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Vogl B, Sularz A, Lilly S, Thourani VH, Lindman BR, Alkhouli M, Hatoum H. Effect of Blood Pressure Levels on Sinus Hemodynamics in Relation to Calcification After Bioprosthetic Aortic Valve Replacement. Ann Biomed Eng 2024; 52:888-897. [PMID: 38157105 DOI: 10.1007/s10439-023-03426-4] [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: 08/29/2023] [Accepted: 12/11/2023] [Indexed: 01/03/2024]
Abstract
Coexisting hypertension and aortic stenosis are common. Some studies showed that elevated blood pressures may be associated with progression of calcific aortic valve disease (CAVD) while others showed no correlation. Flow dynamics in the sinuses of Valsalva are considered key factors in the progression of CAVD. While the relationship between hemodynamics and CAVD is not yet fully understood, it has been demonstrated that they are tightly correlated. This study aims to investigate the effect of changing systolic and diastolic blood pressures (SBP and DBP, respectively) on sinus hemodynamics in relation to potential initiation or progression of CAVD after aortic valve replacement (AVR). Evolut R, SAPIEN 3 and Magna valves were deployed in an aortic root under pulsatile conditions. Using particle image velocimetry, the hemodynamics in the sinus were assessed. The velocity, vorticity, circulation ( Γ ) and shear stress were calculated. This study shows that under elevated SBP and DBP, velocity, vorticity, and shear stress nearby the leaflets increased. Additionally, larger fluctuations of Γ and area under the curve throughout the cardiac cycle were observed. Elevated blood pressures are associated with higher velocity, vorticity, and shear stress near the leaflets which may initiate or accelerate pro-calcific changes in the prosthetic leaflets leading to bioprosthetic valve degeneration.
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Affiliation(s)
- Brennan Vogl
- Biomedical Engineering Department, Michigan Technological University, 1400 Townsend Dr, Houghton, MI, 49931, USA
| | - Agata Sularz
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Scott Lilly
- Department of Cardiovascular Medicine, The Ohio State University, Columbus, OH, USA
| | - Vinod H Thourani
- Department of Cardiovascular Surgery, Marcus Valve Center, Piedmont Heart Institute, Atlanta, GA, USA
| | - Brian R Lindman
- Division of Cardiovascular Medicine, Structural Heart and Valve Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Mohamad Alkhouli
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Hoda Hatoum
- Biomedical Engineering Department, Michigan Technological University, 1400 Townsend Dr, Houghton, MI, 49931, USA.
- Health Research Institute, Center of Biocomputing and Digital Health and Institute of Computing and Cybernetics, Michigan Technological University, Houghton, MI, USA.
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2
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Ghahremani-Nasab L, Toufan-Tabrizi M, Javanshir E, Rahimi M. Assessing cardiac power output values in a healthy adult population. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2024; 40:517-526. [PMID: 38085404 DOI: 10.1007/s10554-023-03019-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 11/21/2023] [Indexed: 03/20/2024]
Abstract
Cardiac power output (CPO), which combines pressure and flow capacities, directly measures the heart's pumping capability. It is proposed as a superior alternative to ejection fraction in assessing cardiac function. However, there is a lack of data on CPO in healthy individuals, prompting a study to determine the cardiac power output in healthy adults in the Iranian population. This cross-sectional descriptive study investigated cardiac power in a sample of healthy individuals. Participants were recruited from healthy individuals referred to the Echocardiography department using convenience sampling. In this study, we examined the echocardiographic parameters in 173 individuals, of which 52% were men. Men exhibited significantly higher values for stroke volume, cardiac output, and cardiac power output (CPO) in both ventricles, as well as larger body surface area (BSA) and systemic mean arterial pressure (MAP), compared to women. Individuals under the age of 40 had significantly higher BSA and right ventricular cardiac output compared to those aged 40 or above. Multivariate analysis revealed that MAP, left ventricular (LV) cardiac output, LVCPO, pulmonary MAP, right ventricular (RV) CPO, and RV cardiac power index (CPI) were significant predictors of LVCPI changes. Our findings emphasize the importance of cardiac power output as a comprehensive measure of cardiac function, complementing the traditional use of ejection fraction. Further research is warranted to validate these results, establish accurate reference ranges, and explore the clinical implications of cardiac power output in various patient populations.
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Affiliation(s)
- Leila Ghahremani-Nasab
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Daneshgah Street, Tabriz, Eastern Azerbaijan, Iran
| | - Mehrnoush Toufan-Tabrizi
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Daneshgah Street, Tabriz, Eastern Azerbaijan, Iran.
| | - Elnaz Javanshir
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Daneshgah Street, Tabriz, Eastern Azerbaijan, Iran
| | - Mehran Rahimi
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Daneshgah Street, Tabriz, Eastern Azerbaijan, Iran
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3
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Muacevic A, Adler JR, Oniki T, Nobe S, Takahashi N. Acute Heart Failure in an Almost-Centenarian Patient With Symptomatic Severe Aortic Stenosis Treated With Ivabradine. Cureus 2022; 14:e32142. [PMID: 36601174 PMCID: PMC9805905 DOI: 10.7759/cureus.32142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/02/2022] [Indexed: 12/04/2022] Open
Abstract
We report the case of a 99-year-old woman with acute chest pain caused by myocardial ischemia due to severe aortic stenosis (AS) and severe anemia. Red blood cells were transfused; however, this increased the preload and worsened pulmonary congestion. Treatment with drugs and non-invasive positive pressure ventilation could not sufficiently improve the pulmonary congestion. Ivabradine was administered to control the resting heart rate, following which the pulmonary congestion significantly improved. Ivabradine is a promising drug for acute heart failure of patients with AS by improving cardiac output by prolonging the left ventricular diastolic filling time without a negative inotropic effect.
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Albu A, Para I, Bidian C. Arterial stiffness in aortic stenosis - complex clinical and prognostic implications. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2022; 166:369-379. [PMID: 36128849 DOI: 10.5507/bp.2022.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 08/31/2022] [Indexed: 12/15/2022] Open
Abstract
Arterial stiffness and degenerative aortic stenosis (AoS) are frequently associated leading to a combined valvular and vascular load imposed on the left ventricle (LV). Vascular load consists of a pulsatile load represented by arterial stiffness and a steady load corresponding to vascular resistance. Increased vascular load in AoS has been associated with LV dysfunction and poor prognosis in pre-intervention state, as well as after aortic valve replacement (AVR), suggesting that the evaluation of arterial load in AoS may have clinical benefits. Nevertheless, studies that investigated arterial stiffness in AoS either before or after AVR used various methods of measurement and their results are conflicting. The aim of the present review was to summarize the main pathophysiological mechanisms which may explain the complex valvulo-arterial interplay in AoS and their consequences on LV structure and function on the patients' outcome. Future larger studies are needed to clarify the complex hemodynamic modifications produced by increased vascular load in AoS and its changes after AVR. Prospective evaluation is needed to confirm the prognostic value of arterial stiffness in patients with AoS. Simple, non-invasive, reliable methods which must be validated in AoS still remain to be established before implementing arterial stiffness measurement in patients with AoS in clinical practice.
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Affiliation(s)
- Adriana Albu
- 2nd Department of Internal Medicine, "Iuliu Hatieganu" University of Medicine and Pharmacy, 8 Babes Street, Cluj-Napoca, 400012, Romania
| | - Ioana Para
- 4th Department of Internal Medicine, "Iuliu Hatieganu" University of Medicine and Pharmacy, 8 Babes Street, Cluj-Napoca, 400012, Romania
| | - Cristina Bidian
- Department of Physiology, "Iuliu Hatieganu" University of Medicine and Pharmacy, 8 Babes Street, Cluj-Napoca, 400012, Romania
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5
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Lauder L, Mahfoud F, Azizi M, Bhatt DL, Ewen S, Kario K, Parati G, Rossignol P, Schlaich MP, Teo KK, Townsend RR, Tsioufis C, Weber MA, Weber T, Böhm M. Hypertension management in patients with cardiovascular comorbidities. Eur Heart J 2022:6808663. [DOI: 10.1093/eurheartj/ehac395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 06/23/2022] [Accepted: 07/08/2022] [Indexed: 11/09/2022] Open
Abstract
Abstract
Arterial hypertension is a leading cause of death globally. Due to ageing, the rising incidence of obesity, and socioeconomic and environmental changes, its incidence increases worldwide. Hypertension commonly coexists with Type 2 diabetes, obesity, dyslipidaemia, sedentary lifestyle, and smoking leading to risk amplification. Blood pressure lowering by lifestyle modifications and antihypertensive drugs reduce cardiovascular (CV) morbidity and mortality. Guidelines recommend dual- and triple-combination therapies using renin–angiotensin system blockers, calcium channel blockers, and/or a diuretic. Comorbidities often complicate management. New drugs such as angiotensin receptor-neprilysin inhibitors, sodium–glucose cotransporter 2 inhibitors, glucagon-like peptide-1 receptor agonists, and non-steroidal mineralocorticoid receptor antagonists improve CV and renal outcomes. Catheter-based renal denervation could offer an alternative treatment option in comorbid hypertension associated with increased sympathetic nerve activity. This review summarises the latest clinical evidence for managing hypertension with CV comorbidities.
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Affiliation(s)
- Lucas Lauder
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University , Kirrberger Str. 1, 66421 Homburg , Germany
| | - Felix Mahfoud
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University , Kirrberger Str. 1, 66421 Homburg , Germany
| | - Michel Azizi
- Université Paris Cité, INSERM CIC1418 , F-75015 Paris , France
- AP-HP, Hôpital Européen Georges-Pompidou, Hypertension Department, DMU CARTE , F-75015 Paris , France
- FCRIN INI-CRCT , Nancy , France
| | - Deepak L Bhatt
- Brigham and Women’s Hospital Heart and Vascular Center, Harvard Medical School , Boston, MA , USA
| | - Sebastian Ewen
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University , Kirrberger Str. 1, 66421 Homburg , Germany
| | - Kazuomi Kario
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine , Tochigi , Japan
| | - Gianfranco Parati
- Department of Medicine and Surgery, Cardiology Unit, University of Milano-Bicocca and Istituto Auxologico Italiano, IRCCS , Milan , Italy
| | - Patrick Rossignol
- FCRIN INI-CRCT , Nancy , France
- Université de Lorraine, INSERM, Centre d'Investigations Cliniques - Plurithématique 14-33 and INSERM U1116 , Nancy , France
- CHRU de Nancy , Nancy , France
| | - Markus P Schlaich
- Dobney Hypertension Centre, Medical School—Royal Perth Hospital Unit, Medical Research Foundation, The University of Western Australia , Perth, WA , Australia
- Departments of Cardiology and Nephrology, Royal Perth Hospital , Perth, WA , Australia
| | - Koon K Teo
- Population Health Research Institute, McMaster University , Hamilton, ON , Canada
| | - Raymond R Townsend
- Perelman School of Medicine, University of Pennsylvania , Philadelphia, PA , USA
| | - Costas Tsioufis
- National and Kapodistrian University of Athens, 1st Cardiology Clinic, Hippocratio Hospital , Athens , Greece
| | | | - Thomas Weber
- Department of Cardiology, Klinikum Wels-Grieskirchen , Wels , Austria
| | - Michael Böhm
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University , Kirrberger Str. 1, 66421 Homburg , Germany
- Cape Heart Institute (CHI), Faculty of Health Sciences, University of Cape Town , Cape Town , South Africa
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6
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Rodríguez-Carbó J, Torres-Arellano JM, Ávila-Vanzzini N, Springall R, Bojalil R, Infante O, Lerma C, Echeverría JC. Association of the Heart Rate Variability Response to Active Standing with the Severity of Calcific Aortic Valve Disease: Novel Insights of a Neurocardiovascular Pathology. J Clin Med 2022; 11:jcm11164771. [PMID: 36013009 PMCID: PMC9409634 DOI: 10.3390/jcm11164771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Revised: 07/29/2022] [Accepted: 08/12/2022] [Indexed: 11/20/2022] Open
Abstract
The aim of this work was to obtain insights of the participation of the autonomic nervous system in different stages of calcific aortic valve disease (CAVD) by heart rate variability (HRV) analysis. Studying subjects with no valve impairments and CAVD patients, we also sought to quantify the independent contribution or explanatory capacity of the aortic valve echocardiographic parameters involved in the HRV changes caused by active standing using hierarchical partitioning models to consider other variables or potential confounders. We detected smaller adjustments of the cardiac autonomic response at active standing caused specifically by the aortic valve deterioration. The highest association (i.e., the highest percentage of independent exploratory capacity) was found between the aortic valve area and the active standing changes in the short-term HRV scaling exponent α1 (4.591%). The valve’s maximum pressure gradient echocardiographic parameter was present in most models assessed (in six out of eight models of HRV indices that included a valve parameter as an independent variable). Overall, our study provides insights with a wider perspective to explore and consider CAVD as a neurocardiovascular pathology. This pathology involves autonomic-driven compensatory mechanisms that seem generated by the aortic valve deterioration.
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Affiliation(s)
- Jimena Rodríguez-Carbó
- Posgrado en Ingeniería Biomédica, División de Ciencias Básicas e Ingeniería, Universidad Autónoma Metropolitana, Unidad Iztapalapa, Mexico City 09340, Mexico
| | - José M. Torres-Arellano
- Departamento de Instrumentación Electromecánica, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City 14080, Mexico
| | - Nydia Ávila-Vanzzini
- Departamento de Consulta Externa, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City 14080, Mexico
| | - Rashidi Springall
- Departamento de Inmunología, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City 14080, Mexico
| | - Rafael Bojalil
- Departamento de Atención a la Salud, División de Ciencias Biológicas y de la Salud, Universidad Autónoma Metropolitana, Unidad Xochimilco, Mexico City 04960, Mexico
| | - Oscar Infante
- Departamento de Instrumentación Electromecánica, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City 14080, Mexico
| | - Claudia Lerma
- Departamento de Instrumentación Electromecánica, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City 14080, Mexico
- Correspondence: (C.L.); (J.C.E.)
| | - Juan Carlos Echeverría
- Departamento de Ingeniería Eléctrica, División de Ciencias Básicas e Ingeniería, Universidad Autónoma Metropolitana, Unidad Iztapalapa, Mexico City 09340, Mexico
- Correspondence: (C.L.); (J.C.E.)
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7
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Kammoun I, Sghaier A, Bennour E, Laroussi L, Miled M, Neji H, Ben Halima A, Addad F, Marrakchi S, Kachboura S. Current and new imaging techniques in risk stratification of asymptomatic severe aortic stenosis. Acta Cardiol 2022; 77:288-296. [PMID: 34151729 DOI: 10.1080/00015385.2021.1939513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Aortic stenosis (AS) is one of the most common valvular diseases in clinical practice. The prevalence of calcified AS with moderate or severe stenosis exceeds 2% after 75 years. The optimal timing of intervention for asymptomatic severe AS is uncertain and controversial. Identification of high-risk patients is based on echocardiographic parameters (left ventricular dysfunction, AS severity and progression), hemodynamic response to exercise, pulmonary hypertension, and elevated brain natriuretic peptides. However, early surgical aortic valve replacement (AVR), when compared to the watchful waiting approach, was associated with survival advantage. Moreover, new insights into pathophysiology of AS and advances in imaging modalities were helpful in the management of asymptomatic AS. In this report, we detail the potential role of echocardiography to guide timing of surgery and we discussed the use of early risk features based on recent imaging modalities.
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Affiliation(s)
- Ikram Kammoun
- Cardiology Department, Abderrahmane Mami’s Hospital, Ariana, Tunisia
| | - Ahmed Sghaier
- Cardiology Department, Abderrahmane Mami’s Hospital, Ariana, Tunisia
| | - Emna Bennour
- Cardiology Department, Abderrahmane Mami’s Hospital, Ariana, Tunisia
| | - Lobna Laroussi
- Cardiology Department, Abderrahmane Mami’s Hospital, Ariana, Tunisia
| | - Manel Miled
- Cardiology Department, Abderrahmane Mami’s Hospital, Ariana, Tunisia
| | - Henda Neji
- Radiology Department, Abderrahmane Mami’s Hospital, Ariana, Tunisia
| | - Afef Ben Halima
- Cardiology Department, Abderrahmane Mami’s Hospital, Ariana, Tunisia
| | - Faouzi Addad
- Cardiology Department, Abderrahmane Mami’s Hospital, Ariana, Tunisia
| | - Sonia Marrakchi
- Cardiology Department, Abderrahmane Mami’s Hospital, Ariana, Tunisia
| | - Salem Kachboura
- Cardiology Department, Abderrahmane Mami’s Hospital, Ariana, Tunisia
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8
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Prioritization of Candidate Biomarkers for Degenerative Aortic Stenosis through a Systems Biology-Based In-Silico Approach. J Pers Med 2022; 12:jpm12040642. [PMID: 35455758 PMCID: PMC9026876 DOI: 10.3390/jpm12040642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 04/04/2022] [Accepted: 04/13/2022] [Indexed: 11/17/2022] Open
Abstract
Degenerative aortic stenosis is the most common valve disease in the elderly and is usually confirmed at an advanced stage when the only treatment is surgery. This work is focused on the study of previously defined biomarkers through systems biology and artificial neuronal networks to understand their potential role within aortic stenosis. The goal was generating a molecular panel of biomarkers to ensure an accurate diagnosis, risk stratification, and follow-up of aortic stenosis patients. We used in silico studies to combine and re-analyze the results of our previous studies and, with information from multiple databases, established a mathematical model. After this, we prioritized two proteins related to endoplasmic reticulum stress, thrombospondin-1 and endoplasmin, which have not been previously validated as markers for aortic stenosis, and analyzed them in a cell model and in plasma from human subjects. Large-scale bioinformatics tools allow us to extract the most significant results after using high throughput analytical techniques. Our results could help to prevent the development of aortic stenosis and open the possibility of a future strategy based on more specific therapies.
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9
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Pitoulis FG, Nunez-Toldra R, Xiao K, Kit-Anan W, Mitzka S, Jabbour RJ, Harding SE, Perbellini F, Thum T, de Tombe PP, Terracciano CM. Remodelling of adult cardiac tissue subjected to physiological and pathological mechanical load in vitro. Cardiovasc Res 2022; 118:814-827. [PMID: 33723566 PMCID: PMC8859636 DOI: 10.1093/cvr/cvab084] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 03/11/2021] [Indexed: 01/14/2023] Open
Abstract
AIMS Cardiac remodelling is the process by which the heart adapts to its environment. Mechanical load is a major driver of remodelling. Cardiac tissue culture has been frequently employed for in vitro studies of load-induced remodelling; however, current in vitro protocols (e.g. cyclic stretch, isometric load, and auxotonic load) are oversimplified and do not accurately capture the dynamic sequence of mechanical conformational changes experienced by the heart in vivo. This limits translational scope and relevance of findings. METHODS AND RESULTS We developed a novel methodology to study chronic load in vitro. We first developed a bioreactor that can recreate the electromechanical events of in vivo pressure-volume loops as in vitro force-length loops. We then used the bioreactor to culture rat living myocardial slices (LMS) for 3 days. The bioreactor operated based on a 3-Element Windkessel circulatory model enabling tissue mechanical loading based on physiologically relevant parameters of afterload and preload. LMS were continuously stretched/relaxed during culture simulating conditions of physiological load (normal preload and afterload), pressure-overload (normal preload and high afterload), or volume-overload (high preload & normal afterload). At the end of culture, functional, structural, and molecular assays were performed to determine load-induced remodelling. Both pressure- and volume-overloaded LMS showed significantly decreased contractility that was more pronounced in the latter compared with physiological load (P < 0.0001). Overloaded groups also showed cardiomyocyte hypertrophy; RNAseq identified shared and unique genes expressed in each overload group. The PI3K-Akt pathway was dysregulated in volume-overload while inflammatory pathways were mostly associated with remodelling in pressure-overloaded LMS. CONCLUSION We have developed a proof-of-concept platform and methodology to recreate remodelling under pathophysiological load in vitro. We show that LMS cultured in our bioreactor remodel as a function of the type of mechanical load applied to them.
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Affiliation(s)
- Fotios G Pitoulis
- National Heart and Lung Institute, Imperial College London, 72 Du Cane Road, Hammersmith Hospital, ICTEM Building, W12 0NN London, UK
| | - Raquel Nunez-Toldra
- National Heart and Lung Institute, Imperial College London, 72 Du Cane Road, Hammersmith Hospital, ICTEM Building, W12 0NN London, UK
| | - Ke Xiao
- Institute for Molecular and Translational Therapeutic Strategies, Hannover Medical School, OE 8886, Carl-Neuberg-Str. 1, J3 Building, Level 1, Room 3030, 30625 Hannover, Germany
| | - Worrapong Kit-Anan
- National Heart and Lung Institute, Imperial College London, 72 Du Cane Road, Hammersmith Hospital, ICTEM Building, W12 0NN London, UK
| | - Saskia Mitzka
- Institute for Molecular and Translational Therapeutic Strategies, Hannover Medical School, OE 8886, Carl-Neuberg-Str. 1, J3 Building, Level 1, Room 3030, 30625 Hannover, Germany
| | - Richard J Jabbour
- National Heart and Lung Institute, Imperial College London, 72 Du Cane Road, Hammersmith Hospital, ICTEM Building, W12 0NN London, UK
| | - Sian E Harding
- National Heart and Lung Institute, Imperial College London, 72 Du Cane Road, Hammersmith Hospital, ICTEM Building, W12 0NN London, UK
| | - Filippo Perbellini
- Institute for Molecular and Translational Therapeutic Strategies, Hannover Medical School, OE 8886, Carl-Neuberg-Str. 1, J3 Building, Level 1, Room 3030, 30625 Hannover, Germany
| | - Thomas Thum
- National Heart and Lung Institute, Imperial College London, 72 Du Cane Road, Hammersmith Hospital, ICTEM Building, W12 0NN London, UK
- Institute for Molecular and Translational Therapeutic Strategies, Hannover Medical School, OE 8886, Carl-Neuberg-Str. 1, J3 Building, Level 1, Room 3030, 30625 Hannover, Germany
| | - Pieter P de Tombe
- Department of Physiology and Biophysics, University of Illinois at Chicago, 835 S. Wolcott Rm E202 (MC901), Chicago, IL 60612-7342, USA
| | - Cesare M Terracciano
- National Heart and Lung Institute, Imperial College London, 72 Du Cane Road, Hammersmith Hospital, ICTEM Building, W12 0NN London, UK
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10
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Mantha Y, Futami S, Moriyama S, Hieda M. Valvulo-Arterial Impedance and Dimensionless Index for Risk Stratifying Patients With Severe Aortic Stenosis. Front Cardiovasc Med 2021; 8:742297. [PMID: 34926605 PMCID: PMC8674501 DOI: 10.3389/fcvm.2021.742297] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 10/25/2021] [Indexed: 11/22/2022] Open
Abstract
The hemodynamic effects of aortic stenosis (AS) consist of increased left ventricular (LV) afterload, reduced myocardial compliance, and increased myocardial workload. The LV in AS patients faces a double load: valvular and arterial loads. As such, the presence of symptoms and occurrence of adverse events in AS should better correlate with calculating the global burden faced by the LV in addition to the transvalvular gradient and aortic valve area (AVA). The valvulo-arterial impedance (Zva) is a useful parameter providing an estimate of the global LV hemodynamic load that results from the summation of the valvular and vascular loads. In addition to calculating the global LV afterload, it is paramount to estimate the stenosis severity accurately. In clinical practice, the management of low-flow low-gradient (LF-LG) severe AS with preserved LV ejection fraction requires careful confirmation of stenosis severity. In addition to the Zva, the dimensionless index (DI) is a very useful parameter to express the size of the effective valvular area as a proportion of the cross-section area of the left ventricular outlet tract velocity-time integral (LVOT-VTI) to that of the aortic valve jet (dimensionless velocity ratio). The DI is calculated by a ratio of the sub-valvular velocity obtained by pulsed-wave Doppler (LVOT-VTI) divided by the maximum velocity obtained by continuous-wave Doppler across the aortic valve (AV-VTI). In contrast to AVA measurement, the DI does not require the calculation of LVOT cross-sectional area, a major cause of erroneous assessment and underestimation of AVA. Hence, among patients with LG severe AS and preserved LV ejection fraction, calculation of DI in routine echocardiographic practice may be useful to identify a subgroup of patients at higher risk of mortality who may derive benefit from aortic valve replacement. This article aims to elucidate the Zva and DI in different clinical situations, correlate with the standard indexes of AS severity, LV geometry, and function, and thus prove to improve risk stratification and clinical decision making in patients with severe AS.
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Affiliation(s)
- Yogamaya Mantha
- Division of Cardiovascular Medicine, University of Texas Health Sciences, San Antonio, TX, United States
| | - Shutaro Futami
- Department of Medicine and Biosystemic Science, Hematology, Oncology and Cardiovascular Medicine, School of Medicine, Kyushu University, Fukuoka, Japan
| | - Shohei Moriyama
- Department of Medicine and Biosystemic Science, Hematology, Oncology and Cardiovascular Medicine, School of Medicine, Kyushu University, Fukuoka, Japan
| | - Michinari Hieda
- Department of Medicine and Biosystemic Science, Hematology, Oncology and Cardiovascular Medicine, School of Medicine, Kyushu University, Fukuoka, Japan
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11
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Wu M, Gu P, Cao Q, Gong A, Tan W, Hong D. Antihypertensive treatment and risk factors for syncope in asymptomatic aortic stenosis patients with hypertension. Clin Exp Hypertens 2021; 44:191-197. [PMID: 34872422 DOI: 10.1080/10641963.2021.1883047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Evidence for treating hypertension in patients with asymptomatic aortic valve stenosis(AS) is scarce. OBJECTIVES Given the paucity of data on the relationship between syncope and antihypertensive treatment in aortic stenosis. This study sought to investigate this association in patients admitted to our hospital. METHODS A total of 158 patients with asymptomatic moderate or severe aortic stenosis were analyzed. Follow-up was conducted by clinic visit, telephone contact, or review of electronic medical records. Outcomes were syncope. RESULTS Hypertension were documented in 90 of the 158 patients with moderate or severe AS, and 77 of them received antihypertensive medications. During an average 28 months follow-up period, the occurrence of syncope was observed in 13 patients. Among them, 8 were in antihypertensive group (n = 77) and 5 in normotensive group (n = 68). There was no significant difference in incidence of syncope between the two groups. Patients with treated hypertension and syncope had a lower stroke volume index (SVi), a higher valve arterial impedance (ZVA), a smaller SAC than those without. Kaplan-Meier analysis showed that there was no significant difference in syncope cumulative incidence between antihypertensive group and normotensive group (log rank P = .478). Multivariate cox regression analysis showed that both ZVA (hazard ratio:19.006, 95% confidence interval: 4.664 to77.448;P = .002) and LVMI (hazard ratio:1.484, 95% confidence interval: 1.427 to 5.157;P = .016) were associated with development of syncope, whereas hypertension were not related independently to syncope (hazard ratio:0.935, 95% confidence interval: 0.786 to3.173; P = .869). CONCLUSIONS In patients with moderate or severe AS, concomitant hypertension, and antihypertensive treatment didn't increase the occurrence of syncope, whereas higher ZVA was independently associated with greater risk of syncope.
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Affiliation(s)
- Meihua Wu
- Department of Cardiovascular Medicine, Jiangxi Provincial People's Hospital Affiliated to Nanchang University, Jiangxi, China
| | - Ping Gu
- Echocardiography Laboratory, Jiangxi Provincial People's Hospital Affiliated to Nanchang University, Jiangxi, China
| | - Qianqiang Cao
- Department of Cardiovascular Medicine, Jiangxi Provincial People's Hospital Affiliated to Nanchang University, Jiangxi, China
| | - Aibin Gong
- Department of Cardiovascular Medicine, Jiangxi Provincial People's Hospital Affiliated to Nanchang University, Jiangxi, China
| | - Wenliang Tan
- Department of Cardiovascular Medicine, Jiangxi Provincial People's Hospital Affiliated to Nanchang University, Jiangxi, China
| | - Dezhi Hong
- Department of Cardiovascular Medicine, Jiangxi Provincial People's Hospital Affiliated to Nanchang University, Jiangxi, China
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12
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Arterial Hypertension in Aortic Valve Stenosis: A Critical Update. J Clin Med 2021; 10:jcm10235553. [PMID: 34884254 PMCID: PMC8658702 DOI: 10.3390/jcm10235553] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 11/23/2021] [Accepted: 11/24/2021] [Indexed: 02/04/2023] Open
Abstract
Aortic stenosis (AS) is a very common valve disease and is associated with high mortality once it becomes symptomatic. Arterial hypertension (HT) has a high prevalence among patients with AS leading to worse left ventricle remodeling and faster degeneration of the valve. HT also interferes with the assessment of the severity of AS, leading to an underestimation of the real degree of stenosis. Treatment of HT in AS has not historically been pursued due to the fear of excess reduction in afterload without a possibility of increasing stroke volume due to the fixed aortic valve, but most recent evidence shows that several drugs are safe and effective in reducing BP in patients with HT and AS. RAAS inhibitors and beta-blockers provide benefit in selected populations based on their profile of pharmacokinetics and pharmacodynamics. Different drugs, on the other hand, have proved to be unsafe, such as calcium channel blockers, or simply not easy enough to handle to be recommended in clinical practice, such as PDE5i, MRA or sodium nitroprusside. The present review highlights all available studies on HT and AS to guide antihypertensive treatment.
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13
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Maeda M, Omori T, Kagawa S, Uno G, Rader F, Siegel RJ, Shiota T. Impact of Systolic Blood Pressure on Heart Failure Symptoms With Moderate Aortic Stenosis. Am J Cardiol 2021; 155:96-102. [PMID: 34315571 DOI: 10.1016/j.amjcard.2021.06.018] [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: 04/09/2021] [Revised: 05/26/2021] [Accepted: 06/01/2021] [Indexed: 11/30/2022]
Abstract
In patients with moderate aortic stenosis (AS), heart failure (HF) symptoms are often unrelated to the AS severity, and the causes of HF symptoms are often unclear. Hypertension is known as one of the most common comorbidities in degenerative AS. Therefore, we assessed the impact of systolic blood pressure (BP) on HF symptoms in patients with moderate AS. We retrospectively analyzed 317 patients with moderate AS (mean transaortic pressure gradient 20 to 39 mm Hg) and preserved left ventricular ejection fraction (left ventricular ejection fraction ≥50%). We classified patients according to the presence or absence of HF symptoms. One hundred patients (32%) had HF symptoms. Symptomatic patients had higher systolic BP (141±21 versus 129±21 mm Hg; p<0.001) and mean transaortic pressure gradient, and lower aortic valve area than asymptomatic patients. In the multivariable analysis after adjustment for age, atrial fibrillation, Charlson comorbidity index, brain natriuretic peptide, and the use of diuretics, HF symptoms in patients with moderate AS were independently associated with systolic BP (odds ratio, 1.43 per 10 mm Hg increase in systolic BP; 95% confidence interval, 1.14-1.78; p=0.001) and left atrial volume index (odds ratio, 1.04 per 1 mL/m2 increase in left atrial volume index; 95% confidence interval, 1.00-1.08; p=0.026). Receiver operating characteristics curve analysis identified systolic BP 133 mm Hg as the cutoff value associated with HF symptoms. In conclusion, systolic BP as well as left atrial volume index were independent correlates of HF symptoms in patients with moderate AS.
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Affiliation(s)
- Mika Maeda
- Smidt Heart Institute, Cedars-Sinai Medical Center, California
| | - Taku Omori
- Smidt Heart Institute, Cedars-Sinai Medical Center, California
| | - Shunsuke Kagawa
- Smidt Heart Institute, Cedars-Sinai Medical Center, California
| | - Goki Uno
- Smidt Heart Institute, Cedars-Sinai Medical Center, California
| | - Florian Rader
- Smidt Heart Institute, Cedars-Sinai Medical Center, California
| | - Robert J Siegel
- Smidt Heart Institute, Cedars-Sinai Medical Center, California
| | - Takahiro Shiota
- Smidt Heart Institute, Cedars-Sinai Medical Center, California.
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14
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Aldrugh S, Valle JE, Parker MW, Harrington CM, Aurigemma GP. Prevalence of Left Ventricular Hypertrophy Caused by Systemic Hypertension Preceding the Development of Severe Aortic Stenosis. Am J Cardiol 2021; 150:89-94. [PMID: 34052014 DOI: 10.1016/j.amjcard.2021.03.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 03/24/2021] [Accepted: 03/26/2021] [Indexed: 12/31/2022]
Abstract
It is generally assumed that left ventricular (LV) hypertrophy in aortic stenosis (AS) is a compensatory adaptation to chronic outflow obstruction. The advent of transcutaneous aortic valve replacement has stimulated more focus on AS in older patients, most of whom have antecedent hypertension. Accordingly, our aim was to investigate the interaction between hypertension and AS on LV remodeling in contemporary practice. We studied consecutive patients referred for echocardiograms with initial aortic valve (AV) peak velocity <3.0 m/s and a peak velocity of >3.5 m/s on a subsequent study performed at least 5 years later. LV size and geometry were measured echocardiographically. Midwall fractional shortening (FSmw) and peak systolic stress were calculated from 2-dimensional echocardiographic and Doppler data. Of 80 patients with progressive AS, 59% were women with mean age 82 ± 9 years. The average interval between the 2 echocardiograms was 5.9 ± 1.8 years. During the study period, peak velocity increased from 2.5 ± 0.4 to 4.2 ± 0.6 m/s (p < 0.01) and LV mass indexed to body surface area increased from 80 ± 28 to 122 ± 51 g/m2 (p < 0.01) with a corresponding shift from normal or concentric LV remodeling geometry to concentric hypertrophy. There was no correlation between change in LV mass index and AV mean gradient or valvulo-arterial impedance. However, change in LV mass index did correlate positively with initial peak velocity and inversely with initial LV mass. Plots of FSmw against circumferential stress at baseline and follow-up suggest that systolic function more than compensates for increasing load in many patients. In conclusion, most patients seen in our practice with severe AS have antecedent hypertension and LV remodeling at a time when outflow obstruction is mild. LV remodeling worsens in parallel with worsening severity of AS. Remodeling in these patients features increasing concentric remodeling of the LV, rather than LV dilation. Systolic function, as assessed by FSmw, remains compensated, or even improves relative to afterload, during progression of AS. Given these findings, we speculate that regression of LV hypertrophy to normal will not be affected by transcutaneous aortic valve replacement because LV hypertrophy preceded hemodynamically severe AS.
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Affiliation(s)
- Summer Aldrugh
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Jorge Escobar Valle
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Matthew W Parker
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Colleen M Harrington
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Gerard P Aurigemma
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts.
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15
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Chen S, Redfors B, Nazif T, Kirtane A, Crowley A, Ben-Yehuda O, Kapadia S, Finn MT, Goel S, Lindman BR, Alu MC, Chau KH, Thourani VH, Vahl TP, Douglas PS, Kodali SK, Leon MB. Impact of renin-angiotensin system inhibitors on clinical outcomes in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement: an analysis of from the PARTNER 2 trial and registries. Eur Heart J 2021; 41:943-954. [PMID: 31711153 DOI: 10.1093/eurheartj/ehz769] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 07/08/2019] [Accepted: 10/15/2019] [Indexed: 01/09/2023] Open
Abstract
AIMS Left ventricular pressure overload is associated with activation of the cardiac renin-angiotensin system, which may contribute to myocardial fibrosis and worse clinical outcomes. We sought to assess the association between treatment with angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) at baseline and clinical outcomes in patients with symptomatic, severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR) in the PARTNER 2 trial and registries. METHODS AND RESULTS A total of 3979 intermediate, high, or prohibitive risk patients who underwent TAVR in the PARTNER 2 trial and registries (excluding the valve in valve registry) were included in the study. Clinical outcomes at 2 years were compared according to baseline ACEI/ARB treatment status using Kaplan-Meier event rates and study-stratified multivariable Cox proportional hazards regression models. Sensitivity analysis was conducted using propensity score matching. Of 3979 patients who were included in the current analysis, 1736 (43.6%) were treated and 2243 (56.4%) were not treated with ACEI/ARB at baseline. Treatment with ACEI/ARB was associated with lower 2-year all-cause mortality (18.6% vs. 27.5%, P < 0.0001), cardiovascular mortality (12.3% vs. 17.9%, P < 0.0001), and non-cardiovascular mortality (7.2% vs. 11.7%, P < 0.0001). Angiotensin-converting enzyme inhibitor/ARB treatment at baseline remained independently associated with a lower hazard of 2-year all-cause and cardiovascular mortality after multivariable adjustment, and propensity score matching. CONCLUSION In a large cohort of patients with severe symptomatic AS from the PARTNER 2 trial and registries, ACEI/ARB treatment at baseline was independently associated with a lower risk of 2-year all-cause and cardiovascular mortality.
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Affiliation(s)
- Shmuel Chen
- Cardiovascular Research Foundation, 1700 Broadway, Floor 9, New York, NY 10019, USA.,Center for Interventional Vascular Therapy, Columbia University Irving Medical Center/ NewYork-Presbyterian Hospital, 161 Ft. Washington Ave. HIP-6, New York, NY 10032, USA
| | - Bjorn Redfors
- Cardiovascular Research Foundation, 1700 Broadway, Floor 9, New York, NY 10019, USA.,Center for Interventional Vascular Therapy, Columbia University Irving Medical Center/ NewYork-Presbyterian Hospital, 161 Ft. Washington Ave. HIP-6, New York, NY 10032, USA.,Department of Cardiology, Sahlgrenska University Hospital, Bruna Straket 16, 413 45 Gothenburg, Sweden
| | - Tamim Nazif
- Center for Interventional Vascular Therapy, Columbia University Irving Medical Center/ NewYork-Presbyterian Hospital, 161 Ft. Washington Ave. HIP-6, New York, NY 10032, USA
| | - Ajay Kirtane
- Center for Interventional Vascular Therapy, Columbia University Irving Medical Center/ NewYork-Presbyterian Hospital, 161 Ft. Washington Ave. HIP-6, New York, NY 10032, USA
| | - Aaron Crowley
- Cardiovascular Research Foundation, 1700 Broadway, Floor 9, New York, NY 10019, USA
| | - Ori Ben-Yehuda
- Cardiovascular Research Foundation, 1700 Broadway, Floor 9, New York, NY 10019, USA
| | - Samir Kapadia
- Department of Cardiovascular Medicine, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, USA
| | - Matthew T Finn
- Center for Interventional Vascular Therapy, Columbia University Irving Medical Center/ NewYork-Presbyterian Hospital, 161 Ft. Washington Ave. HIP-6, New York, NY 10032, USA
| | - Sachin Goel
- Department of Cardiovascular Medicine, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, USA
| | - Brian R Lindman
- Structural Heart and Valve Center, Cardiovascular Medicine Division, Vanderbilt University Medical Center, 1161 21st Ave S., Nashville, TN 37232, USA
| | - Maria C Alu
- Cardiovascular Research Foundation, 1700 Broadway, Floor 9, New York, NY 10019, USA.,Center for Interventional Vascular Therapy, Columbia University Irving Medical Center/ NewYork-Presbyterian Hospital, 161 Ft. Washington Ave. HIP-6, New York, NY 10032, USA
| | - Katherine H Chau
- Center for Interventional Vascular Therapy, Columbia University Irving Medical Center/ NewYork-Presbyterian Hospital, 161 Ft. Washington Ave. HIP-6, New York, NY 10032, USA
| | - Vinod H Thourani
- Department of Cardiac Surgery, Piedmont Heart Institute, 95 Collier Road NW, Atlanta, GA 30309, USA
| | - Torsten P Vahl
- Center for Interventional Vascular Therapy, Columbia University Irving Medical Center/ NewYork-Presbyterian Hospital, 161 Ft. Washington Ave. HIP-6, New York, NY 10032, USA
| | - Pamela S Douglas
- Duke Clinical Research Institute, Duke University School of Medicine, 300 W Morgan St, Durham NC 27701, USA
| | - Susheel K Kodali
- Center for Interventional Vascular Therapy, Columbia University Irving Medical Center/ NewYork-Presbyterian Hospital, 161 Ft. Washington Ave. HIP-6, New York, NY 10032, USA
| | - Martin B Leon
- Cardiovascular Research Foundation, 1700 Broadway, Floor 9, New York, NY 10019, USA.,Center for Interventional Vascular Therapy, Columbia University Irving Medical Center/ NewYork-Presbyterian Hospital, 161 Ft. Washington Ave. HIP-6, New York, NY 10032, USA
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16
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Harrington CM, Sorour N, Gottbrecht M, Nagy A, Kovell LC, Truong V, Chung ES, Aurigemma GP. Effect of Transaortic Valve Intervention for Aortic Stenosis on Myocardial Mechanics. Am J Cardiol 2021; 146:56-61. [PMID: 33529618 DOI: 10.1016/j.amjcard.2021.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 01/12/2021] [Accepted: 01/15/2021] [Indexed: 10/22/2022]
Abstract
Chronic afterload excess in aortic stenosis results in compensatory concentric hypertrophy which mitigates the increased systolic load. Surgical aortic valve replacement has been shown to decrease afterload and improve left ventricular (LV) ejection fraction (EF). The extent to which these changes take place in patients undergoing TAVI (transcatheter aortic valve intervention) may be different than what has been observed in the surgical aortic valve replacement patients who were generally younger with few co-morbidities. Accordingly, we analyzed indices of LV structure and ventricular mechanics pre- and 1-year after TAVI in 397 patients (mean age 81±9, 46% women) with severe symptomatic aortic stenosis, complete echocardiographic data was available in 156 patients and these patients compromised our study population. Our principal findings are: (1) LV remodeling occurs after TAVI; (2) afterload decreases significantly; (3) LV chamber and myocardial function, assessed by left ventricular ejection fraction and midwall fractional shortening, and stroke volume, respectively, remain unchanged or decrease. In conclusion, TAVI effects LV remodeling despite significant co-morbidities. Thus, TAVI reduces afterload and leads to LV remodeling. Surprisingly, however, systolic function does not improve. These data run counter to the paradigm that afterload reduction improves systolic function and suggest that the response to afterload reduction is complex in the TAVI population.
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17
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Donato M, Ferri N, Lupo MG, Faggin E, Rattazzi M. Current Evidence and Future Perspectives on Pharmacological Treatment of Calcific Aortic Valve Stenosis. Int J Mol Sci 2020; 21:ijms21218263. [PMID: 33158204 PMCID: PMC7663524 DOI: 10.3390/ijms21218263] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 10/31/2020] [Accepted: 11/02/2020] [Indexed: 02/07/2023] Open
Abstract
Calcific aortic valve stenosis (CAVS), the most common heart valve disease, is characterized by the slow progressive fibro-calcific remodeling of the valve leaflets, leading to progressive obstruction to the blood flow. CAVS is an increasing health care burden and the development of an effective medical treatment is a major medical need. To date, no effective pharmacological therapies have proven to halt or delay its progression to the severe symptomatic stage and aortic valve replacement represents the only available option to improve clinical outcomes and to increase survival. In the present report, the current knowledge and latest advances in the medical management of patients with CAVS are summarized, placing emphasis on lipid-lowering agents, vasoactive drugs, and anti-calcific treatments. In addition, novel potential therapeutic targets recently identified and currently under investigation are reported.
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Affiliation(s)
- Maristella Donato
- Department of Pharmaceutical and Pharmacological Sciences, University of Padova, 35122 Padova, Italy; (M.D.); (N.F.); (M.G.L.)
| | - Nicola Ferri
- Department of Pharmaceutical and Pharmacological Sciences, University of Padova, 35122 Padova, Italy; (M.D.); (N.F.); (M.G.L.)
| | - Maria Giovanna Lupo
- Department of Pharmaceutical and Pharmacological Sciences, University of Padova, 35122 Padova, Italy; (M.D.); (N.F.); (M.G.L.)
| | - Elisabetta Faggin
- Department of Medicine—DIMED, University of Padova, 35122 Padova, Italy;
| | - Marcello Rattazzi
- Department of Medicine—DIMED, University of Padova, 35122 Padova, Italy;
- Correspondence: ; Tel.: +39-0498-211-867 or +39-0422-322-207
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18
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Crousillat D, Namasivayam M, Passeri JJ. Severe, Symptomatic Aortic Stenosis: an Update on the Diagnostic and Treatment Tools in Our Arsenal. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2020. [DOI: 10.1007/s11936-020-00847-5] [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: 11/30/2022]
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19
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Abstract
INTRODUCTION Ventricular function in elderly patients with aortic stenosis is impeded both by restricted aortic flow and arterial stiffening. A number of patients continue to have exertional intolerance after relief of aortic valvular obstruction due to unrecognized ventriculo-arterial coupling mismatch. HYPOTHESIS Quantification of valvulo-arterial load (VAL), using a simultaneous applanation tonometry/cardiac magnetic resonance (CMR) technique, can accurately assess the relative contributions of aortic stiffness and valve gradient in older patients with aortic stenosis. METHODS Elderly patients with aortic stenosis underwent a simultaneous applanation tonometry/CMR protocol. CMR provided left ventricular volume and aortic flow simultaneously with radial applanation tonometry pressure acquisition. Central aortic pressure was derived by transformation of the radial applanation tonometry waveform. VAL was determined as the relationship of derived aortic pressure to CMR aortic flow in frequency domain (central illustration). RESULTS Twenty patients (age 80 ± 9 years; 12 males; blood pressure 140/75 ± 20 mmHg) with aortic stenosis on transthoracic echocardiogram (16 severe; mean gradient 45 ± 16 mmHg; aortic valve area 0.8 ± 0.2 cm2) were enrolled. Derived aortic pressure and flow waveforms correlated well with invasive data. Increased VAL was significantly associated with advanced age (P = 0.04) and raised SBP (P < 0.01), irrespective of aortic stenosis severity. CONCLUSION Difficulties in the measurement and accuracy of ventriculo-arterial coupling means that it is not routinely measured in patients with aortic stenosis. We describe a new noninvasive index that provides an accurate assessment of valvular and arterial load on the left ventricle. VAL may help detect those at risk of ventriculo-arterial coupling mismatch and assist in selection of those most likely to benefit from an invasive procedure.
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20
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Sen J, Chung E, Neil C, Marwick T. Antihypertensive therapies in moderate or severe aortic stenosis: a systematic review and meta-analysis. BMJ Open 2020; 10:e036960. [PMID: 33020089 PMCID: PMC7537451 DOI: 10.1136/bmjopen-2020-036960] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 08/19/2020] [Accepted: 08/25/2020] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Hypertension confers a poor prognosis in moderate or severe aortic stenosis (AS), however, antihypertensive therapy (AHT) is often not prescribed due to the perceived deleterious effects of vasodilation and negative inotropes. OBJECTIVE To assess the efficacy and safety outcomes of AHT in adults with moderate or severe AS. DESIGN Systematic review and meta-analysis. DATA SOURCES The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and grey literature were searched without language restrictions up to 9 September 2019. STUDY ELIGIBILITY CRITERIA, APPRAISAL AND SYNTHESIS METHODS Two independent reviewers performed screening, data extraction and risk of bias assessments from a systematic search of observational studies and randomised controlled trials comparing AHT with a placebo or no AHT in adults with moderate or severe AS for any parameter of efficacy and safety outcomes. Conflicts were resolved by the third reviewer. Meta-analysis with pooled effect sizes using random-effects model, were estimated in R. MAIN OUTCOME MEASURES Mortality, Left Ventricular (LV) Mass Index, systolic blood pressure, diastolic blood pressure and LV ejection fraction RESULTS: From 3025 publications, 31 studies (26 500 patients) were included in the qualitative synthesis and 24 studies in the meta-analysis. AHT was not associated with mortality when all studies were pooled, but heterogeneity was substantial across studies. The effect size of AHT differed according to drug class. Renin-angiotensin-aldosterone system inhibitors (RAASi) were associated with reduced risk of mortality (Pooled HR 0.58, 95% CI 0.43 to 0.80, p=0.006), The differences in changes of haemodynamic or echocardiographic parameters from baseline with and without AHT did not reach statistical significance. CONCLUSION AHT appears safe, is well tolerated. RAASi were associated with clinical benefit in patients with moderate or severe AS.
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Affiliation(s)
- Jonathan Sen
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Erin Chung
- Graduate Department of Pharmaceutical Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Christopher Neil
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Thomas Marwick
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
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21
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Waqanivavalagi SWFR, Bhat S, Ground MB, Milsom PF, Cornish J. Clinical performance of decellularized heart valves versus standard tissue conduits: a systematic review and meta-analysis. J Cardiothorac Surg 2020; 15:260. [PMID: 32948234 PMCID: PMC7501674 DOI: 10.1186/s13019-020-01292-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 09/03/2020] [Indexed: 02/06/2023] Open
Abstract
Background Valve replacement surgery is the definitive management strategy for patients with severe valvular disease. However, valvular conduits currently in clinical use are associated with significant limitations. Tissue-engineered (decellularized) heart valves are alternative prostheses that have demonstrated promising early results. The purpose of this systematic review and meta-analysis is to perform robust evaluation of the clinical performance of decellularized heart valves implanted in either outflow tract position, in comparison with standard tissue conduits. Methods Systematic searches were conducted in the PubMed, Scopus, and Web of Science databases for articles in which outcomes between decellularized heart valves surgically implanted within either outflow tract position of human subjects and standard tissue conduits were compared. Primary endpoints included postoperative mortality and reoperation rates. Meta-analysis was performed using a random-effects model via the Mantel-Haenszel method. Results Seventeen articles were identified, of which 16 were included in the meta-analysis. In total, 1418 patients underwent outflow tract reconstructions with decellularized heart valves and 2725 patients received standard tissue conduits. Decellularized heart valves were produced from human pulmonary valves and implanted within the right ventricular outflow tract in all cases. Lower postoperative mortality (4.7% vs. 6.1%; RR 0.94, 95% CI: 0.60–1.47; P = 0.77) and reoperation rates (4.8% vs. 7.4%; RR 0.55, 95% CI: 0.36–0.84; P = 0.0057) were observed in patients with decellularized heart valves, although only reoperation rates were statistically significant. There was no statistically significant heterogeneity between the analyzed articles (I2 = 31%, P = 0.13 and I2 = 33%, P = 0.10 respectively). Conclusions Decellularized heart valves implanted within the right ventricular outflow tract have demonstrated significantly lower reoperation rates when compared to standard tissue conduits. However, in order to allow for more accurate conclusions about the clinical performance of decellularized heart valves to be made, there need to be more high-quality studies with greater consistency in the reporting of clinical outcomes.
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Affiliation(s)
- Steve W F R Waqanivavalagi
- Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Grafton, Auckland, 1023, New Zealand. .,Adult Emergency Department, Auckland City Hospital, Auckland District Health Board, Grafton, Auckland, 1023, New Zealand.
| | - Sameer Bhat
- Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Grafton, Auckland, 1023, New Zealand.,Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Grafton, Auckland, 1023, New Zealand
| | - Marcus B Ground
- Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Grafton, Auckland, 1023, New Zealand.,Department of Medicine, Dunedin School of Medicine, University of Otago, Dunedin, 9054, New Zealand
| | - Paget F Milsom
- Green Lane Cardiothoracic Surgical Unit, Auckland City Hospital, Auckland District Health Board, Grafton, Auckland, 1023, New Zealand
| | - Jillian Cornish
- Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Grafton, Auckland, 1023, New Zealand
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22
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Mogadam E, Shavelle DM, Giesler GM, Economides C, Lidia SP, Duquette S, Matthews RV, Pahlevan NM. Intrinsic frequency method for instantaneous assessment of left ventricular-arterial coupling after transcatheter aortic valve replacement. Physiol Meas 2020; 41:085002. [DOI: 10.1088/1361-6579/aba67f] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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23
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Impact of Arterial Blood Pressure on Ultrasound Hemodynamic Assessment of Aortic Valve Stenosis Severity. J Am Soc Echocardiogr 2020; 33:1324-1333. [PMID: 32868157 DOI: 10.1016/j.echo.2020.06.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 05/05/2020] [Accepted: 06/14/2020] [Indexed: 01/13/2023]
Abstract
BACKGROUND Aortic stenosis (AS) severity assessment is based on several indices. Aortic valve area (AVA) is subject to inaccuracies inherent to the measurement method, while velocities and gradients depend on hemodynamic status. There is controversy as to whether blood pressure directly affects common indices of AS severity. OBJECTIVES The study objective was to assess the effect of systolic blood pressure (SBP) variation on AS indices, in a clinical setting. METHODS A prospective, single-center study included 100 patients with at least moderately severe AS with preserved left ventricle ejection fraction. Patients underwent ultrasound examination during which AS severity indices were collected, with three hemodynamic conditions: (1) low SBP: <120 mm Hg; (2) intermediate SBP: between 120 and 150 mm Hg; (3) high SBP: ≥150 mm Hg. For each patient, SBP profiles were obtained by injection of isosorbide dinitrate or phenylephrine. RESULTS At baseline state, 59% presented a mean gradient (Gmean) ≥ 40 mm Hg, 44% a peak aortic jet velocity (Vpeak) ≥4 m/sec, 66% a dimensionless index (DI) ≤0.25, and 87% an indexed AVA (AVAi) ≤ 0.6 cm2/m2. Compared with intermediate and low SBP, high SBP induced a significant decrease in Gmean (39 ± 12 vs 43 ± 12 and 47 ± 12 mm Hg, respectively; P < .05) and in Vpeak (3.8 ± 0.6 vs 4.0 ± 0.6 and 4.2 ± 0.6 mm Hg; P < .05). Compared with the baseline measures, in 16% of patients with an initial Gmean< 40 mm Hg, gradient rose above 40 mm Hg after optimization of the afterload (low SBP; P < .05). Conversely, DI and AVAi did not vary with changes in hemodynamic conditions. Flow rate, not stroke volume was found to impact Gmean and Vpeak but not AVA and DI (P < .05). CONCLUSIONS Hemodynamic conditions may affect the AS ultrasound assessment. High SBP, or afterload, leads to an underestimation of AS severity when based on gradients and velocities. Systolic blood pressure monitoring and control are crucial during AS ultrasound assessment.
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Schauer A, Draskowski R, Jannasch A, Kirchhoff V, Goto K, Männel A, Barthel P, Augstein A, Winzer E, Tugtekin M, Labeit S, Linke A, Adams V. ZSF1 rat as animal model for HFpEF: Development of reduced diastolic function and skeletal muscle dysfunction. ESC Heart Fail 2020; 7:2123-2134. [PMID: 32710530 PMCID: PMC7524062 DOI: 10.1002/ehf2.12915] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 07/02/2020] [Accepted: 07/13/2020] [Indexed: 12/17/2022] Open
Abstract
AIMS The prevalence of heart failure with preserved ejection fraction (HFpEF) is still increasing, and so far, no pharmaceutical treatment has proven to be effective. A key obstacle for testing new pharmaceutical substances is the availability of suitable animal models for HFpEF, which realistically reflect the clinical picture. The aim of the present study was to characterize the development of HFpEF and skeletal muscle (SM) dysfunction in ZSF1 rats over time. METHODS AND RESULTS Echocardiography and functional analyses of the SM were performed in 6-, 10-, 15-, 20-, and 32-week-old ZSF1-lean and ZSF1-obese. Furthermore, myocardial and SM tissue was collected for molecular and histological analyses. HFpEF markers were evident as early as 10 weeks of age. Diastolic dysfunction, confirmed by a significant increase in E/e', was detectable at 10 weeks. Increased left ventricular mRNA expression of collagen and BNP was detected in ZSF1-obese animals as early as 15 and 20 weeks, respectively. The loss of muscle force was measurable in the extensor digitorum longus starting at 15 weeks, whereas the soleus muscle function was impaired at Week 32. In addition, at Week 20, markers for aortic valve sclerosis were increased. CONCLUSIONS Our measurements confirmed the appearance of HFpEF in ZSF1-obese rats as early as 10 weeks of age, most likely as a result of the pre-existing co-morbidities. In addition, SM function was reduced after the manifestation of HFpEF. In conclusion, the ZSF1 rat may serve as a suitable animal model to study pharmaceutical strategies for the treatment of HFpEF.
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Affiliation(s)
- Antje Schauer
- Laboratory of Molecular and Experimental Cardiology, TU Dresden, Heart Center Dresden, Fetscherstrasse 76, Dresden, 01307, Germany
| | - Runa Draskowski
- Laboratory of Molecular and Experimental Cardiology, TU Dresden, Heart Center Dresden, Fetscherstrasse 76, Dresden, 01307, Germany
| | - Anett Jannasch
- Department of Cardiac Surgery, Carl Gustav Carus Faculty of Medicine, Technische Universität Dresden, Heart Centre Dresden, Dresden, Germany
| | - Virginia Kirchhoff
- Laboratory of Molecular and Experimental Cardiology, TU Dresden, Heart Center Dresden, Fetscherstrasse 76, Dresden, 01307, Germany
| | - Keita Goto
- Laboratory of Molecular and Experimental Cardiology, TU Dresden, Heart Center Dresden, Fetscherstrasse 76, Dresden, 01307, Germany
| | - Anita Männel
- Laboratory of Molecular and Experimental Cardiology, TU Dresden, Heart Center Dresden, Fetscherstrasse 76, Dresden, 01307, Germany
| | - Peggy Barthel
- Laboratory of Molecular and Experimental Cardiology, TU Dresden, Heart Center Dresden, Fetscherstrasse 76, Dresden, 01307, Germany
| | - Antje Augstein
- Laboratory of Molecular and Experimental Cardiology, TU Dresden, Heart Center Dresden, Fetscherstrasse 76, Dresden, 01307, Germany
| | - Ephraim Winzer
- Laboratory of Molecular and Experimental Cardiology, TU Dresden, Heart Center Dresden, Fetscherstrasse 76, Dresden, 01307, Germany
| | - Malte Tugtekin
- Department of Cardiac Surgery, Carl Gustav Carus Faculty of Medicine, Technische Universität Dresden, Heart Centre Dresden, Dresden, Germany
| | - Siegfried Labeit
- Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Germany.,Myomedix GmbH, Neckargemünd, Germany
| | - Axel Linke
- Laboratory of Molecular and Experimental Cardiology, TU Dresden, Heart Center Dresden, Fetscherstrasse 76, Dresden, 01307, Germany.,Dresden Cardiovascular Research Institute and Core Laboratories GmbH, Dresden, Germany
| | - Volker Adams
- Laboratory of Molecular and Experimental Cardiology, TU Dresden, Heart Center Dresden, Fetscherstrasse 76, Dresden, 01307, Germany.,Dresden Cardiovascular Research Institute and Core Laboratories GmbH, Dresden, Germany
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25
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Katsi V, Georgiopoulos G, Oikonomou D, Aggeli C, Grassos C, Papadopoulos DP, Thomopoulos C, Marketou M, Dimitriadis K, Toutouzas K, Nihoyannopoulos P, Tsioufis C, Tousoulis D. Aortic Stenosis, Aortic Regurgitation and Arterial Hypertension. Curr Vasc Pharmacol 2020; 17:180-190. [PMID: 29295699 DOI: 10.2174/1570161116666180101165306] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 12/19/2017] [Accepted: 12/21/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND Hypertension (HT) is an important risk factor for cardiovascular disease and might precipitate pathology of the aortic valve. OBJECTIVE To investigate the association of HT with aortic dysfunction (including both aortic regurgitation and stenosis) and the impact of antihypertensive treatment on the natural course of underlying aortic disease. METHODS We performed a systematic review of the literature for all relevant articles assessing the correlation between HT and phenotype of aortic disease. RESULTS Co-existence of HT with aortic stenosis and aortic regurgitation is highly prevalent in hypertensive patients and predicts a worse prognosis. Certain antihypertensive agents may improve haemodynamic parameters (aortic jet velocity, aortic regurgitation volume) and remodeling of the left ventricle, but there is no strong evidence of benefit regarding clinical outcomes. Renin-angiotensin system inhibitors, among other vasodilators, are well-tolerated in aortic stenosis. CONCLUSION Several lines of evidence support a detrimental association between HT and aortic valve disease. Therefore, HT should be promptly treated in aortic valvulopathy. Despite conventional wisdom, specific vasodilators can be used with caution in aortic stenosis.
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Affiliation(s)
- V Katsi
- First Department of Cardiology, 'Hippokration' Hospital, University of Athens, Medical School, Athens, Greece
| | - G Georgiopoulos
- First Department of Cardiology, 'Hippokration' Hospital, University of Athens, Medical School, Athens, Greece
| | - D Oikonomou
- Department of Cardiology, 'Evaggelismos' General Hospital, Athens, Greece
| | - C Aggeli
- First Department of Cardiology, 'Hippokration' Hospital, University of Athens, Medical School, Athens, Greece
| | - C Grassos
- Department of Cardiology, 'KAT' General Hospital, Athens, Greece
| | - D P Papadopoulos
- Department of Cardiology, 'Laiko' General Hospital, Athens, Greece
| | - C Thomopoulos
- Department of Cardiology, Helena Venizelou Hospital, Athens, Greece
| | - M Marketou
- Department of Cardiology, Heraklion University Hospital, Crete, Greece
| | - K Dimitriadis
- First Department of Cardiology, 'Hippokration' Hospital, University of Athens, Medical School, Athens, Greece
| | - K Toutouzas
- First Department of Cardiology, 'Hippokration' Hospital, University of Athens, Medical School, Athens, Greece
| | - P Nihoyannopoulos
- First Department of Cardiology, 'Hippokration' Hospital, University of Athens, Medical School, Athens, Greece
| | - C Tsioufis
- First Department of Cardiology, 'Hippokration' Hospital, University of Athens, Medical School, Athens, Greece
| | - D Tousoulis
- First Department of Cardiology, 'Hippokration' Hospital, University of Athens, Medical School, Athens, Greece
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Mancusi C, de Simone G, Brguljan Hitij J, Sudano I, Mahfoud F, Parati G, Kahan T, Barbato E, Pierard LA, Garbi M, Flachskampf FA, Gerdts E. Management of patients with combined arterial hypertension and aortic valve stenosis: a consensus document from the Council on Hypertension and Council on Valvular Heart Disease of the European Society of Cardiology, the European Association of Cardiovascular Imaging (EACVI), and the European Association of Percutaneous Cardiovascular Interventions (EAPCI). EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2020; 7:242-250. [PMID: 32353143 DOI: 10.1093/ehjcvp/pvaa040] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 04/15/2020] [Accepted: 04/23/2020] [Indexed: 12/13/2022]
Abstract
Aortic valve stenosis (AS) is the third most common cardiovascular disease. The prevalence of both AS and arterial hypertension increases with age, and the conditions therefore often co-exist. Co-existence of AS and arterial hypertension is associated with higher global left ventricular (LV) pressure overload, more abnormal LV geometry and function, and more adverse cardiovascular outcome. Arterial hypertension may also influence grading of AS, leading to underestimation of the true AS severity. Current guidelines suggest re-assessing patients once arterial hypertension is controlled. Management of arterial hypertension in AS has historically been associated with prudence and concerns, mainly related to potential adverse consequences of drug-induced peripheral vasodilatation combined with reduced stroke volume due to the fixed LV outflow obstruction. Current evidence suggests that patients should be treated with antihypertensive drugs blocking the renin-angiotensin-aldosterone system, adding further drug classes when required, to achieve similar target blood pressure (BP) values as in hypertensive patients without AS. The introduction of transcatheter aortic valve implantation has revolutionized the management of patients with AS, but requires proper BP management during and following valve replacement. The purpose of this document is to review the recent evidence and provide practical expert advice on management of hypertension in patients with AS.
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Affiliation(s)
- Costantino Mancusi
- Hypertension Research Center, Federico II University Hospital, Naples, Italy.,Department of Advanced Biomedical Science, Federico II University of Naples, Naples, Italy
| | - Giovanni de Simone
- Hypertension Research Center, Federico II University Hospital, Naples, Italy.,Department of Advanced Biomedical Science, Federico II University of Naples, Naples, Italy
| | - Jana Brguljan Hitij
- Hypertension Division, Department of Internal Medicine, University Medical Centre Ljubljana, Medical Faculty Ljubljana, Ljubljana, Slovenia
| | - Isabella Sudano
- Department of Cardiology, University Heart Center Zurich, University Hospital of Zürich, Zürich, Switzerland
| | - Felix Mahfoud
- Department for Cardiology, Angiology, Intensive Medicine, Saarland University Hospital, Homburg/Saar, Germany
| | - Gianfranco Parati
- Department of Medicine and Surgery, University of Milano-Bicocca & Istituto Auxologico Italiano, IRCCS, Cardiology Unit, Milan, Italy
| | - Thomas Kahan
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Emanuele Barbato
- Hypertension Research Center, Federico II University Hospital, Naples, Italy.,Department of Advanced Biomedical Science, Federico II University of Naples, Naples, Italy
| | - Luc A Pierard
- Department of Cardiology, Heart Valve Clinic, University Hospital Sart-Tilman, Liège, Belgium
| | - Madalina Garbi
- Royal Papworth Hospital NHS Foundation Trust Papworth Road, Cambridge Biomedical Campus, Cambridge, UK
| | - Frank A Flachskampf
- Department of Medical Sciences, Uppsala University, and Clinical Physiology and Cardiology, Akademiska, Uppsala, Sweden
| | - Eva Gerdts
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
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Rahimi K, Mohseni H, Kiran A, Tran J, Nazarzadeh M, Rahimian F, Woodward M, Dwyer T, MacMahon S, Otto CM. Elevated blood pressure and risk of aortic valve disease: a cohort analysis of 5.4 million UK adults. Eur Heart J 2019; 39:3596-3603. [PMID: 30212891 PMCID: PMC6186276 DOI: 10.1093/eurheartj/ehy486] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 08/07/2018] [Indexed: 12/30/2022] Open
Abstract
Aims To test two related hypotheses that elevated blood pressure (BP) is a risk factor for aortic valve stenosis (AS) or regurgitation (AR). Methods and results In this cohort study of 5.4 million UK patients with no known cardiovascular disease or aortic valve disease at baseline, we investigated the relationship between BP and risk of incident AS and AR using multivariable-adjusted Cox regression models. Over a median follow-up of 9.2 years, 20 680 patients (0.38%) were diagnosed with AS and 6440 (0.12%) patients with AR. Systolic BP (SBP) was continuously related to the risk of AS and AR with no evidence of a nadir down to 115 mmHg. Each 20 mmHg increment in SBP was associated with a 41% higher risk of AS (hazard ratio 1.41, 95% confidence interval 1.38–1.45) and a 38% higher risk of AR (1.38, 1.31–1.45). Associations were stronger in younger patients but with no strong evidence for interaction by gender or body mass index. Each 10 mmHg increment in diastolic BP was associated with a 24% higher risk of AS (1.24, 1.19–1.29) but not AR (1.04, 0.97–1.11). Each 15 mmHg increment in pulse pressure was associated with a 46% greater risk of AS (1.46, 1.42–1.50) and a 53% higher risk of AR (1.53, 1.45–1.62). Conclusion Long-term exposure to elevated BP across its whole spectrum was associated with increased risk of AS and AR. The possible causal nature of the observed associations warrants further investigation.
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Affiliation(s)
- Kazem Rahimi
- The George Institute for Global Health, University of Oxford, Le Gros Clark Building, South Park Road, Oxford, UK.,Deep Medicine, Oxford Martin School, University of Oxford, UK.,Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Hamid Mohseni
- The George Institute for Global Health, University of Oxford, Le Gros Clark Building, South Park Road, Oxford, UK
| | - Amit Kiran
- The George Institute for Global Health, University of Oxford, Le Gros Clark Building, South Park Road, Oxford, UK
| | - Jenny Tran
- The George Institute for Global Health, University of Oxford, Le Gros Clark Building, South Park Road, Oxford, UK.,Deep Medicine, Oxford Martin School, University of Oxford, UK
| | - Milad Nazarzadeh
- The George Institute for Global Health, University of Oxford, Le Gros Clark Building, South Park Road, Oxford, UK.,Deep Medicine, Oxford Martin School, University of Oxford, UK.,The Collaboration Center of Meta-analysis Research, Torbat Heydariyeh University of Medical Sciences, Torbat Heydariyeh, Iran
| | - Fatemeh Rahimian
- The George Institute for Global Health, University of Oxford, Le Gros Clark Building, South Park Road, Oxford, UK.,Deep Medicine, Oxford Martin School, University of Oxford, UK
| | - Mark Woodward
- The George Institute for Global Health, University of Oxford, Le Gros Clark Building, South Park Road, Oxford, UK.,The George Institute for Global Health, University of Sydney, Sydney, Australia.,Department of Epidemiology, Johns Hopkins University, Baltimore MD, USA
| | - Terence Dwyer
- The George Institute for Global Health, University of Oxford, Le Gros Clark Building, South Park Road, Oxford, UK
| | - Stephen MacMahon
- The George Institute for Global Health, University of Oxford, Le Gros Clark Building, South Park Road, Oxford, UK.,The George Institute for Global Health, University of Sydney, Sydney, Australia
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28
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Gerdts E, Saeed S, Midtbø H, Rossebø A, Chambers JB, Einarsen E, Bahlmann E, Devereux R. Higher left ventricular mass-wall stress-heart rate product and outcome in aortic valve stenosis. Heart 2019; 105:1629-1633. [PMID: 31154431 PMCID: PMC6855785 DOI: 10.1136/heartjnl-2018-314462] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 05/08/2019] [Accepted: 05/09/2019] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVE Whether increased myocardial oxygen demand could help explain the association of left ventricular (LV) hypertrophy with higher adverse event rate in patients with aortic valve stenosis (AS) is unknown. METHODS Data from 1522 patients with asymptomatic mostly moderate AS participating in the Simvastatin-Ezetimibe in AS study followed for a median of 4.3 years was used. High LV mass-wall stress-heart rate product was identified as >upper 95% CI limit in normal subjects. The association of higher LV mass-wall stress-heart rate product with major cardiovascular (CV) events, combined CV death and hospitalised heart failure and all-cause mortality was tested in Cox regression analyses, and reported as HR and 95% CI. RESULTS High LV mass-wall stress-heart rate product was found in 19% at baseline, and associated with male sex, higher body mass index, hypertension, LV hypertrophy, more severe AS and lower LV ejection fraction (all p<0.01). Adjusting for these confounders in time-varying Cox regression analysis, 1 SD higher LV mass-wall stress-heart rate product was associated with higher HR of major CV events (HR 1.16(95% CI 1.06 to 1.29)), combined CV death and hospitalised heart failure (HR 1.29(95% CI 1.09 to 1.54)) and all-cause mortality (HR 1.34(95% CI 1.13 to 1.58), all p<0.01). CONCLUSION In patients with initially mild-moderate AS, higher LV mass-wall stress-heart rate product was associated with higher mortality and heart failure hospitalisation. Our results suggest that higher myocardial oxygen demand is contributing to the higher adverse event rate reported in AS patients with LV hypertrophy. TRIAL REGISTRATION NUMBER NCT000092677;Post-results.
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Affiliation(s)
- Eva Gerdts
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Sahrai Saeed
- Department of Heart Disease, Haukeland Universitetssjukehus, Bergen, Norway
| | - Helga Midtbø
- Department of Heart Disease, Haukeland Universitetssjukehus, Bergen, Norway
| | - Anne Rossebø
- Cardiology Department, Oslo University Hospital, Ullevål, Norway
| | | | - Eigir Einarsen
- Department of Clinical Science, University of Bergen, Bergen, Hordaland, Norway
| | - Edda Bahlmann
- Cardiology, Asklepios Clinic St. Georg, Hamburg, Germany
| | - Richard Devereux
- NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, USA
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Abstract
Regulation of coronary blood flow is maintained through a delicate balance of ventriculoarterial and neurohumoral mechanisms. The aortic valve is integral to the functions of these systems, and disease states that compromise aortic valve integrity have the potential to seriously disrupt coronary blood flow. Aortic stenosis (AS) is the most common cause of valvular heart disease requiring medical intervention, and the prevalence and associated socio-economic burden of AS are set to increase with population ageing. Valvular stenosis precipitates a cascade of structural, microcirculatory, and neurohumoral changes, which all lead to impairment of coronary flow reserve and myocardial ischaemia even in the absence of notable coronary stenosis. Coronary physiology can potentially be normalized through interventions that relieve severe AS, but normality is often not immediately achievable and probably requires continued adaptation. Finally, the physiological assessment of coronary artery disease in patients with AS represents an ongoing challenge, as the invasive physiological measures used in current cardiology practice are yet to be validated in this population. This Review discusses the key concepts of coronary pathophysiology in patients with AS through presentation of contemporary basic science and data from animal and human studies.
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30
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Aurigemma GP, Harrington CM. Left Ventricular Systolic Function and Outcome in Aortic Stenosis: The Long- and Short-Axis of it. JACC Cardiovasc Imaging 2019; 13:370-373. [PMID: 31005529 DOI: 10.1016/j.jcmg.2019.03.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 03/03/2019] [Accepted: 03/06/2019] [Indexed: 10/27/2022]
Affiliation(s)
- Gerard P Aurigemma
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts.
| | - Colleen M Harrington
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
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Ikonomidis I, Aboyans V, Blacher J, Brodmann M, Brutsaert DL, Chirinos JA, De Carlo M, Delgado V, Lancellotti P, Lekakis J, Mohty D, Nihoyannopoulos P, Parissis J, Rizzoni D, Ruschitzka F, Seferovic P, Stabile E, Tousoulis D, Vinereanu D, Vlachopoulos C, Vlastos D, Xaplanteris P, Zimlichman R, Metra M. The role of ventricular-arterial coupling in cardiac disease and heart failure: assessment, clinical implications and therapeutic interventions. A consensus document of the European Society of Cardiology Working Group on Aorta & Peripheral Vascular Diseases, European Association of Cardiovascular Imaging, and Heart Failure Association. Eur J Heart Fail 2019; 21:402-424. [PMID: 30859669 DOI: 10.1002/ejhf.1436] [Citation(s) in RCA: 183] [Impact Index Per Article: 36.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 01/09/2019] [Accepted: 01/10/2019] [Indexed: 02/06/2023] Open
Abstract
Ventricular-arterial coupling (VAC) plays a major role in the physiology of cardiac and aortic mechanics, as well as in the pathophysiology of cardiac disease. VAC assessment possesses independent diagnostic and prognostic value and may be used to refine riskstratification and monitor therapeutic interventions. Traditionally, VAC is assessed by the non-invasive measurement of the ratio of arterial (Ea) to ventricular end-systolic elastance (Ees). With disease progression, both Ea and Ees may become abnormal and the Ea/Ees ratio may approximate its normal values. Therefore, the measurement of each component of this ratio or of novel more sensitive markers of myocardial (e.g. global longitudinal strain) and arterial function (e.g. pulse wave velocity) may better characterize VAC. In valvular heart disease, systemic arterial compliance and valvulo-arterial impedance have an established diagnostic and prognostic value and may monitor the effects of valve replacement on vascular and cardiac function. Treatment guided to improve VAC through improvement of both or each one of its components may delay incidence of heart failure and possibly improve prognosis in heart failure. In this consensus document, we describe the pathophysiology, the methods of assessment as well as the clinical implications of VAC in cardiac diseases and heart failure. Finally, we focus on interventions that may improve VAC and thus modify prognosis.
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Affiliation(s)
- Ignatios Ikonomidis
- Second Cardiology Department, Echocardiography Department and Laboratory of Preventive Cardiology, Athens University Hospital Attikon, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Victor Aboyans
- Department of Cardiology, Dupuytren University Hospital, Limoges, France.,Inserm 1094, Limoges School of Medicine, Limoges, France
| | - Jacque Blacher
- Diagnosis and Therapeutic Center, Hypertension and Cardiovascular Prevention Unit, Paris-Descartes University, Hôtel-Dieu Hospital, AP-HP, Paris, France
| | - Marianne Brodmann
- Division of Angiology, Department of Internal Medicine, Medical University Graz, Graz, Austria
| | - Dirk L Brutsaert
- Department of Cardiology, University Hospital Antwerp, Edegem, Belgium
| | - Julio A Chirinos
- Perelman School of Medicine and Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia, PA, USA
| | - Marco De Carlo
- Cardiac Catheterization Laboratory, Cardiothoracic and Vascular Department, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Victoria Delgado
- Department of Cardiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Patrizio Lancellotti
- Department of Cardiology, University of Liège Hospital, GIGA Cardiovascular Sciences, CHU SantTilman, Liège, Belgium.,Gruppo Villa Maria Care and Research, Anthea Hospital, Bari, Italy
| | - John Lekakis
- Second Cardiology Department, Echocardiography Department and Laboratory of Preventive Cardiology, Athens University Hospital Attikon, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Dania Mohty
- Department of Cardiology, Dupuytren University Hospital, Limoges, France.,Inserm 1094, Limoges School of Medicine, Limoges, France
| | - Petros Nihoyannopoulos
- NHLI - National Heart and Lung Institute, Imperial College London, London, UK.,1st Department of Cardiology, Hippokration Hospital, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - John Parissis
- Heart Failure Unit, School of Medicine and Department of Cardiology, National and Kapodistrian University of Athens, Athens University Hospital Attikon, Athens, Greece
| | - Damiano Rizzoni
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Frank Ruschitzka
- Department of Cardiology, University Hospital, Zurich, University Heart Center, Zurich, Switzerland
| | - Petar Seferovic
- Cardiology Department, Clinical Centre Serbia, School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Eugenio Stabile
- Department of Advanced Biomedical Sciences, 'Federico II' University, Naples, Italy
| | - Dimitrios Tousoulis
- 1st Department of Cardiology, Hippokration Hospital, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Dragos Vinereanu
- University of Medicine and Pharmacy 'Carol Davila', and Department of Cardiology, University and Emergency Hospital, Bucharest, Romania
| | - Charalambos Vlachopoulos
- 1st Department of Cardiology, Hippokration Hospital, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Dimitrios Vlastos
- Second Cardiology Department, Echocardiography Department and Laboratory of Preventive Cardiology, Athens University Hospital Attikon, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Panagiotis Xaplanteris
- 1st Department of Cardiology, Hippokration Hospital, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Reuven Zimlichman
- Department of Medicine and Hypertension Institute, Brunner Institute for Cardiovascular Research, Sackler Faculty of Medicine, The E. Wolfson Medical Center, Institute for Quality in Medicine, Israeli Medical Association, Tel Aviv University, Tel Aviv, Israel
| | - Marco Metra
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
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32
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Tiwari N, Madan N. Hypertension and transcatheter aortic valve replacement: parallel or series? Integr Blood Press Control 2018; 11:81-91. [PMID: 30538539 PMCID: PMC6260138 DOI: 10.2147/ibpc.s177258] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Aortic stenosis (AS) is the most common valvular heart disease in the elderly and it causes significant morbidity and mortality. Hypertension is also highly prevalent in elderly patients with AS, and AS patients with hypertension have worse outcomes. Accurate assessment of AS severity and understanding its relationship with arterial compliance has become increasingly important as the options for valve management, particularly transcatheter interventions, have grown. The parameters used for quantifying stenosis severity have traditionally mainly focused on the valve itself. However, AS is now recognized as a systemic disease involving aging ventricles and stiff arteries rather than one limited solely to the valve. Over the last decade, valvuloarterial impedance, a measure of global ventricular load, has contributed to our understanding of the pathophysiology and course of AS in heterogeneous patients, even when segregated by symptoms and severity. This review summarizes our growing understanding of the interplay between ventricle, valve, and vessel, with a particular emphasis on downstream vascular changes after transcatheter aortic valve replacement and the role of valvuloarterial impedance in predicting left ventricular changes and prognosis in patients with various transvalvular flow patterns.
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Affiliation(s)
- Nidhish Tiwari
- Department of Internal Medicine, Jacobi Medical Center, Bronx, NY, USA, .,Department of Internal Medicine, Albert Einstein College of Medicine, Bronx, NY, USA,
| | - Nidhi Madan
- Department of Cardiology, Rush University Medical Center, Chicago, IL, USA
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Di Nora C, Cervesato E, Cosei I, Ravasel A, Popescu BA, Zito C, Carerj S, Antonini-Canterin F, Popescu AC. New classification of geometric ventricular patterns in severe aortic stenosis: Could it be clinically useful? Echocardiography 2018; 35:1077-1084. [PMID: 29663506 DOI: 10.1111/echo.13892] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND In severe aortic stenosis, different left ventricle (LV) remodeling patterns as a response to pressure overload have distinct hemodynamic profiles, cardiac function, and outcomes. The most common classification considers LV relative wall thickness and LV mass index to create 4 different groups. A new classification including also end-diastolic volume index has been recently proposed. AIM To describe the prevalence of the newly identified remodeling patterns in patients with severe aortic stenosis and to evaluate their clinical relevance according to symptoms. METHODS We analyzed 286 consecutive patients with isolated severe aortic stenosis. Current guidelines were used for echocardiographic evaluation. Symptoms were defined as the presence of angina, syncope, or NYHA class III-IV. RESULTS The mean age was 75 ± 9 years, 156 patients (54%) were men, while 158 (55%) were symptomatic. According to the new classification, the most frequent remodeling pattern was concentric hypertrophy (57.3%), followed by mixed (18.9%) and dilated hypertrophy (8.4%). There were no patients with eccentric remodeling; only 4 patients had a normalLV geometry. Symptomatic patients showed significantly more mixed hypertrophy (P < .05), while the difference regarding the prevalence of the other patterns was not statistically significant. When we analyzed the distribution of the classic 4 patterns stratified by the presence of symptoms, however, we did not find a significant difference (P = .157). CONCLUSIONS The new classification had refined the description of different cardiac geometric phenotypes that develop as a response to pressure overload. It might be superior to the classic 4 patterns in terms of association with symptoms.
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Affiliation(s)
- Concetta Di Nora
- Cardiovascular Department, ASUITS, University of Trieste, Trieste, Italy
| | | | - Iulian Cosei
- Institute of Cardiovascular Diseases "Prof. Dr. C. C. Iliescu", Bucharest, Romania
| | - Andreea Ravasel
- Institute of Cardiovascular Diseases "Prof. Dr. C. C. Iliescu", Bucharest, Romania
| | - Bogdan A Popescu
- Institute of Cardiovascular Diseases "Prof. Dr. C. C. Iliescu", Bucharest, Romania.,University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania
| | - Concetta Zito
- Cardiology Department, University of Messina, Messina, Italy
| | - Scipione Carerj
- Cardiology Department, University of Messina, Messina, Italy
| | | | - Andreea C Popescu
- University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania.,Cardiology Department, Elias Emergency Hospital, Bucharest, Romania
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Hahn RT, Nicoara A, Kapadia S, Svensson L, Martin R. Echocardiographic Imaging for Transcatheter Aortic Valve Replacement. J Am Soc Echocardiogr 2018; 31:405-433. [DOI: 10.1016/j.echo.2017.10.022] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Indexed: 02/06/2023]
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Hervault M, Clavel MA. Sex-related Differences in Calcific Aortic Valve Stenosis: Pathophysiology, Epidemiology, Etiology, Diagnosis, Presentation, and Outcomes. STRUCTURAL HEART-THE JOURNAL OF THE HEART TEAM 2018. [DOI: 10.1080/24748706.2017.1420273] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Maxime Hervault
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, Canada
| | - Marie-Annick Clavel
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, Canada
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Ngiam JN, Kuntjoro I, Tan BYQ, Sim HW, Kong WKF, Yeo TC, Poh KK. Predicting changes in flow category in patients with severe aortic stenosis and preserved left ventricular ejection fraction on medical therapy. Echocardiography 2017; 34:1568-1574. [DOI: 10.1111/echo.13676] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
Affiliation(s)
| | - Ivandito Kuntjoro
- Department of Cardiology; National University Heart Centre Singapore; National University Health System; Singapore Singapore
| | - Benjamin Y. Q. Tan
- Department of Medicine; National University Health System; Singapore Singapore
| | - Hui-Wen Sim
- Department of Cardiology; National University Heart Centre Singapore; National University Health System; Singapore Singapore
| | - William K. F. Kong
- Department of Cardiology; National University Heart Centre Singapore; National University Health System; Singapore Singapore
- Yong Loo Lin School of Medicine; National University of Singapore; Singapore Singapore
| | - Tiong-Cheng Yeo
- Department of Cardiology; National University Heart Centre Singapore; National University Health System; Singapore Singapore
- Yong Loo Lin School of Medicine; National University of Singapore; Singapore Singapore
| | - Kian-Keong Poh
- Department of Cardiology; National University Heart Centre Singapore; National University Health System; Singapore Singapore
- Yong Loo Lin School of Medicine; National University of Singapore; Singapore Singapore
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Abstract
Aortic stenosis (AS) is the most common primary valve disorder in the elderly with an increasing prevalence. It is increasingly clear that it is also a disease of the left ventricle (LV) rather than purely the aortic valve. The transition from left ventricular hypertrophy to fibrosis results in the eventual adverse effects on systolic and diastolic function. Appropriate selection of patients for aortic valve intervention is crucial, and current guidelines recommend aortic valve replacement in severe AS with symptoms or in asymptomatic patients with left ventricular ejection fraction (LVEF) <50 %. LVEF is not a sensitive marker and there are other parameters used in multimodality imaging techniques, including longitudinal strain, exercise stress echo and cardiac MRI that may assist in detecting subclinical and subtle LV dysfunction. These findings offer potentially better ways to evaluate patients, time surgery, predict recovery and potentially offer targets for specific therapies. This article outlines the pathophysiology behind the LV response to aortic stenosis and the role of advanced multimodality imaging in describing it.
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Côté N, Simard L, Zenses AS, Tastet L, Shen M, Clisson M, Clavel MA. Impact of Vascular Hemodynamics on Aortic Stenosis Evaluation: New Insights Into the Pathophysiology of Normal Flow-Small Aortic Valve Area-Low Gradient Pattern. J Am Heart Assoc 2017; 6:JAHA.117.006276. [PMID: 28687561 PMCID: PMC5586319 DOI: 10.1161/jaha.117.006276] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background About 50% of normal‐flow/low‐gradient patients (ie, low mean gradient [MG] or peak aortic jet velocity and small aortic valve area) have severe aortic valve calcification as measured by computed tomography. However, they are considered to have moderate aortic stenosis (AS) in current American College of Cardiology/American Heart Association guidelines. The objective was thus to evaluate the effect of hypertension and reduced arterial compliance (rAC) on MG and Vpeak measurements. Methods and Results Doppler‐echocardiography was performed in 4 sheep with experimentally induced severe and critical AS at: (1) normal aortic pressure, (2) during hypertension, and (3) with rAC. Hypertension and rAC induced a substantial decrease in MG/Vpeak compared with normal stage (both P≤0.03) despite a stable transvalvular flow (P>0.16). Hypertension and rAC resulted in a greater reduction of MG in critical (−42%) compared with severe (−35%) AS (P˂0.0001). Comprehensive Doppler‐echocardiography and computed tomography were performed in 220 AS patients (mean age: 69±13 years; MG 29±18 mm Hg) with normal flow. The population was divided in 3 groups according to the presence of hypertension and rAC. The slope of the linear association between MG/Vpeak and aortic valve calcification divided by the cross‐sectional area of the aortic annulus was significantly reduced in patients with hypertension and/or rAC compared with normotensive/normal AC patients (P<0.01). Accordingly, patients with normal‐flow/low‐gradient and severe aortic valve calcification density were more frequent in hypertension and rAC groups compared with the normotensive/normal‐AC group (16% and 12% compared with 2%; P=0.03). Conclusions Hypertension and rAC are associated with a substantial reduction in MG/Vpeak for similar aortic valve calcification (ie, similar AS anatomic severity), which may lead to underestimation of AS hemodynamic severity.
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Affiliation(s)
- Nancy Côté
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart & Lung Institute, Laval University, Québec City, Québec, Canada
| | - Louis Simard
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart & Lung Institute, Laval University, Québec City, Québec, Canada
| | - Anne-Sophie Zenses
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart & Lung Institute, Laval University, Québec City, Québec, Canada
| | - Lionel Tastet
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart & Lung Institute, Laval University, Québec City, Québec, Canada
| | - Mylène Shen
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart & Lung Institute, Laval University, Québec City, Québec, Canada
| | - Marine Clisson
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart & Lung Institute, Laval University, Québec City, Québec, Canada
| | - Marie-Annick Clavel
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart & Lung Institute, Laval University, Québec City, Québec, Canada
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Liakos CI, Grassos CA, Papadopoulos DP, Dimitriadis KS, Tsioufis CP, Tousoulis D. Arterial hypertension and aortic valve stenosis: Shedding light on a common “liaison”. Hellenic J Cardiol 2017; 58:261-266. [DOI: 10.1016/j.hjc.2017.03.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Revised: 03/11/2017] [Accepted: 03/17/2017] [Indexed: 10/19/2022] Open
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Sobczak S, Sakowicz A, Pietrucha T, Lelonek M. Diagnostic utility of biomarkers of left ventricular stress in patients with aortic stenosis and preserved left ventricular ejection fraction. KARDIOCHIRURGIA I TORAKOCHIRURGIA POLSKA = POLISH JOURNAL OF CARDIO-THORACIC SURGERY 2017; 14:93-98. [PMID: 28747939 PMCID: PMC5519833 DOI: 10.5114/kitp.2017.68737] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/10/2016] [Accepted: 04/11/2017] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Aortic stenosis (AS) is the most common acquired valvular heart disease. The early identification of patients with severe AS is crucial. NT-proBNP is a well-known biomarker of pressure overload, and its role in patients with AS has been demonstrated in previous studies. Another, less well-known biomarker of pressure overload is sST2 protein, and its role in AS is unclear. AIM To evaluate the utility of sST2 protein, NT-proBNP and selected clinical parameters in the assessment of degenerative AS severity in a population with preserved left ventricular ejection fraction (LVEF). MATERIAL AND METHODS Sixty-nine consecutive patients (mean age: 68.42 ±12.58 years, 55.07% male) with symptomatic degenerative AS and preserved LVEF ≥ 45% were prospectively included. At enrollment complete transthoracic echocardiographic examination, ECG analysis, and standard laboratory tests including NT-proBNP were performed and blood samples for sST2 were obtained. RESULTS There were 43 (62.32%) patients with severe AS. The multivariate stepwise linear regression models revealed that only systolic blood pressure (SBP), Sokolow-Lyon index and left ventricular end-diastolic diameter (LVEDD) were independently associated with severe AS. Spearman correlation coefficients analysis showed no correlations between sST2 levels and a mild to moderate correlation between NT-proBNP concentration and parameters of AS severity. However, levels of NT-proBNP (p = 0.1857) and sST2 (p = 0.7851) did not differentiate patients according to severity of AS. CONCLUSIONS In the study population with degenerative AS and preserved LVEF neither the NT-proBNP nor sST2 concentrations can be used to differentiate patients according to the severity of AS.
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Affiliation(s)
- Sebastian Sobczak
- Department of Noninvasive Cardiology, Medical University of Lodz, Poland
| | - Agata Sakowicz
- Department of Medical Biotechnology, Medical University of Lodz, Poland
| | - Tadeusz Pietrucha
- Department of Medical Biotechnology, Medical University of Lodz, Poland
| | - Malgorzata Lelonek
- Department of Noninvasive Cardiology, Medical University of Lodz, Poland
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Mirtschink P, Krek W. Hypoxia-driven glycolytic and fructolytic metabolic programs: Pivotal to hypertrophic heart disease. BIOCHIMICA ET BIOPHYSICA ACTA-MOLECULAR CELL RESEARCH 2016; 1863:1822-8. [DOI: 10.1016/j.bbamcr.2016.02.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 01/28/2016] [Accepted: 02/13/2016] [Indexed: 01/21/2023]
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Abstract
Calcified aortic stenosis is one of the most common causes of heart failure in the elderly. Current guidelines recommend aortic valve replacement in patients with severe disease and evidence of decompensation based on either symptoms or impaired systolic ejection fraction. However, symptoms are often subjective whilst impaired ejection fraction is not a sensitive marker of ventricular decompensation. Interest has surrounded the use of cardiac biochemical markers as objective measures of left ventricular decompensation in aortic stenosis. We will first examine mechanisms of release of biochemical markers associated with myocardial wall stress (BNP/NT-proBNP), myocardial fibrosis (markers of collagen metabolism, galectin-3, soluble ST2) and myocyte death/myocardial ischemia (high-sensitivity cardiac troponins, heart-type fatty acid binding protein, myosin-binding protein C); and discuss future directions of these markers.
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Affiliation(s)
- Calvin W L Chin
- a Department of Cardiovascular Medicine , National Heart Center Singapore , Singapore .,b Duke-NUS Graduate Medical School , Singapore
| | - Andie H Djohan
- c Barts and the London School of Medicine & Dentistry, Queen Mary, University of London , London , UK , and
| | - Chim C Lang
- d Division of Cardiovascular and Diabetes Medicine , University of Dundee , Dundee , UK
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Tastet L, Capoulade R, Clavel MA, Larose É, Shen M, Dahou A, Arsenault M, Mathieu P, Bédard É, Dumesnil JG, Tremblay A, Bossé Y, Després JP, Pibarot P. Systolic hypertension and progression of aortic valve calcification in patients with aortic stenosis: results from the PROGRESSA study. Eur Heart J Cardiovasc Imaging 2016; 18:70-78. [PMID: 26896413 DOI: 10.1093/ehjci/jew013] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 01/14/2016] [Indexed: 01/12/2023] Open
Abstract
AIMS Hypertension is highly prevalent in patients with aortic stenosis (AS) and is associated with worse outcomes. The current prospective study assessed the impact of systolic hypertension (SHPT) on the progression of aortic valve calcification (AVC) measured by multidetector computed tomography (MDCT) in patients with AS. METHODS AND RESULTS The present analysis includes the first series of 101 patients with AS prospectively recruited in the PROGRESSA study. Patients underwent comprehensive Doppler echocardiography and MDCT exams at baseline and after 2-year follow-up. AVC and coronary artery calcification (CAC) were measured using the Agatston method. Patients with SHPT at baseline (i.e. systolic blood pressure ≥140 mmHg; n = 37, 37%) had faster 2-year AVC progression compared with those without SHPT (i.e. systolic blood pressure <140 mmHg) (AVC median [25th percentile-75th percentile]: +370 [126-824] vs. +157 [58-303] AU; P = 0.007, respectively). Similar results were obtained with the analysis of AVC progression divided by the cross-sectional area of the aortic annulus (AVCdensity: +96 [34-218] vs. +45 [14-82] AU/cm2, P = 0.01, respectively). In multivariable analysis, SHPT remained significantly associated with faster progression of AVC or AVCdensity (all P = 0.001). There was no significant difference between groups with respect to progression of CAC (+39 [3-199] vs. +41 [0-156] AU, P = 0.88). CONCLUSION This prospective study shows for the first time that SHPT is associated with faster AVC progression but not with CAC progression in AS patients. These findings provide further support for the elaboration of randomized clinical trials to assess the efficacy of antihypertensive medication to slow the stenosis progression in patients with AS.
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Affiliation(s)
- Lionel Tastet
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, 2725 Chemin Sainte-Foy, Québec city, Québec, Canada G1V-4G5
| | - Romain Capoulade
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, 2725 Chemin Sainte-Foy, Québec city, Québec, Canada G1V-4G5
| | - Marie-Annick Clavel
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, 2725 Chemin Sainte-Foy, Québec city, Québec, Canada G1V-4G5
| | - Éric Larose
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, 2725 Chemin Sainte-Foy, Québec city, Québec, Canada G1V-4G5
| | - Mylène Shen
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, 2725 Chemin Sainte-Foy, Québec city, Québec, Canada G1V-4G5
| | - Abdellaziz Dahou
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, 2725 Chemin Sainte-Foy, Québec city, Québec, Canada G1V-4G5
| | - Marie Arsenault
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, 2725 Chemin Sainte-Foy, Québec city, Québec, Canada G1V-4G5
| | - Patrick Mathieu
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, 2725 Chemin Sainte-Foy, Québec city, Québec, Canada G1V-4G5
| | - Élisabeth Bédard
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, 2725 Chemin Sainte-Foy, Québec city, Québec, Canada G1V-4G5
| | - Jean G Dumesnil
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, 2725 Chemin Sainte-Foy, Québec city, Québec, Canada G1V-4G5
| | - Alexe Tremblay
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, 2725 Chemin Sainte-Foy, Québec city, Québec, Canada G1V-4G5
| | - Yohan Bossé
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, 2725 Chemin Sainte-Foy, Québec city, Québec, Canada G1V-4G5
| | - Jean-Pierre Després
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, 2725 Chemin Sainte-Foy, Québec city, Québec, Canada G1V-4G5
| | - Philippe Pibarot
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, 2725 Chemin Sainte-Foy, Québec city, Québec, Canada G1V-4G5
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Ma SP, Vunjak-Novakovic G. Tissue-Engineering for the Study of Cardiac Biomechanics. J Biomech Eng 2016; 138:021010. [PMID: 26720588 PMCID: PMC4845250 DOI: 10.1115/1.4032355] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Indexed: 12/13/2022]
Abstract
The notion that both adaptive and maladaptive cardiac remodeling occurs in response to mechanical loading has informed recent progress in cardiac tissue engineering. Today, human cardiac tissues engineered in vitro offer complementary knowledge to that currently provided by animal models, with profound implications to personalized medicine. We review here recent advances in the understanding of the roles of mechanical signals in normal and pathological cardiac function, and their application in clinical translation of tissue engineering strategies to regenerative medicine and in vitro study of disease.
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Affiliation(s)
- Stephen P. Ma
- Department of Biomedical Engineering,
Columbia University,
622 West 168th Street,
VC12-234,
New York, NY 10032
e-mail:
| | - Gordana Vunjak-Novakovic
- Department of Biomedical Engineering
and Department of Medicine,
Columbia University,
622 West 168th Street,
VC12-234,
New York, NY 10032
e-mail:
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Kurisu S, Higaki T, Ikenaga H, Watanabe N, Shimonaga T, Iwasaki T, Ishibashi K, Dohi Y, Fukuda Y, Kihara Y. Mean platelet volume and left ventricular geometry in patients with aortic valve stenosis. Clin Exp Hypertens 2015; 37:661-5. [PMID: 26151824 DOI: 10.3109/10641963.2015.1047942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Mean platelet volume (MPV) is a well-established marker of platelet activation. In the current study, we compared MPV between patients with aortic valve stenosis (AS) and control subjects. We also assessed the association between MPV and left ventricular geometry in patients with AS. METHODS AND RESULTS The study population consisted of 75 patients with AS and 38 age- and sex-matched control subjects. In patients with AS, peak pressure gradient was 83.0 ± 30.8 mm Hg. MPV was significantly larger in patients with AS than control subjects (10.57 ± 1.05 fl versus 9.72 ± 0.66 fl, p < 0.001). There was a significant association between peak pressure gradient and MPV in 75 patients with AS and 38 control subjects (r = 0.35, p < 0.001). Among the patients with AS, there were 12 patients with normal geometry, 10 patients with concentric remodeling, 14 patients with eccentric hypertrophy and 39 patients with concentric hypertrophy. There was no significant difference in MPV among the four groups. There was no significant association between MPV and LVM index. CONCLUSIONS Our data suggested that MPV increased in patients with AS, but did not reflect left ventricular geometry.
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Affiliation(s)
- Satoshi Kurisu
- a Department of Cardiovascular Medicine , Hiroshima University Graduate School of Biomedical and Health Sciences , Hiroshima , Japan
| | - Tadanao Higaki
- a Department of Cardiovascular Medicine , Hiroshima University Graduate School of Biomedical and Health Sciences , Hiroshima , Japan
| | - Hiroki Ikenaga
- a Department of Cardiovascular Medicine , Hiroshima University Graduate School of Biomedical and Health Sciences , Hiroshima , Japan
| | - Noriaki Watanabe
- a Department of Cardiovascular Medicine , Hiroshima University Graduate School of Biomedical and Health Sciences , Hiroshima , Japan
| | - Takashi Shimonaga
- a Department of Cardiovascular Medicine , Hiroshima University Graduate School of Biomedical and Health Sciences , Hiroshima , Japan
| | - Toshitaka Iwasaki
- a Department of Cardiovascular Medicine , Hiroshima University Graduate School of Biomedical and Health Sciences , Hiroshima , Japan
| | - Ken Ishibashi
- a Department of Cardiovascular Medicine , Hiroshima University Graduate School of Biomedical and Health Sciences , Hiroshima , Japan
| | - Yoshihiro Dohi
- a Department of Cardiovascular Medicine , Hiroshima University Graduate School of Biomedical and Health Sciences , Hiroshima , Japan
| | - Yukihiro Fukuda
- a Department of Cardiovascular Medicine , Hiroshima University Graduate School of Biomedical and Health Sciences , Hiroshima , Japan
| | - Yasuki Kihara
- a Department of Cardiovascular Medicine , Hiroshima University Graduate School of Biomedical and Health Sciences , Hiroshima , Japan
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Calin A, Mateescu AD, Popescu BA. Considerations of hypertensive status in treating aortic stenosis. Interv Cardiol 2015. [DOI: 10.2217/ica.15.16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Cramariuc D, Gerdts E, Hjertaas JJ, Cramariuc A, Davidsen ES, Matre K. Myocardial function in aortic stenosis--insights from radial multilayer Doppler strain. Cardiovasc Ultrasound 2015; 13:8. [PMID: 25890306 PMCID: PMC4340885 DOI: 10.1186/s12947-015-0001-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Accepted: 02/05/2015] [Indexed: 01/19/2023] Open
Abstract
Background Left ventricular (LV) radial tissue Doppler imaging (TDI) strain increases gradually from the subepicardial to the subendocardial layer in healthy individuals. A speckle tracking echocardiography study suggested this gradient to be reduced in parallel with increasing aortic stenosis (AS) severity. Methods We used TDI strain in 84 patients with AS (mean age 73 ± 10 years, 56% hypertensive) for superior assessment of layer strain. 38 patients had non-severe and 46 severe AS by aortic valve area corrected for pressure recovery. Peak systolic radial TDI strain was measured in the subendocardial, mid-myocardial and subepicardial layers of the basal inferior LV wall, each within a region of interest of 2 × 6 mm (strain length 2 mm). Results Radial strain was lower in the subepicardial layer (33.4 ± 38.6%) compared to the mid-myocardial and subendocardial layers (50.3 ± 37.3% and 53.0 ± 40.0%, respectively, both p < 0.001 vs. subepicardial). In the subendo- and midmyocardium, radial strain was lower in patients with severe AS compared to those with non-severe AS (p < 0.05). In multivariate regression analyses including age, heart rate, inferior wall thickness, hypertension, and AS severity, radial strain in the mid-myocardium was primarily attenuated by presence of hypertension (β = −0.23) and AS severity (β = −0.26, both p < 0.05), while radial strain in the subendocardium was significantly influenced by AS severity only (β = −0.35, p < 0.01). Conclusions In AS, both the AS severity and concomitant hypertension attenuate radial TDI strain in the inferior LV wall. The subendocardial radial strain is mainly influenced by AS severity, while midmyocardial radial strain is attenuated by both hypertension and AS severity.
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Affiliation(s)
- Dana Cramariuc
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway.
| | - Eva Gerdts
- Department of Clinical Science, University of Bergen, Bergen, Norway.
| | | | | | | | - Knut Matre
- Department of Clinical Science, University of Bergen, Bergen, Norway.
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Magne J, Mohty D, Boulogne C, Deltreuil M, Cassat C, Echahidi N, Laskar M, Lacroix P, Virot P, Aboyans V. Prognostic impact of global left ventricular hemodynamic afterload in severe aortic stenosis with preserved ejection fraction. Int J Cardiol 2015; 180:158-64. [DOI: 10.1016/j.ijcard.2014.11.180] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Accepted: 11/23/2014] [Indexed: 11/27/2022]
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Kruszelnicka O, Chmiela M, Bobrowska B, Świerszcz J, Bhagavatula S, Bednarek J, Surdacki A, Nessler J, Hryniewiecki T. Depressed Systemic Arterial Compliance is Associated with the Severity of Heart Failure Symptoms in Moderate-to-Severe Aortic Stenosis: a Cross-Sectional Retrospective Study. Int J Med Sci 2015; 12:552-8. [PMID: 26180511 PMCID: PMC4502059 DOI: 10.7150/ijms.12262] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Accepted: 05/25/2015] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Patients with aortic stenosis (AS) may develop heart failure even in the absence of severe valve stenosis. Our aim was to assess the contribution of systemic arterial properties and the global left ventricular afterload to graded heart failure symptoms in AS. METHODS We retrospectively reviewed medical records of 157 consecutive subjects (mean age, 71±10 years; 79 women and 78 men) hospitalized owing to moderate-to-severe degenerative AS. Exclusion criteria included more than mild aortic insufficiency or disease of another valve, atrial fibrillation, coronary artery disease, severe respiratory disease or anemia. Heart failure symptoms were graded by NYHA class at admission. Systemic arterial compliance (SAC) and valvulo-arterial impedance (Zva) were derived from routine echocardiography and blood pressure. RESULTS Sixty-one patients were asymptomatic, 49 presented mild (NYHA II) and 47 moderate-to-severe (NYHA III-IV) heart failure symptoms. Mild symptoms were associated with lower SAC and transvalvular gradients, while more severe exercise intolerance coincided with older age, lower systolic blood pressure, smaller aortic valve area and depressed ejection fraction. By multiple ordinal logistic regression, the severity of heart failure symptoms was related to older age, depressed ejection fraction and lower SAC. Each decrease in SAC by 0.1 ml/m² per mmHg was associated with an increased adjusted odds ratio (OR) of a patient being in one higher category of heart failure symptoms graded as no symptoms, mild exercise intolerance and advanced exercise intolerance (OR: 1.16 [95% CI, 1.01-1.35], P=0.045). CONCLUSIONS Depressed SAC may enhance exercise intolerance irrespective of stenosis severity or left ventricular systolic function in moderate-to-severe AS. This finding supports the importance of non-valvular factors for symptomatic status in AS.
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Affiliation(s)
- Olga Kruszelnicka
- 1. Department of Coronary Artery Disease and Heart Failure, Jagiellonian University Medical College and John Paul II Hospital, Cracow, Poland
| | - Mark Chmiela
- 2. School of Medicine in English, Jagiellonian University Medical College, Cracow, Poland
| | - Beata Bobrowska
- 3. Second Department of Cardiology and Cardiovascular Interventions, Jagiellonian University Medical College and University Hospital, Cracow, Poland
| | - Jolanta Świerszcz
- 3. Second Department of Cardiology and Cardiovascular Interventions, Jagiellonian University Medical College and University Hospital, Cracow, Poland
| | - Seetha Bhagavatula
- 2. School of Medicine in English, Jagiellonian University Medical College, Cracow, Poland
| | - Jacek Bednarek
- 4. Department of Electrocardiology, Jagiellonian University Medical College and John Paul II Hospital, Cracow, Poland
| | - Andrzej Surdacki
- 3. Second Department of Cardiology and Cardiovascular Interventions, Jagiellonian University Medical College and University Hospital, Cracow, Poland
| | - Jadwiga Nessler
- 1. Department of Coronary Artery Disease and Heart Failure, Jagiellonian University Medical College and John Paul II Hospital, Cracow, Poland
| | - Tomasz Hryniewiecki
- 5. Department of Valvular Heart Defects, Institute of Cardiology, Warsaw, Poland
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50
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Kurisu S, Iwasaki T, Ikenaga H, Watanabe N, Higaki T, Shimonaga T, Ishibashi K, Mitsuba N, Dohi Y, Kihara Y. Thallium-201 gated single-photon emission tomography for assessing left ventricular volumes and function in patients with aortic valve stenosis: Comparison with echocardiography as the reference standard. IJC HEART & VASCULATURE 2014; 5:74-78. [PMID: 28785618 PMCID: PMC5497158 DOI: 10.1016/j.ijcha.2014.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 09/21/2014] [Indexed: 11/25/2022]
Abstract
Background Aortic valve stenosis (AS) is characterized by chronic left ventricular pressure overload, leading to left ventricular hypertrophy (LVH). We assessed correlations in left ventricular volumes and function between echocardiography and quantitative gated SPECT (QGS) in patients with AS. Methods and results The study population consisted of 28 patients with AS defined as a peak velocity of > 3.0 m/s and 28 age- and sex-matched control subjects. Patients with AS had a peak pressure gradient of 73.4 ± 24.5 mm Hg and a larger LVM index compared to control subjects (115.5 ± 29.2 g/m2 vs 78.3 ± 12.1 g/m2, p < 0.01). There were good correlations in end-diastolic volume and end-systolic volume between echocardiography and QGS in patients with AS as well as control subjects. Bland–Altman plot for end-systolic volume showed a significant negative slope of − 0.51 in patients with AS. There was a good correlation in ejection fraction between the 2 methods in patients with AS as well as control subjects. However, Bland–Altman plots showed significant negative slopes of − 0.40 in patients with AS and − 0.74 in control subjects. Conclusions Our data suggested that QGS was a useful method for assessing left ventricular volumes and function even in patients with AS. Cardiologists should recognize its specific characteristics.
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