluhm Cardiovascular Institute, Chicago, IL, USA
| | - Patrick M McCarthy
- Northwestern University Feinberg School of Medicine, Bluhm Cardiovascular Institute, Chicago, IL, USA
| | - Vera H Rigolin
- Northwestern University Feinberg School of Medicine, Bluhm Cardiovascular Institute, Chicago, IL, USA
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Petitto M, Esposito R, Sorrentino R, Lembo M, Luciano F, De Roberto AM, La Mura L, Pezzullo E, Maffei S, Galderisi M, Lancellotti P. Sex-specific echocardiographic reference values: the women's point of view. J Cardiovasc Med (Hagerstown) 2019; 19:527-535. [PMID: 30015781 DOI: 10.2459/jcm.0000000000000696] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
: Clinical presentation, diagnosis and outcomes of cardiac diseases are influenced by the activity of sex steroid hormones. These hormonal differences explain the later development of heart diseases in women in comparison with men and the different clinical picture, management and prognosis. Echocardiography is a noninvasive and easily available technique for the analysis of cardiac structure and function. The aim of the present review is to underline the most important echocardiographic differences between sexes. Several echocardiographic studies have found differences in healthy populations between women and men. Sex-specific difference of some of these parameters, such as left ventricular (LV) linear dimensions and left atrial volume, can be explained on the grounds of smaller body size of women, but other parameters (LV volumes, stroke volume and ejection fraction, right ventricular size and systolic function) are specifically lower in women, even after adjusting for body size and age. Sex-specific differences of standard Doppler and Tissue Doppler diastolic indices remain controversial, but it is likely for aging to affect LV diastolic function more in women than in men. Global longitudinal strain appears to be higher in women during the childbearing age - a finding that also highlights a possible hormonal influence in women. All these findings have practical implications, and sex-specific reference values are necessary for the majority of echocardiographic parameters in order to distinguish normalcy from disease. Careful attention on specific cut-off points in women could avoid misinterpretation, inappropriate management and delayed treatment of cardiac diseases such as valvular disease and heart failure.
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Affiliation(s)
- Marta Petitto
- Interdepartmental Laboratory of Cardiac Imaging, Department of Advanced Biomedical Sciences, Federico II University Hospital, Naples
| | - Roberta Esposito
- Interdepartmental Laboratory of Cardiac Imaging, Department of Advanced Biomedical Sciences, Federico II University Hospital, Naples
| | - Regina Sorrentino
- Interdepartmental Laboratory of Cardiac Imaging, Department of Advanced Biomedical Sciences, Federico II University Hospital, Naples
| | - Maria Lembo
- Interdepartmental Laboratory of Cardiac Imaging, Department of Advanced Biomedical Sciences, Federico II University Hospital, Naples
| | - Federica Luciano
- Interdepartmental Laboratory of Cardiac Imaging, Department of Advanced Biomedical Sciences, Federico II University Hospital, Naples
| | - Anna Maria De Roberto
- Interdepartmental Laboratory of Cardiac Imaging, Department of Advanced Biomedical Sciences, Federico II University Hospital, Naples
| | - Lucia La Mura
- Interdepartmental Laboratory of Cardiac Imaging, Department of Advanced Biomedical Sciences, Federico II University Hospital, Naples
| | - Enrica Pezzullo
- Interdepartmental Laboratory of Cardiac Imaging, Department of Advanced Biomedical Sciences, Federico II University Hospital, Naples
| | - Silvia Maffei
- Cardiovascular and Gynecological Endocrinology, Fondazione Toscana 'G. Monasterio' for Clinical Research and Public Health, CNR-Regione Toscana, Pisa, Italy
| | - Maurizio Galderisi
- Interdepartmental Laboratory of Cardiac Imaging, Department of Advanced Biomedical Sciences, Federico II University Hospital, Naples
| | - Patrizio Lancellotti
- Department of Cardiology and Cardiovascular Surgery, Heart Valve Clinic, GIGA Cardiovascular Sciences, University of Liège Hospital, CHU Sart Tilman, Liège, Belgium.,Gruppo Villa Maria Care and Research, Anthea Hospital, Bari, Italy
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Sannino A, Szerlip M, Harrington K, Schiattarella GG, Grayburn PA. Comparison of Baseline Characteristics and Outcomes in Men Versus Women With Aortic Stenosis Undergoing Transcatheter Aortic Valve Implantation. Am J Cardiol 2018; 121:844-849. [PMID: 29397106 DOI: 10.1016/j.amjcard.2017.12.020] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 12/10/2017] [Accepted: 12/18/2017] [Indexed: 01/31/2023]
Abstract
Female gender has been linked to increased risk of adverse events after surgical aortic valve replacement; however, the evidence regarding the role of gender differences on clinical outcomes in patients who underwent transcatheter aortic valve implantation (TAVI) is still debated. This retrospective study included 910 consecutive patients with severe, symptomatic aortic stenosis who underwent TAVI in 2 institutions from January 2012 to July 2016. The primary end point was all-cause mortality at 1 year after TAVI in women versus men. Women had a higher incidence of in-hospital vascular complications (7.8% vs 4.1%) and major or life-threatening bleeding (4.0% vs 1.6%) than men. At 1 year, women showed a lower mortality rate than men (7.0% vs 12.7%, adjusted hazard ratio [HR] 0.42, 95% confidence interval [CI] [0.23 to 0.76], p = 0.004). When stratifying by specific subgroups of interest, the survival benefit in women persisted in (1) patients with a Society of Thoracic Surgery risk score ≤ 8 (adjusted HR 0.35, 95% CI [0.14 to 0.88], p = 0.026); (2) patients treated with first-generation devices (adjusted HR 0.46, 95% CI [0.24 to 0.86], p = 0.016); and (3) patients treated with balloon-expandable valves (adjusted HR 0.40, 95% CI [0.19 to 0.86], p = 0.019). In conclusion, in this large patient cohort, women had lower 1-year mortality after TAVI than men, particularly with an STS score ≤ 8, or treated with first-generation and balloon-expandable devices.
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Affiliation(s)
- Anna Sannino
- Baylor Heart and Vascular Hospital, Baylor University Medical Center, Dallas, Texas
| | - Molly Szerlip
- Cardiology Section, The Heart Hospital Baylor Plano, Plano, Texas
| | | | | | - Paul A Grayburn
- Baylor Heart and Vascular Hospital, Baylor University Medical Center, Dallas, Texas.
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27
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Sex-Specific Outcomes of Transcatheter Aortic Valve Replacement With the SAPIEN 3 Valve. JACC Cardiovasc Interv 2018; 11:13-20. [DOI: 10.1016/j.jcin.2017.09.035] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 09/26/2017] [Accepted: 09/28/2017] [Indexed: 01/10/2023]
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28
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Triki F, Jdidi J, Abid D, Tabbabi N, Charfeddine S, Ben Kahla S, Hentati M, Abid L, Kammoun S. Characteristics, aetiological spectrum and management of valvular heart disease in a Tunisian cardiovascular centre. Arch Cardiovasc Dis 2017; 110:439-446. [DOI: 10.1016/j.acvd.2016.08.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 07/01/2016] [Accepted: 08/01/2016] [Indexed: 12/31/2022]
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Spiliotopoulos K, Price MD, Amarasekara HS, Green SY, Zhang Q, Preventza O, Coselli JS, LeMaire SA. Are outcomes of thoracoabdominal aortic aneurysm repair different in men versus women? A propensity-matched comparison. J Thorac Cardiovasc Surg 2017; 154:1203-1214.e6. [PMID: 28668459 DOI: 10.1016/j.jtcvs.2017.05.089] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 04/12/2017] [Accepted: 05/07/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Women fare worse than men after many cardiovascular operations, including coronary artery bypass grafting and valve surgery. We sought to determine whether sex affects outcomes after open thoracoabdominal aortic aneurysm repair. METHODS We evaluated data on 3353 consecutive patients (1281 women, 38.2%) who underwent open thoracoabdominal aortic aneurysm repair between October 1986 and July 2015. We compared preoperative characteristics, surgical variables, and outcomes between men and women in the overall group. A propensity-matching analysis was performed to adjust for preoperative and intraoperative differences. A multivariable analysis was conducted to identify predictors of poor outcomes using relevant preoperative and intraoperative factors. RESULTS Men had a significantly higher prevalence of comorbid conditions, including coronary artery disease, and presented more often with dissection; women were slightly older than men (median age, 69 [62-74] years vs 67 [57-73] years; P < .001) and more often symptomatic. Men underwent extent II and IV repairs more often, whereas women more often had extent I and III repairs. The propensity analysis resulted in 958 matched pairs. Overall, women and men had similar early mortality (7.9% vs 7.2%, P = .5) and adverse event rates (14.8% vs 14.1%, P = .6), which were similar in propensity-matched groups. Multivariable analysis showed that predictors of operative death and adverse event differed between the sexes. Survival and freedom from repair failure were similar between the overall and matched groups. CONCLUSIONS Men and women who undergo thoracoabdominal aortic aneurysm repair have similar outcomes, but there are important differences in several perioperative factors and predictors of poor outcomes.
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Affiliation(s)
- Konstantinos Spiliotopoulos
- Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex; CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Tex
| | - Matt D Price
- Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex; Surgical Research Core, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Hiruni S Amarasekara
- Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex; Surgical Research Core, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Susan Y Green
- Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex; Surgical Research Core, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Qianzi Zhang
- Cardiovascular Research Institute, Baylor College of Medicine, Houston, Tex
| | - Ourania Preventza
- Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex; CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Tex; Cardiovascular Research Institute, Baylor College of Medicine, Houston, Tex
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex; CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Tex; Cardiovascular Research Institute, Baylor College of Medicine, Houston, Tex
| | - Scott A LeMaire
- Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex; CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Tex; Surgical Research Core, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Cardiovascular Research Institute, Baylor College of Medicine, Houston, Tex.
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Michelena HI, Suri RM, Katan O, Eleid MF, Clavel MA, Maurer MJ, Pellikka PA, Mahoney D, Enriquez-Sarano M. Sex Differences and Survival in Adults With Bicuspid Aortic Valves: Verification in 3 Contemporary Echocardiographic Cohorts. J Am Heart Assoc 2016; 5:e004211. [PMID: 27688238 PMCID: PMC5121517 DOI: 10.1161/jaha.116.004211] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Accepted: 09/01/2016] [Indexed: 11/21/2022]
Abstract
BACKGROUND Sex-related differences in morbidity and survival in bicuspid aortic valve (BAV) adults are fundamentally unknown. Contemporary studies portend excellent survival for BAV patients identified at early echocardiographic-clinical stages. Whether BAV adults incur a survival disadvantage throughout subsequent echocardiographic-clinical stages remains undetermined. METHODS AND RESULTS Analysis was done of 3 different cohorts of consecutive patients with echocardiographic diagnosis of BAV identified retrospectively: (1) a community cohort of 416 patients with first BAV diagnosis (age 35±21 years, follow-up 16±7 years), (2) a tertiary clinical referral cohort of 2824 BAV adults (age 51±16 years, follow-up 9±6 years), and (3) a surgical referral cohort of 2242 BAV adults referred for aortic valve replacement (AVR) (age 62±14 years, follow-up 6±5 years). For the community cohort, 20-year risks of aortic regurgitation (AR), AVR, and infective endocarditis were higher in men (all P≤0.04); for a total BAV-related morbidity risk of 52±4% vs 35±6% in women (P=0.01). The cohort's 25-year survival was identical to that in the general population (P=0.98). AR independently predicted mortality in women (P=0.001). Baseline AR was more common in men (P≤0.02) in the tertiary cohort, with 20-year survival lower than that in the general population (P<0.0001); age-adjusted relative death risk was 1.16 (95% confidence interval [CI] 1.05-1.29) for men versus 1.67 (95% CI 1.38-2.03) for women (P=0.001). AR independently predicted mortality in women (P=0.01). Baseline AR and infective endocarditis were higher in men (both ≤0.001) for the surgical referral cohort, with 15-year survival lower than that in the general population (P<0.0001); age-adjusted relative death risk was 1.34 (95% CI 1.22-1.47) for men versus 1.63 (95% CI 1.40-1.89) for women (P=0.026). AR and NYHA class independently predicted mortality in women (both P≤0.04). CONCLUSIONS Within evolving echocardiographic-clinical stages, the long-term survival of adults with BAV is not benign, as both men and women incur excess mortality. Although BAV-related morbidity is higher in men in the community, and AR and infective endocarditis are more prevalent in men, women exhibit a significantly higher relative risk of death in tertiary and surgical referral cohorts, which is independently associated with AR.
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Affiliation(s)
| | - Rakesh M Suri
- Division of Cardiovascular Surgery, Cleveland Clinic, Abu Dhabi, United Arab Emirates
| | - Ognjen Katan
- Division of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Mackram F Eleid
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | | | - Mathew J Maurer
- Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | | | - Douglas Mahoney
- Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
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Dhurandhar V, Parikh R, Saxena A, Vallely MP, Wilson MK, Black DA, Tran L, Reid C, Bannon PG. Early and Late Outcomes Following Valve Sparing Aortic Root Reconstruction: The ANZSCTS Database. Heart Lung Circ 2016; 25:505-11. [DOI: 10.1016/j.hlc.2015.10.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2014] [Revised: 09/20/2015] [Accepted: 10/27/2015] [Indexed: 10/22/2022]
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32
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Mantovani F, Clavel MA, Michelena HI, Suri RM, Schaff HV, Enriquez-Sarano M. Comprehensive Imaging in Women With Organic Mitral Regurgitation. JACC Cardiovasc Imaging 2016; 9:388-96. [DOI: 10.1016/j.jcmg.2016.02.017] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 02/19/2016] [Accepted: 02/25/2016] [Indexed: 11/25/2022]
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33
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Long Term Follow-Up After Aortic Valve Replacement (Ross Procedure): Echocardiographic Determinants of Ventricular Recovery. Heart Lung Circ 2014; 23:132-43. [DOI: 10.1016/j.hlc.2013.07.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2010] [Revised: 06/28/2013] [Accepted: 07/10/2013] [Indexed: 11/21/2022]
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34
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Thuny F, Giorgi R, Habachi R, Ansaldi S, Le Dolley Y, Casalta JP, Avierinos JF, Riberi A, Renard S, Collart F, Raoult D, Habib G. Excess mortality and morbidity in patients surviving infective endocarditis. Am Heart J 2012; 164:94-101. [PMID: 22795288 DOI: 10.1016/j.ahj.2012.04.003] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2011] [Accepted: 04/12/2012] [Indexed: 06/01/2023]
Abstract
BACKGROUND Mortality and morbidity associated with infective endocarditis may extend beyond successful treatment. The primary objective was to analyze rates, temporal changes, and predictors of excess mortality in patients surviving the acute phase of endocarditis. The secondary objective was to determine the rate of recurrence and the need for late cardiac surgery. METHODS An observational cohort study was conducted at a university-affiliated tertiary medical center, among 328 patients who survived the active phase of endocarditis. We used age-, sex-, and calendar year-specific mortality hazard rates of the Bouches-du-Rhone French district population to calculate expected survival and excess mortality. The risk of recurrence and late valve surgery was also assessed. RESULT Compared with expected survival, patients surviving a first episode of endocarditis had significantly worse outcomes (P = .001). The relative survival rates at 1, 3, and 5 years were 92% (95% CI, 88%-95%), 86% (95% CI, 77%-92%), and 82% (95% CI, 59%-91%), respectively. This excess mortality was observed during the entire follow-up period but was the highest during the first year after hospital discharge. Most of the recurrences and late cardiac surgeries also occurred during this period. Women exhibited a higher risk of age-adjusted excess mortality (adjusted excess hazard ratio, 2.0; 95% CI, 1.05-3.82; P = .03). Comorbidity index, recurrence of endocarditis, and history of an aortic valve endocarditis in women were independent predictors of excess mortality. CONCLUSIONS These results justify close monitoring of patients after successful treatment of endocarditis, at least during the first year. Special attention should be paid to women with aortic valve damage.
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Affiliation(s)
- Franck Thuny
- Département de Cardiologie, Hôpital La Timone, Aix-Marseille Université, Marseille, France.
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Enache R, Antonini-Canterin F, Piazza R, Popescu BA, Leiballi E, Marinigh R, Andriani C, Pecoraro R, Ginghina C, Nicolosi GL. CME: long-term outcome in asymptomatic patients with severe aortic regurgitation, normal left ventricular ejection fraction, and severe left ventricular dilatation. Echocardiography 2011; 27:915-22. [PMID: 20572853 DOI: 10.1111/j.1540-8175.2010.01193.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Although the guidelines consider severe left ventricular (LV) dilatation a class IIaC indication for surgery in asymptomatic patients with severe aortic regurgitation (AR) and normal LV function, the optimal management remains controversial. We aimed to assess the LV enlargement, hypertrophy and function, and the outcomes in these patients by the presence of severe LV dilatation at baseline. METHODS From our 20-year database, we identified all asymptomatic patients with severe AR and LV ejection fraction (EF) >50% and ≥2 echocardiograms ≥1 year apart. LV end-diastolic diameter >70 mm or LV end-systolic diameter >50 mm or LV end-systolic diameter index >25 mm/m(2) defined severe LV dilatation. A composite end point included onset of symptoms or LV dysfunction. RESULTS Eighty-four patients (52 ± 18 years, 61 men) were enrolled and followed-up for 7.1 ± 5.1 years. Two groups were defined: 22 patients with and 62 patients without severe LV dilatation at baseline. The progression of LV dilatation and hypertrophy, and the LVEF at last exam were similar in both groups. Twelve of 22 and 34 of 62 patients (P = 0.59) reached the end point. Vasodilators did not modify the progression of LV enlargement/hypertrophy. Ten of 22 and 25 of 62 patients (P = 0.45) underwent surgery and had similar postoperative LV diameters, mass, EF. CONCLUSIONS The progression of LV enlargement/hypertrophy and outcomes in asymptomatic patients with severe AR, normal LV function, and severe LV dilatation or the postoperative LV parameters were not influenced by the severe LV dilatation, suggesting that a close follow-up could delay surgery in this population.
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Affiliation(s)
- Roxana Enache
- Cardiology ARC, S. Maria degli Angeli Hospital, Via Montereale 24, Pordenone, Italy
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Helin LM, Tamás É, Nylander E. Preoperative Longitudinal Left Ventricular Function by Tissue Doppler Echocardiography at Rest and During Exercise Is Valuable in Timing of Aortic Valve Surgery in Male Aortic Regurgitation Patients. J Am Soc Echocardiogr 2010; 23:387-95. [DOI: 10.1016/j.echo.2010.01.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2009] [Indexed: 10/19/2022]
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Detaint D, Messika-Zeitoun D, Maalouf J, Tribouilloy C, Mahoney DW, Tajik AJ, Enriquez-Sarano M. Quantitative echocardiographic determinants of clinical outcome in asymptomatic patients with aortic regurgitation: a prospective study. JACC Cardiovasc Imaging 2009; 1:1-11. [PMID: 19356398 DOI: 10.1016/j.jcmg.2007.10.008] [Citation(s) in RCA: 106] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2007] [Revised: 10/11/2007] [Accepted: 10/18/2007] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The purpose of this study was to define the link between aortic regurgitation (AR) quantitation and clinical outcome in asymptomatic patients with AR. BACKGROUND Quantitative American Society of Echocardiography (QASE) thresholds are recommended for AR assessment, but impact on clinical outcome is unknown. METHODS We prospectively enrolled (1991 to 2003) 251 asymptomatic patients (age 60 +/- 17 years) with isolated AR and ejection fraction > or =50% with quantified AR and left ventricular (LV) volumes using Doppler-echocardiography. RESULTS Survival under medical management was independently determined by baseline regurgitant volume (RVol) (adjusted hazard ratio [HR] 1.22 [95% confidence interval (CI) 1.08 to 1.35] per 10 ml/beat, p = 0.002) and effective regurgitant orifice (ERO) (adjusted HR 1.52 [95% CI 1.19 to 1.91] per 10 mm(2), p = 0.002), which superseded traditional AR grading. Patients with QASE-severe AR (RVol > or =60 ml/beat or ERO > or =30 mm(2)) versus QASE-mild AR (RVol <30 ml and ERO <10 mm(2)) had lower survival (10 years: 69 +/- 9% vs. 92 +/- 4%, p = 0.05) independently of all clinical characteristics (adjusted HR 4.1 [95% CI 1.4 to 14.1], p = 0.01) and lower survival free of surgery for AR (10 years: 20 +/- 5% vs. 92 +/- 4%, p < 0.001, adjusted HR 12.9 [95% CI 5.4 to 38.5]). Cardiac events were considerably more frequent with QASE-severe versus -moderate or -mild AR (10 years: 63 +/- 8% vs. 34 +/- 6% and 21 +/- 8%, p < 0.0001). Independent determinants of cardiac events were quantitative AR grading (QASE-severe adjusted HR 5.2 [95% CI 2.2 to 14.8], p < 0.001; QASE-moderate adjusted HR 2.4 [95% CI 1.06 to 6.6], p = 0.035), which superseded traditional AR assessment (p < 0.001) and LV end-systolic volume index (ESVI) (adjusted HR 1.09 [95% CI 1.03 to 1.14 per 10 ml/m(2)], p = 0.002), which superseded LV M-mode diameters. In QASE-severe AR, patients with ESVI > or =45 versus <45 ml/m(2) had higher cardiac event rates (10 years: 87 +/- 8% vs. 40 +/- 10%, p < 0.001). Cardiac surgery for AR reduced cardiac events in patients with QASE-severe AR (adjusted HR 0.23 [95% CI 0.09 to 0.57], p = 0.002). CONCLUSIONS Echocardiographic quantitation of AR severity and ESVI provides independent and superior predictors of clinical outcome in asymptomatic patients with AR and ejection fraction > or =50% and should be widely clinically applied. Patients with QASE-severe AR and ESVI > or =45 ml/m(2) should be carefully considered for cardiac surgery, which reduces cardiac events risk.
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Affiliation(s)
- Delphine Detaint
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA
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Indexed Left Ventricular Dimensions Best Predict Survival After Aortic Valve Replacement in Patients With Aortic Valve Regurgitation. Ann Thorac Surg 2009; 87:1170-5; discussion 1175-6. [DOI: 10.1016/j.athoracsur.2008.12.086] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2008] [Revised: 12/22/2008] [Accepted: 12/26/2008] [Indexed: 11/21/2022]
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Hamed O, Persson PJ, Engel AM, McDonough S, Smith JM. Gender differences in outcomes following aortic valve replacement surgery. Int J Surg 2009; 7:214-7. [PMID: 19332158 DOI: 10.1016/j.ijsu.2009.03.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2009] [Accepted: 03/23/2009] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The objective of this study was to assess outcome differences in aortic valve replacement based on gender. METHODS A study from a ten-year hospitalization cohort with prospective data collection was conducted. Included in the study were patients undergoing aortic valve replacement surgery between March 1997 and July 2003 (N=406). There were 223 males and 183 females included in the study. The study examined 41 potential confounding risk factors and 16 outcome variables. RESULTS Univariate analysis on potential confounding risk factors revealed a significant difference between males and females on 12 factors. Co-morbid disease, hypertension, current vascular disease, aortic insufficiency, body surface area, blood added on pump, and annulus size significantly correlated with age. The correlation resulted in five confounding risk factors: age, tobacco history, obesity, left ventricular hypertrophy, and creatinine level. Logistic regression analysis found that after controlling for age, tobacco history, obesity, left ventricular hypertrophy, and creatinine level, there is no difference between males and females on outcomes following aortic valve replacement. Additionally, choice of vascular prosthesis had no impact on post-operative outcomes. CONCLUSION After controlling for confounding variables, similar outcomes were observed for males and females undergoing aortic valve replacement.
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Affiliation(s)
- Osama Hamed
- Department of Surgery, Good Samaritan Hospital, Cincinnati, OH 45220, USA.
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Aboud A, Breuer M, Bossert T, Gummert JF. Quality of Life after Mechanical vs. Biological Aortic Valve Replacement. Asian Cardiovasc Thorac Ann 2009; 17:35-8. [DOI: 10.1177/0218492309102522] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
To assess the quality of life after biological and mechanical aortic valve replacement, data of 136 patients were assessed retrospectively after 2 years of follow-up. Bioprostheses were implanted in 53 patients with a mean age of 74 years, and mechanical prostheses were used in 83 with a mean age of 64 years; there were 47 women and 89 men. Quality of life was evaluated using the Short Form 36-Item Health Survey questionnaire. Physical function scores were significantly better in patients with a mechanical prosthesis. Mental health indices were identical in both groups. Younger patients with mechanical valves and older patients with biological valves had significantly better item scores. In all age groups, men tended to have better scores than women, but a significant difference was noted only in the physical functioning index. The quality of life in patients with mechanical and biological valves was similar at 2 years postoperatively.
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Affiliation(s)
- Anas Aboud
- Department of Cardiothoracic Surgery, Herz- und Diabeteszentrum NRW, Bad Oeynhausen, Germany
| | - Martin Breuer
- Department of Cardiothoracic Surgery, Friedrich Schiller University, Jena, Germany
| | - Torsten Bossert
- Department of Cardiothoracic Surgery, Friedrich Schiller University, Jena, Germany
| | - Jan F Gummert
- Department of Cardiothoracic Surgery, Herz- und Diabeteszentrum NRW, Bad Oeynhausen, Germany
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Stewart WJ. Criteria for Operative Intervention in Valvular Heart Disease Based on Echocardiography. Echocardiography 2009. [DOI: 10.1007/978-1-84882-293-1_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Detaint D, Maalouf J, Tribouilloy C, Mahoney DW, Schaff HV, Tajik AJ, Enriquez-Sarano M. Congestive heart failure complicating aortic regurgitation with medical and surgical management: A prospective study of traditional and quantitative echocardiographic markers. J Thorac Cardiovasc Surg 2008; 136:1549-57. [DOI: 10.1016/j.jtcvs.2008.07.036] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2008] [Revised: 06/10/2008] [Accepted: 07/22/2008] [Indexed: 01/09/2023]
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Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O'Gara PT, O'Rourke RA, Otto CM, Shah PM, Shanewise JS, Nishimura RA, Carabello BA, Faxon DP, Freed MD, Lytle BW, O'Gara PT, O'Rourke RA, Shah PM. 2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1998 guidelines for the management of patients with valvular heart disease). Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 2008; 52:e1-142. [PMID: 18848134 DOI: 10.1016/j.jacc.2008.05.007] [Citation(s) in RCA: 1058] [Impact Index Per Article: 66.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Sambola A, Tornos P, Ferreira-Gonzalez I, Evangelista A. Prognostic value of preoperative indexed end-systolic left ventricle diameter in the outcome after surgery in patients with chronic aortic regurgitation. Am Heart J 2008; 155:1114-20. [PMID: 18513527 DOI: 10.1016/j.ahj.2007.12.025] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2007] [Accepted: 12/26/2007] [Indexed: 11/26/2022]
Abstract
BACKGROUND End-systolic diameter (ESD) is an important parameter in the prognosis and indication for surgery in chronic aortic regurgitation (AR). It has been suggested that ESD values noncorrected for body surface area (BSA) could be inappropriate in the management of patients with extreme BSA. The aim of the study was to assess the usefulness of indexed ESD (IESD) of the left ventricle in the management of patients with severe isolated chronic AR. METHODS One hundred forty-seven patients underwent surgery for chronic AR and were followed up for a mean of 8 +/- 6 years (1-22 years). A post hoc assessment was made of the prognostic value of preoperative ESD and IESD in different BSA percentiles: group 1, <or= 25th percentile (BSA 1.43-1.68 m(2), n = 40); group 2, >25th percentile and <or=75th percentile (BSA 1.69-1.91 m(2), n = 68); and group 3, >75th percentile (BSA 1.92-2.24 m(2), n = 39). RESULTS Age-adjusted preoperative ESD and IESD were independent predictors of mortality or heart failure in the entire population. Magnitude of the relative risk was slightly greater using preoperative IESD than ESD (HR 1.07, 95% CI 1.01-1.29, P = .017; HR 1.04, 95% CI 1.01-1.08, P = .016). In group 1, the age-adjusted expected mortality rate would drop if IESD of 25 mm/m(2) was used as a surgical criterion instead of ESD 50 mm, from 37.94% to 24.27% at 10 years (P = .002). CONCLUSIONS The use of IESD improves the prediction of unfavorable outcomes after surgery in patients with low BSA but not in those with high BSA. In patients with low BSA, IESD >or=25 mm/m(2) should be used as a cutoff point for surgery rather than ESD >50 mm.
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Aortic regurgitation: disease progression and management. ACTA ACUST UNITED AC 2008; 5:269-79. [DOI: 10.1038/ncpcardio1179] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2007] [Accepted: 01/18/2008] [Indexed: 11/08/2022]
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Sorrell VL, Altbach MI, Kudithipudi V, Squire SW, Goldberg SJ, Klewer SE. Cardiac MRI Is an Important Complementary Tool to Doppler Echocardiography in the Management of Patients with Pulmonary Regurgitation. Echocardiography 2007; 24:316-28. [PMID: 17313649 DOI: 10.1111/j.1540-8175.2006.00395.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Cardiac MRI (CMR) is a noninvasive diagnostic tool with comprehensive capabilities similar to that of two-dimensional echocardiography with Doppler. In addition to the ability to evaluate the etiology and severity of pulmonary valve regurgitation (PR), CMR is well designed to serially monitor the impact of the PR on the right ventricle (RV). Importantly, RV dilation and dysfunction is a critical determinate to time surgical intervention. CMR gives the silent RV, suffering from PR, a voice.
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Affiliation(s)
- Vincent L Sorrell
- Department of Cardiology, University of Arizona, Sarver Heart Center, University Medical Center, Tucson, Arisona 85724-5037, USA.
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Duncan AI, Lin J, Koch CG, Gillinov AM, Xu M, Starr NJ. The impact of gender on in-hospital mortality and morbidity after isolated aortic valve replacement. Anesth Analg 2006; 103:800-8. [PMID: 17000785 DOI: 10.1213/01.ane.0000231890.95212.12] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The objective of our retrospective investigation was to examine the influence of gender on in-hospital mortality and morbidity after isolated aortic valve replacement (AVR). Between January 1993 and June 2002, 2212 patients (782 females, 1430 males) underwent AVR. Propensity matching was used to adjust for numerous differences in baseline characteristics and perioperative variables between groups. Unadjusted in-hospital mortality was higher in females (27 [3.5%] females versus 23 [1.6%] males; P = 0.005). An analysis using 1:1 matching by propensity score did not find a significant difference in in-hospital mortality [OR (95% confidence intervals), 1.0 [0.4, 2.6]; P = 0.99) or overall morbidity (1.4 [0.7, 2.5]; P = 0.29) between groups. Further analyses, including classification of women and men into quintile groups by propensity scores and logistic regression models with propensity score adjustment, found that females were at increased risk for cardiac morbidity [OR (95% CI), 3.4 [1.1, 10.8]; P = 0.038), but not mortality (0.9 [0.3, 2.5]; P = 0.88) nor other morbidities. These results suggest that there is no greater than a 2.5-fold increase in risk for females compared with males undergoing AVR. Female gender, however, may impart increased risk for cardiac morbidity after AVR.
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Affiliation(s)
- Andra Ibrahim Duncan
- Department of Cardiothoracic Anesthesia, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
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Nkomo VT, Gardin JM, Skelton TN, Gottdiener JS, Scott CG, Enriquez-Sarano M. Burden of valvular heart diseases: a population-based study. Lancet 2006; 368:1005-11. [PMID: 16980116 DOI: 10.1016/s0140-6736(06)69208-8] [Citation(s) in RCA: 3120] [Impact Index Per Article: 173.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Valvular heart diseases are not usually regarded as a major public-health problem. Our aim was to assess their prevalence and effect on overall survival in the general population. METHODS We pooled population-based studies to obtain data for 11 911 randomly selected adults from the general population who had been assessed prospectively with echocardiography. We also analysed data from a community study of 16 501 adults who had been assessed by clinically indicated echocardiography. FINDINGS In the general population group, moderate or severe valve disease was identified in 615 adults. There was no difference in the frequency of such diseases between men and women (p=0.90). Prevalence increased with age, from 0.7% (95% CI 0.5-1.0) in 18-44 year olds to 13.3% (11.7-15.0) in the 75 years and older group (p<0.0001). The national prevalence of valve disease, corrected for age and sex distribution from the US 2000 population, is 2.5% (2.2-2.7). In the community group, valve disease was diagnosed in 1505 (1.8% adjusted) adults and frequency increased considerably with age, from 0.3% (0.2-0.3) of the 18-44 year olds to 11.7% (11.0-12.5) of those aged 75 years and older, but was diagnosed less often in women than in men (odds ratio 0.90, 0.81-1.01; p=0.07). The adjusted mortality risk ratio associated with valve disease was 1.36 (1.15-1.62; p=0.0005) in the population and 1.75 (1.61-1.90; p<0.0001) in the community. INTERPRETATION Moderate or severe valvular diseases are notably common in this population and increase with age. In the community, women are less often diagnosed than are men, which could indicate an important imbalance in view of the associated lower survival. Valve diseases thus represent an important public-health problem.
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