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Synetos A, Vlasopoulou K, Drakopoulou M, Apostolos A, Ktenopoulos N, Katsaros O, Korovesis T, Latsios G, Tsioufis K. Impact of Stress Echocardiography on Aortic Valve Stenosis Management. J Clin Med 2024; 13:3495. [PMID: 38930024 PMCID: PMC11204470 DOI: 10.3390/jcm13123495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/23/2024] [Accepted: 06/05/2024] [Indexed: 06/28/2024] Open
Abstract
Rest and stress echocardiography (SE) play a fundamental role in the evaluation of aortic valve stenosis (AS). According to the current guidelines for the echocardiographic evaluation of patients with aortic stenosis, four broad categories can be defined: high-gradient AS (mean gradient ≥ 40 mmHg, peak velocity ≥ 4 m/s, aortic valve area (AVA) ≤ 1 cm2 or indexed AVA ≤ 0.6 cm2/m2); low-flow, low-gradient AS with reduced ejection fraction (mean gradient < 40 mmHg, AVA ≤ 1 cm2, left ventricle ejection fraction (LVEF) < 50%, stroke volume index (Svi) ≤ 35 mL/m2); low-flow, low-gradient AS with preserved ejection fraction (mean gradient < 40 mmHg, AVA ≤ 1 cm2, LVEF ≥ 50%, SVi ≤ 35 mL/m2); and normal-flow, low-gradient AS with preserved ejection fraction (mean gradient < 40 mmHg, AVA ≤ 1 cm2, indexed AVA ≤ 0.6 cm2/m2, LVEF ≥ 50%, SVi > 35 mL/m2). Aortic valve replacement (AVR) is indicated with the onset of symptoms development or LVEF reduction. However, there is often mismatch between resting transthoracic echocardiography findings and patient's symptoms. In these discordant cases, SE and CT calcium scoring are among the indicated methods to guide the management decision making. Additionally, due to the increasing evidence that in asymptomatic severe aortic stenosis an early AVR instead of conservative treatment is associated with better outcomes, SE can help identify those that would benefit from an early AVR by revealing markers of poor prognosis. Low-flow, low-gradient AS represents a challenge both in diagnosis and in therapeutic management. Low-dose dobutamine SE is the recommended method to distinguish true-severe from pseudo-severe stenosis and assess the existence of flow (contractile) reserve to appropriately guide the need for intervention in these patients.
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Affiliation(s)
- Andreas Synetos
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration General Hospital of Athens, 11527 Athens, Greece; (M.D.); (A.A.); (N.K.); (O.K.); (T.K.)
- School of Medicine, European University of Cyprus, 2404 Egkomi, Cyprus
| | - Konstantina Vlasopoulou
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration General Hospital of Athens, 11527 Athens, Greece; (M.D.); (A.A.); (N.K.); (O.K.); (T.K.)
| | - Maria Drakopoulou
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration General Hospital of Athens, 11527 Athens, Greece; (M.D.); (A.A.); (N.K.); (O.K.); (T.K.)
| | - Anastasios Apostolos
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration General Hospital of Athens, 11527 Athens, Greece; (M.D.); (A.A.); (N.K.); (O.K.); (T.K.)
| | - Nikolaos Ktenopoulos
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration General Hospital of Athens, 11527 Athens, Greece; (M.D.); (A.A.); (N.K.); (O.K.); (T.K.)
| | - Odysseas Katsaros
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration General Hospital of Athens, 11527 Athens, Greece; (M.D.); (A.A.); (N.K.); (O.K.); (T.K.)
| | - Theofanis Korovesis
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration General Hospital of Athens, 11527 Athens, Greece; (M.D.); (A.A.); (N.K.); (O.K.); (T.K.)
| | - George Latsios
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration General Hospital of Athens, 11527 Athens, Greece; (M.D.); (A.A.); (N.K.); (O.K.); (T.K.)
| | - Kostas Tsioufis
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration General Hospital of Athens, 11527 Athens, Greece; (M.D.); (A.A.); (N.K.); (O.K.); (T.K.)
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Almeida ALC, Melo MDTD, Bihan DCDSL, Vieira MLC, Pena JLB, Del Castillo JM, Abensur H, Hortegal RDA, Otto MEB, Piveta RB, Dantas MR, Assef JE, Beck ALDS, Santo THCE, Silva TDO, Salemi VMC, Rocon C, Lima MSM, Barberato SH, Rodrigues AC, Rabschkowisky A, Frota DDCR, Gripp EDA, Barretto RBDM, Silva SME, Cauduro SA, Pinheiro AC, Araujo SPD, Tressino CG, Silva CES, Monaco CG, Paiva MG, Fisher CH, Alves MSL, Grau CRPDC, Santos MVCD, Guimarães ICB, Morhy SS, Leal GN, Soares AM, Cruz CBBV, Guimarães Filho FV, Assunção BMBL, Fernandes RM, Saraiva RM, Tsutsui JM, Soares FLDJ, Falcão SNDRS, Hotta VT, Armstrong ADC, Hygidio DDA, Miglioranza MH, Camarozano AC, Lopes MMU, Cerci RJ, Siqueira MEMD, Torreão JA, Rochitte CE, Felix A. Position Statement on the Use of Myocardial Strain in Cardiology Routines by the Brazilian Society of Cardiology's Department Of Cardiovascular Imaging - 2023. Arq Bras Cardiol 2023; 120:e20230646. [PMID: 38232246 DOI: 10.36660/abc.20230646] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2024] Open
Abstract
Central Illustration : Position Statement on the Use of Myocardial Strain in Cardiology Routines by the Brazilian Society of Cardiology's Department Of Cardiovascular Imaging - 2023 Proposal for including strain in the integrated diastolic function assessment algorithm, adapted from Nagueh et al.67 Am: mitral A-wave duration; Ap: reverse pulmonary A-wave duration; DD: diastolic dysfunction; LA: left atrium; LASr: LA strain reserve; LVGLS: left ventricular global longitudinal strain; TI: tricuspid insufficiency. Confirm concentric remodeling with LVGLS. In LVEF, mitral E wave deceleration time < 160 ms and pulmonary S-wave < D-wave are also parameters of increased filling pressure. This algorithm does not apply to patients with atrial fibrillation (AF), mitral annulus calcification, > mild mitral valve disease, left bundle branch block, paced rhythm, prosthetic valves, or severe primary pulmonary hypertension.
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Affiliation(s)
| | | | | | - Marcelo Luiz Campos Vieira
- Instituto do Coração da Faculdade de Medicina da Universidade de São Paulo (Incor/FMUSP), São Paulo, SP - Brasil
| | - José Luiz Barros Pena
- Faculdade Ciências Médicas de Minas Gerais, Belo Horizonte, MG - Brasil
- Hospital Felicio Rocho, Belo Horizonte, MG - Brasil
| | | | - Henry Abensur
- Beneficência Portuguesa de São Paulo, São Paulo, SP - Brasil
| | | | | | | | | | | | | | | | | | - Vera Maria Cury Salemi
- Instituto do Coração da Faculdade de Medicina da Universidade de São Paulo (Incor/FMUSP), São Paulo, SP - Brasil
| | - Camila Rocon
- Hospital do Coração (HCor), São Paulo, SP - Brasil
| | - Márcio Silva Miguel Lima
- Instituto do Coração da Faculdade de Medicina da Universidade de São Paulo (Incor/FMUSP), São Paulo, SP - Brasil
| | | | | | | | | | - Eliza de Almeida Gripp
- Hospital Pró-Cardiaco, Rio de Janeiro, RJ - Brasil
- Hospital Universitário Antônio Pedro da Universidade Federal Fluminense (UFF), Rio de Janeiro, RJ - Brasil
| | | | | | | | | | | | | | | | | | | | | | | | | | - Maria Veronica Camara Dos Santos
- Departamento de Cardiologia Pediátrica (DCC/CP) da Sociedade Brasileira de Cardiologia (SBC), São Paulo, SP - Brasil
- Sociedade Brasileira de Oncologia Pediátrica, São Paulo, SP - Brasil
| | | | | | - Gabriela Nunes Leal
- Instituto da Criança e do Adolescente do Hospital das Clinicas Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
| | | | | | | | | | | | | | | | | | | | - Viviane Tiemi Hotta
- Instituto do Coração da Faculdade de Medicina da Universidade de São Paulo (Incor/FMUSP), São Paulo, SP - Brasil
- Grupo Fleury, São Paulo, SP - Brasil
| | | | - Daniel de Andrade Hygidio
- Hospital Nossa Senhora da Conceição, Tubarão, SC - Brasil
- Universidade do Sul de Santa Catarina (UNISUL), Tubarão, SC - Brasil
| | - Marcelo Haertel Miglioranza
- EcoHaertel - Hospital Mae de Deus, Porto Alegre, RS - Brasil
- Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS - Brasil
| | | | | | | | | | - Jorge Andion Torreão
- Hospital Santa Izabel, Salvador, BA - Brasil
- Santa Casa da Bahia, Salvador, BA - Brasil
| | - Carlos Eduardo Rochitte
- Instituto do Coração da Faculdade de Medicina da Universidade de São Paulo (Incor/FMUSP), São Paulo, SP - Brasil
- Hospital do Coração (HCor), São Paulo, SP - Brasil
| | - Alex Felix
- Diagnósticos da América SA (DASA), São Paulo, SP - Brasil
- Instituto Nacional de Cardiologia (INC), Rio de Janeiro, RJ - Brasil
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Vamvakidou A, Annabi MS, Pibarot P, Plonska-Gosciniak E, Almeida AG, Guzzetti E, Dahou A, Burwash IG, Koschutnik M, Bartko PE, Bergler-Klein J, Mascherbauer J, Orwat S, Baumgartner H, Cavalcante J, Pinto F, Kukulski T, Kasprzak JD, Clavel MA, Flachskampf FA, Senior R. Clinical Value of Stress Transaortic Flow Rate During Dobutamine Echocardiography in Reduced Left Ventricular Ejection Fraction, Low-Gradient Aortic Stenosis: A Multicenter Study. Circ Cardiovasc Imaging 2021; 14:e012809. [PMID: 34743529 DOI: 10.1161/circimaging.121.012809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Low rest transaortic flow rate (FR) has been shown previously to predict mortality in low-gradient aortic stenosis. However limited prognostic data exists on stress FR during low-dose dobutamine stress echocardiography. We aimed to assess the value of stress FR for the detection of aortic valve stenosis (AS) severity and the prediction of mortality. METHODS This is a multicenter cohort study of patients with reduced left ventricular ejection fraction and low-gradient aortic stenosis (aortic valve area <1 cm2 and mean gradient <40 mm Hg) who underwent low-dose dobutamine stress echocardiography to identify the AS severity and presence of flow reserve. The outcome assessed was all-cause mortality. RESULTS Of the 287 patients (mean age, 75±10 years; males, 71%; left ventricular ejection fraction, 31±10%) over a mean follow-up of 24±30 months there were 127 (44.3%) deaths and 147 (51.2%) patients underwent aortic valve intervention. Higher stress FR was independently associated with reduced risk of mortality (hazard ratio, 0.97 [95% CI, 0.94-0.99]; P=0.01) after adjusting for age, chronic kidney disease, heart failure symptoms, aortic valve intervention, and rest left ventricular ejection fraction. The minimum cutoff for prediction of mortality was stress FR 210 mL/s. Following adjustment to the same important clinical and echocardiographic parameters, among the three criteria of AS severity during stress, ie, the guideline definition of aortic valve area <1cm2 and aortic valve mean gradient ≥40 mm Hg, or aortic valve mean gradient ≥40 mm Hg, or the novel definition of aortic valve area <1 cm2 at stress FR ≥210 mL/s, only the latter was independently associated with mortality (hazard ratio, 1.72 [95% CI, 1.05-2.82]; P=0.03). Furthermore aortic valve area <1cm2 at stress FR ≥210 mL/s was the only severe aortic stenosis criterion that was associated with improved outcome following aortic valve intervention (P<0.001). Guideline-defined stroke volume flow reserve did not predict mortality. CONCLUSIONS Stress FR during low-dose dobutamine stress echocardiography was useful for the detection of both AS severity and flow reserve and was associated with improved prediction of outcome following aortic valve intervention.
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Affiliation(s)
- Anastasia Vamvakidou
- Department of Echocardiography, Royal Brompton Hospital, London, United Kingdom (A.V., R.S.).,National Heart and Lung Institute, Imperial College, London, United Kingdom (A.V., R.S.).,Department of Cardiovascular Research, Northwick Park Hospital, Harrow, United Kingdom (A.V., R.S.)
| | - Mohamed-Salah Annabi
- Institut Universitaire de Cardiologie et de Pneumologie, Université Laval, Québec, Canada (M.-S.A., P.P., E.G., A.D., J.C., M.-A.C.)
| | - Phillipe Pibarot
- Institut Universitaire de Cardiologie et de Pneumologie, Université Laval, Québec, Canada (M.-S.A., P.P., E.G., A.D., J.C., M.-A.C.)
| | | | - Ana G Almeida
- Lisbon University, Hospital Santa Maria/CHULN, Portugal (A.G.A., F.P.)
| | - Ezequiel Guzzetti
- Institut Universitaire de Cardiologie et de Pneumologie, Université Laval, Québec, Canada (M.-S.A., P.P., E.G., A.D., J.C., M.-A.C.)
| | - Abdellaziz Dahou
- Institut Universitaire de Cardiologie et de Pneumologie, Université Laval, Québec, Canada (M.-S.A., P.P., E.G., A.D., J.C., M.-A.C.)
| | - Ian G Burwash
- University of Ottawa Heart Institute, Canada (I.G.B.)
| | - Matthias Koschutnik
- Department of Cardiology, Medical University of Vienna, Austria (M.K., P.E.B., J.B.-K.)
| | - Philipp E Bartko
- Department of Cardiology, Medical University of Vienna, Austria (M.K., P.E.B., J.B.-K.)
| | - Jutta Bergler-Klein
- Department of Cardiology, Medical University of Vienna, Austria (M.K., P.E.B., J.B.-K.)
| | - Julia Mascherbauer
- Department of Internal Medicine 3, Karl Landsteiner University of Health Sciences, University Hospital St. Polten, Krems, Austria (J.M.)
| | - Stefan Orwat
- Department of Cardiology III-Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Germany (S.O., H.B.)
| | - Helmut Baumgartner
- Department of Cardiology III-Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Germany (S.O., H.B.)
| | - Joao Cavalcante
- Institut Universitaire de Cardiologie et de Pneumologie, Université Laval, Québec, Canada (M.-S.A., P.P., E.G., A.D., J.C., M.-A.C.)
| | - Fausto Pinto
- Lisbon University, Hospital Santa Maria/CHULN, Portugal (A.G.A., F.P.)
| | - Tomasz Kukulski
- Department of Cardiology, Congenital Heart Disease and Electrotherapy, Silesian Medical University, Zabrze, Poland (T.K.)
| | - Jaroslaw D Kasprzak
- I Department of Cardiology, Medical University of Lodz, Bieganski Hospital, Poland (J.D.K.)
| | - Marie-Annick Clavel
- Institut Universitaire de Cardiologie et de Pneumologie, Université Laval, Québec, Canada (M.-S.A., P.P., E.G., A.D., J.C., M.-A.C.)
| | - Frank A Flachskampf
- Department of Medical Sciences, Uppsala University, Sweden (F.A.F.).,Department of Clinical Physiology, Akademiska University Hospital, Uppsala, Sweden (F.A.F.)
| | - Roxy Senior
- Department of Echocardiography, Royal Brompton Hospital, London, United Kingdom (A.V., R.S.).,National Heart and Lung Institute, Imperial College, London, United Kingdom (A.V., R.S.).,Department of Cardiovascular Research, Northwick Park Hospital, Harrow, United Kingdom (A.V., R.S.)
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Mahajan S, Sanghvi S, Sarda P, Yadav P. Global longitudinal strain in patients with st-elevation myocardial infarction post-percutaneous coronary intervention using speckle tracking echocardiography. JOURNAL OF THE INDIAN ACADEMY OF ECHOCARDIOGRAPHY & CARDIOVASCULAR IMAGING 2020. [DOI: 10.4103/jiae.jiae_38_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Sonny A, Alfirevic A, Sale S, Zimmerman NM, You J, Gillinov AM, Sessler DI, Duncan AE. Reduced Left Ventricular Global Longitudinal Strain Predicts Prolonged Hospitalization: A Cohort Analysis of Patients Having Aortic Valve Replacement Surgery. Anesth Analg 2019; 126:1484-1493. [PMID: 29200066 DOI: 10.1213/ane.0000000000002684] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Left ventricular ejection fraction (LVEF) is often preserved in patients with aortic stenosis and thus cannot distinguish between normal myocardial contractile function and subclinical dysfunction. Global longitudinal strain and strain rate (SR), which measure myocardial deformation, are robust indicators of myocardial function and can detect subtle myocardial dysfunction that is not apparent with conventional echocardiographic measures. Strain and SR may better predict postoperative outcomes than LVEF. The primary aim of our investigation was to assess the association between global longitudinal strain and serious postoperative outcomes in patients with aortic stenosis having aortic valve replacement. Secondarily, we also assessed the associations between global longitudinal SR and LVEF and the outcomes. METHODS In this post hoc analysis of data from a randomized clinical trial (NCT01187329), we examined the association between measures of myocardial function and the following outcomes: (1) need for postoperative inotropic/vasopressor support; (2) prolonged hospitalization (>7 days); and (3) postoperative atrial fibrillation. Standardized transesophageal echocardiographic examinations were performed after anesthetic induction. Myocardial deformation was measured using speckle-tracking echocardiography. Multivariable logistic regression was used to assess associations between measures of myocardial function and outcomes, adjusted for potential confounding factors. The predictive ability of global longitudinal strain, SR, and LVEF was assessed as area under receiver operating characteristics curves (AUCs). RESULTS Of 100 patients enrolled in the clinical trial, 86 patients with aortic stenosis had acceptable images for global longitudinal strain analysis. Primarily, worse intraoperative global longitudinal strain was associated with prolonged hospitalization (odds ratio [98.3% confidence interval], 1.22 [1.01-1.47] per 1% decrease [absolute value] in strain; P = .012), but not with other outcomes. Secondarily, worse global longitudinal SR was associated with prolonged hospitalization (odds ratio [99.7% confidence interval], 1.68 [1.01-2.79] per 0.1 second(-1) decrease [absolute value] in SR; P = .003), but not other outcomes. LVEF was not associated with any outcomes. Global longitudinal SR was the best predictor for prolonged hospitalization (AUC, 0.72), followed by global longitudinal strain (AUC, 0.67) and LVEF (AUC, 0.62). CONCLUSIONS Global longitudinal strain and SR are useful predictors of prolonged hospitalization in patients with aortic stenosis having an aortic valve replacement.
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Affiliation(s)
| | | | - Shiva Sale
- From the Departments of Cardiothoracic Anesthesia
| | | | - Jing You
- Quantitative Health Sciences and Outcomes Research
| | | | | | - Andra E Duncan
- Cardiothoracic Anesthesia and Outcomes Research, Cleveland Clinic, Cleveland, Ohio
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Predictive Value of Left Ventricular Myocardial Deformation for Left Ventricular Remodeling in Patients With Classical Low-Flow, Low-Gradient Aortic Stenosis Undergoing Transcatheter Aortic Valve Replacement. J Am Soc Echocardiogr 2019; 32:730-736. [DOI: 10.1016/j.echo.2019.03.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Indexed: 01/21/2023]
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Runte K, Brosien K, Salcher-Konrad M, Schubert C, Goubergrits L, Kelle S, Schubert S, Berger F, Kuehne T, Kelm M. Hemodynamic Changes During Physiological and Pharmacological Stress Testing in Healthy Subjects, Aortic Stenosis and Aortic Coarctation Patients-A Systematic Review and Meta-Analysis. Front Cardiovasc Med 2019; 6:43. [PMID: 31024935 PMCID: PMC6467940 DOI: 10.3389/fcvm.2019.00043] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 03/22/2019] [Indexed: 12/20/2022] Open
Abstract
Introduction: Exercise testing has become a diagnostic standard in the evaluation and management of heart disease. While different methods of exercise and pharmacological stress testing exist, only little is known about their comparability. We aimed to assess hemodynamic changes during dynamic exercise, isometric exercise, and dobutamine stress testing at different stress intensities in healthy subjects and patients with aortic stenosis (AS) and aortic coarctation (CoA). Methods: A systematic literature search (PROSPERO 2017:CRD42017078608) in MEDLINE of interventional trials was conducted to identify eligible studies providing evidence of changes in hemodynamic parameters under different stress conditions acquired by MRI or echocardiography. A random effects model was used to estimate pooled mean changes in hemodynamics. Results: One hundred and twenty-eight study arms with a total of 3,139 stress-examinations were included. In healthy subjects/(where available) in AS, pooled mean changes (95% CIs) during light dynamic stress were 31.78 (27.82–35.74) bpm in heart rate (HR) and 6.59 (2.58–10.61) ml in stroke volume (SV). Changes during light pharmacological stress were 13.71 (7.87–19.56)/14.0 (9.82–18.18) bpm in HR, and 5.47 (0.3–10.63)/8.0 (3.82–12.18) ml in SV. Changes during light isometric stress were 18.44 (10.74–26.14)/5.0 (−1.17–11.17) bpm in HR and −4.17 (−14.37–6.03)/−4.0 (−16.43–8.43) ml in SV. Changes during moderate dynamic stress were 49.57 (40.03–59.1)/46.45 (42.63–50.27) bpm in HR and 11.64 (5.87–17.42) ml in SV. During moderate pharmacological stress, changes in HR were 42.83 (36.94–48.72)/18.66 (2.38–34.93) bpm and in SV 6.29 (−2.0–14.58)/13.11 (7.99–18.23) ml. During high intensity dynamic stress changes in HR were 89.31 (81.46–97.17)/55.32 (47.31–63.33) bpm and in SV 21.31 (13.42–29.21)/−0.96 (−5.27–3.35) ml. During high pharmacological stress, changes in HR were 53.58 (36.53–70.64)/42.52 (32.77–52.28) bpm, and in SV 0.98 (−9.32–11.27)/14.06 (−1.62–29.74) ml. HR increase and age were inversely correlated at high stress intensities. In CoA, evidence was limited to single studies. Conclusion: This systematic review and meta-analysis presents pooled hemodynamic changes under light, moderate and high intensity exercise and pharmacological stress, while considering the potential influence of age. Despite limited availability of comparative studies, the reference values presented in this review allow estimation of the expected individual range of a circulatory response in healthy individuals and patients with AS and may contribute to future study planning and patient-specific models even when stress testing is contraindicated.
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Affiliation(s)
- Kilian Runte
- Institute for Imaging Science and Computational Modelling in Cardiovascular Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Department of Congenital Heart Disease, German Heart Center Berlin, Berlin, Germany
| | - Kay Brosien
- Institute for Imaging Science and Computational Modelling in Cardiovascular Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Maximilian Salcher-Konrad
- Personal Social Services Research Unit, London School of Economics and Political Science, London, United Kingdom.,LSE Health, London School of Economics and Political Science, London, United Kingdom
| | - Charlotte Schubert
- Institute for Imaging Science and Computational Modelling in Cardiovascular Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Department of Congenital Heart Disease, German Heart Center Berlin, Berlin, Germany
| | - Leonid Goubergrits
- Institute for Imaging Science and Computational Modelling in Cardiovascular Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Sebastian Kelle
- Department of Internal Medicine/Cardiology, German Heart Center Berlin, Berlin, Germany.,Department of Internal Medicine/Cardiology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,German Center for Cardiovascular Research, Partner Site Berlin, Berlin, Germany
| | - Stephan Schubert
- Department of Congenital Heart Disease, German Heart Center Berlin, Berlin, Germany.,German Center for Cardiovascular Research, Partner Site Berlin, Berlin, Germany
| | - Felix Berger
- Department of Congenital Heart Disease, German Heart Center Berlin, Berlin, Germany.,German Center for Cardiovascular Research, Partner Site Berlin, Berlin, Germany
| | - Titus Kuehne
- Institute for Imaging Science and Computational Modelling in Cardiovascular Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Department of Congenital Heart Disease, German Heart Center Berlin, Berlin, Germany.,German Center for Cardiovascular Research, Partner Site Berlin, Berlin, Germany
| | - Marcus Kelm
- Institute for Imaging Science and Computational Modelling in Cardiovascular Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Department of Congenital Heart Disease, German Heart Center Berlin, Berlin, Germany
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9
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Dahou A, Clavel MA, Capoulade R, O’Connor K, Ribeiro HB, Côté N, Le Ven F, Rodés-Cabau J, Dumesnil JG, Mathieu P, Pibarot P. B-Type Natriuretic Peptide and High-Sensitivity Cardiac Troponin for Risk Stratification in Low-Flow, Low-Gradient Aortic Stenosis. JACC Cardiovasc Imaging 2018; 11:939-947. [DOI: 10.1016/j.jcmg.2017.06.018] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 06/09/2017] [Accepted: 06/21/2017] [Indexed: 10/18/2022]
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Antonini-Canterin F, Faganello G, Mantero A, Citro R, Colonna P, Giorgi M, Manuppelli V, Monte I, Petrella L, Posteraro A, Di Bello V, Carerj S, Benedetto F. Cardiovascular Multimodality Imaging: It is Time to Get on Board! A "Società Italiana di Ecocardiografia e CardioVascular Imaging" Statement. J Cardiovasc Echogr 2018; 28:1-8. [PMID: 29629253 PMCID: PMC5875130 DOI: 10.4103/jcecho.jcecho_66_17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Affiliation(s)
- Francesco Antonini-Canterin
- Ospedale Riabilitativo di Alta Specializzazione, Unità Operativa di Cardiologia Riabilitativa e Preventiva, Motta di Livenza, Italy
| | - Giorgio Faganello
- Cardiovascular Center, Azienda Sanitaria Universitaria Integrata di Trieste, Trieste, Italy
| | - Antonio Mantero
- Società Italiana di Ecocardiografia e CardioVascular Imaging, Milano, Italy
| | - Rodolfo Citro
- Department of Cardiology, University Hospital 'San Giovanni di Dio e Ruggi d'Aragona', Salerno, Italy
| | - Paolo Colonna
- Department of Cardiology, Hospital Policlinico of Bari, Bari, Italy
| | - Mauro Giorgi
- Department of Torino Cardiovascular, San Giovanni Battista Hospital, Torino, Italy
| | | | - Ines Monte
- Department of General Surgery and Medical-Surgery Specialties, University of Catania, Catania, Italy
| | - Licia Petrella
- Department of Cardiac Surgery, Giuseppe Mazzini Hospital, Teramo, Italy
| | - Alfredo Posteraro
- Medical Department, Cardiology Unit, Presidio Ospedaliero Integrato Portuense, Roma, Italy
| | | | - Scipione Carerj
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Frank Benedetto
- Unità Operativa Complessa, Clinical and Rehabilitation Cardiology, Reggio Calabria, Italy
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Supariwala A, Sanchez-Ross M, Suma V, Seetharam K, Marrero D, Swistel D, Balaram S, Chaudhry FA. Latent myopathy is more pronounced in patients with low flow versus normal flow aortic stenosis with normal left ventricular ejection fraction who are undergoing surgical aortic valve replacement: Multicenter study with a brief review of the literature. Echocardiography 2018; 35:611-620. [PMID: 29605969 DOI: 10.1111/echo.13839] [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: 11/27/2022] Open
Abstract
BACKGROUND Midwall fibrosis and low stroke volume are independent predictors of mortality in severe aortic stenosis (AS) with preserved LV ejection fraction (LVEF). The role of speckle tracking echocardiography (STE) to identify latent myopathy pre- and post- aortic valve replacement (AVR) in high risk AS patients with normal LVEF is limited. METHODS Demographic, 2D echocardiographic, and STE data were analyzed in patients with severe AS and preserved LVEF who underwent tissue AVR. Velocity vector imaging (VVI) was used to assess regional and global peak systolic longitudinal strain (GLS). Low flow (LF) was defined as an indexed LV stroke volume <35 mL/m2 . RESULTS Between December 2008 and May 2011, 37 patients (75 ± 9 years, 51% male) had both pre- and post-AVR echos within 6.6 ± 6.5 months (median = 4 months; range = 2.5-9.5) of surgery. Compared with pre-AVR, GLS (-6.9 ± 4.9% vs -11.1 ± 4.1%; P < .001) and strain rate (-0.72 ± 0.3s-1 vs -0.87 ± 0.3s-1 ; P = .01) improved post-AVR. Pre-AVR mid-segments showed a similar myopathy as the basal segments (-9.5 ± 4.3% vs -9.0 ± 4.2%;P = .3). The 16 (43%) LF patients in this study had lower pre- and post-AVR strain compared to NF patients (GLS Pre-AVR:LF vs NF: -5.1 ± 4.1% vs -8.4 ± 4.9% (P = .04) and GLS Post-AVR:LF vs NF: -9.2 ± 3.7% vs -12.5 ± 3.9% (P = .01)). However, there was no difference in absolute and %change improvement in GLS post-AVR (LF vs NF:∆ -4.2 ± 3.5% vs ∆-4.1 ± 5.3% (P = .90) and 193 ± 214% vs 143 ± 230% change (P = .5)). The lowest GLS was seen in LF/HG AS followed by LF/LG, NF/LG and NF/HG AS; P = .03. CONCLUSIONS Latent myopathy is more pronounced in LF AS both pre- and post-AVR. Our study provides evidence of improvement in myopathy in LF AS despite a persistent worse myopathy compared to NF patients post-AVR.
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Affiliation(s)
- Azhar Supariwala
- Cardiology, Southside Hospital, Northwell Health System, Bay Shore, NY, USA
| | - Monica Sanchez-Ross
- Cardiology and Cardiothoracic Surgery, Mount Sinai St. Luke's-Roosevelt Hospital, New York, NY, USA
| | - Valentin Suma
- Cardiology, North Shore University Hospital, Northwell Health System, Manhasset, NY, USA
| | | | - Daniel Marrero
- Cardiology and Cardiothoracic Surgery, Mount Sinai St. Luke's-Roosevelt Hospital, New York, NY, USA
| | - Daniel Swistel
- Cardiology and Cardiothoracic Surgery, Mount Sinai St. Luke's-Roosevelt Hospital, New York, NY, USA
| | - Sandhya Balaram
- Cardiology and Cardiothoracic Surgery, Mount Sinai St. Luke's-Roosevelt Hospital, New York, NY, USA
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12
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Bakkestrøm R, Christensen NL, Wolsk E, Banke A, Dahl JS, Andersen MJ, Gustafsson F, Hassager C, Møller JE. Layer-specific deformation analysis in severe aortic valve stenosis, primary mitral valve regurgitation, and healthy individuals validated against invasive hemodynamic measurements of heart function. Echocardiography 2018; 35:170-178. [DOI: 10.1111/echo.13747] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
- Rine Bakkestrøm
- Department of Cardiology; Odense University Hospital; Odense Denmark
| | | | - Emil Wolsk
- The Heart Center; Copenhagen University Hospital; Rigshospitalet; Copenhagen Denmark
| | - Ann Banke
- Department of Cardiology; Odense University Hospital; Odense Denmark
| | - Jordi S. Dahl
- Department of Cardiology; Odense University Hospital; Odense Denmark
| | - Mads J. Andersen
- The Heart Center; Copenhagen University Hospital; Rigshospitalet; Copenhagen Denmark
| | - Finn Gustafsson
- The Heart Center; Copenhagen University Hospital; Rigshospitalet; Copenhagen Denmark
| | - Christian Hassager
- The Heart Center; Copenhagen University Hospital; Rigshospitalet; Copenhagen Denmark
| | - Jacob E. Møller
- Department of Cardiology; Odense University Hospital; Odense Denmark
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13
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Sherwood MW, Kiefer TL. Challenges in Aortic Valve Stenosis: Low-Flow States Diagnosis, Management, and a Review of the Current Literature. Curr Cardiol Rep 2017; 19:130. [DOI: 10.1007/s11886-017-0941-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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14
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Bartko PE, Wiedemann D, Schrutka L, Binder C, Santos-Gallego CG, Zuckermann A, Steinlechner B, Koinig H, Heinz G, Niessner A, Zimpfer D, Laufer G, Lang IM, Distelmaier K, Goliasch G. Impact of Right Ventricular Performance in Patients Undergoing Extracorporeal Membrane Oxygenation Following Cardiac Surgery. J Am Heart Assoc 2017; 6:JAHA.116.005455. [PMID: 28754654 PMCID: PMC5586414 DOI: 10.1161/jaha.116.005455] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [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 Extracorporeal membrane oxygenation following cardiac surgery safeguards end-organ oxygenation but unfavorably alters cardiac hemodynamics. Along with the detrimental effects of cardiac surgery to the right heart, this might impact outcome, particularly in patients with preexisting right ventricular (RV) dysfunction. We sought to determine the prognostic impact of RV function and to improve established risk-prediction models in this vulnerable patient cohort. METHODS AND RESULTS Of 240 patients undergoing extracorporeal membrane oxygenation support following cardiac surgery, 111 had echocardiographic examinations at our institution before implantation of extracorporeal membrane oxygenation and were thus included. Median age was 67 years (interquartile range 60-74), and 74 patients were male. During a median follow-up of 27 months (interquartile range 16-63), 75 patients died. Fifty-one patients died within 30 days, 75 during long-term follow-up (median follow-up 27 months, minimum 5 months, maximum 125 months). Metrics of RV function were the strongest predictors of outcome, even stronger than left ventricular function (P<0.001 for receiver operating characteristics comparisons). Specifically, RV free-wall strain was a powerful predictor univariately and after adjustment for clinical variables, Simplified Acute Physiology Score-3, tricuspid regurgitation, surgery type and duration with adjusted hazard ratios of 0.41 (95%CI 0.24-0.68; P=0.001) for 30-day mortality and 0.48 (95%CI 0.33-0.71; P<0.001) for long-term mortality for a 1-SD (SD=-6%) change in RV free-wall strain. Combined assessment of the additive EuroSCORE and RV free-wall strain improved risk classification by a net reclassification improvement of 57% for 30-day mortality (P=0.01) and 56% for long-term mortality (P=0.02) compared with the additive EuroSCORE alone. CONCLUSIONS RV function is strongly linked to mortality, even after adjustment for baseline variables and clinical risk scores. RV performance improves established risk prediction models for short- and long-term mortality.
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Affiliation(s)
- Philipp E Bartko
- Department of Internal Medicine II, Medical University of Vienna, Austria.,Center for Cardiovascular Medicine, Medical University of Vienna, Austria.,Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Dominik Wiedemann
- Department of Cardiac Surgery, Medical University of Vienna, Austria.,Center for Cardiovascular Medicine, Medical University of Vienna, Austria
| | - Lore Schrutka
- Department of Internal Medicine II, Medical University of Vienna, Austria.,Center for Cardiovascular Medicine, Medical University of Vienna, Austria
| | - Christina Binder
- Department of Internal Medicine II, Medical University of Vienna, Austria.,Center for Cardiovascular Medicine, Medical University of Vienna, Austria
| | | | - Andreas Zuckermann
- Department of Cardiac Surgery, Medical University of Vienna, Austria.,Center for Cardiovascular Medicine, Medical University of Vienna, Austria
| | - Barbara Steinlechner
- Division of Cardiothoracic and Vascular Anaesthesia and Intensive Care Medicine, Medical University of Vienna, Austria
| | - Herbert Koinig
- Department of Anaesthesia and Intensive Care Medicine, Karl Landsteiner University of Health Sciences University Hospital Krems, Krems, Austria
| | - Gottfried Heinz
- Department of Internal Medicine II, Medical University of Vienna, Austria.,Center for Cardiovascular Medicine, Medical University of Vienna, Austria
| | - Alexander Niessner
- Department of Internal Medicine II, Medical University of Vienna, Austria.,Center for Cardiovascular Medicine, Medical University of Vienna, Austria
| | - Daniel Zimpfer
- Department of Cardiac Surgery, Medical University of Vienna, Austria.,Center for Cardiovascular Medicine, Medical University of Vienna, Austria
| | - Günther Laufer
- Department of Cardiac Surgery, Medical University of Vienna, Austria.,Center for Cardiovascular Medicine, Medical University of Vienna, Austria
| | - Irene M Lang
- Department of Internal Medicine II, Medical University of Vienna, Austria.,Center for Cardiovascular Medicine, Medical University of Vienna, Austria
| | - Klaus Distelmaier
- Department of Internal Medicine II, Medical University of Vienna, Austria .,Center for Cardiovascular Medicine, Medical University of Vienna, Austria
| | - Georg Goliasch
- Department of Internal Medicine II, Medical University of Vienna, Austria.,Center for Cardiovascular Medicine, Medical University of Vienna, Austria
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15
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Ng ACT, Prihadi EA, Antoni ML, Bertini M, Ewe SH, Ajmone Marsan N, Leung DY, Delgado V, Bax JJ. Left ventricular global longitudinal strain is predictive of all-cause mortality independent of aortic stenosis severity and ejection fraction. Eur Heart J Cardiovasc Imaging 2017; 19:859-867. [DOI: 10.1093/ehjci/jex189] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Accepted: 07/05/2017] [Indexed: 12/19/2022] Open
Affiliation(s)
- Arnold C T Ng
- Department of Cardiology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
- Department of Cardiology, Princess Alexandra Hospital, Centre for Advanced Imaging, The University of Queensland, Australia
| | - Edgard A Prihadi
- Department of Cardiology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - M Louisa Antoni
- Department of Cardiology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Matteo Bertini
- Department of Cardiology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - See Hooi Ewe
- Department of Cardiology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Nina Ajmone Marsan
- Department of Cardiology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Dominic Y Leung
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Victoria Delgado
- Department of Cardiology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
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16
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Abstract
BACKGROUND The immediate effect of aortic valve replacement (AVR) for aortic stenosis on perioperative myocardial function is unclear. Left ventricular (LV) function may be impaired by cardioplegia-induced myocardial arrest and ischemia-reperfusion injury, especially in patients with LV hypertrophy. Alternatively, LV function may improve when afterload is reduced after AVR. The right ventricle (RV), however, experiences cardioplegic arrest without benefiting from improved loading conditions. Which of these effects on myocardial function dominate in patients undergoing AVR for aortic stenosis has not been thoroughly explored. Our primary objective is thus to characterize the effect of intraoperative events on LV function during AVR using echocardiographic measures of myocardial deformation. Second, we evaluated RV function. METHODS In this supplementary analysis of 100 patients enrolled in a clinical trial (NCT01187329), 97 patients underwent AVR for aortic stenosis. Of these patients, 95 had a standardized intraoperative transesophageal echocardiographic examination of systolic and diastolic function performed before surgical incision and repeated after chest closure. Echocardiographic images were analyzed off-line for global longitudinal myocardial strain and strain rate using 2D speckle-tracking echocardiography. Myocardial deformation assessed at the beginning of surgery was compared with the end of surgery using paired t tests corrected for multiple comparisons. RESULTS LV volumes and arterial blood pressure decreased, and heart rate increased at the end of surgery. Echocardiographic images were acceptable for analysis in 72 patients for LV strain, 67 for LV strain rate, and 54 for RV strain and strain rate. In 72 patients with LV strain images, 9 patients required epinephrine, 22 required norepinephrine, and 2 required both at the end of surgery. LV strain did not change at the end of surgery compared with the beginning of surgery (difference: 0.7 [97.6% confidence interval, -0.2 to 1.5]%; P = 0.07), whereas LV systolic strain rate improved (became more negative) (-0.3 [-0.4 to -0.2] s; P < 0.001). In contrast, RV systolic strain worsened (became less negative) at the end of surgery (difference: 4.6 [3.1 to 6.0]%; P < 0.001) although RV systolic strain rate was unchanged (0.0 [97.6% confidence interval, -0.1 to 0.1]; P = 0.83). CONCLUSIONS LV function improved after replacement of a stenotic aortic valve demonstrated by improved longitudinal strain rate. In contrast, RV function, assessed by longitudinal strain, was reduced.
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17
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Naji P, Shah S, Svensson LG, Gillinov AM, Johnston DR, Rodriguez LL, Grimm RA, Griffin BP, Desai MY. Incremental Prognostic Use of Left Ventricular Global Longitudinal Strain in Asymptomatic/Minimally Symptomatic Patients With Severe Bioprosthetic Aortic Stenosis Undergoing Redo Aortic Valve Replacement. Circ Cardiovasc Imaging 2017; 10:CIRCIMAGING.116.005942. [PMID: 28559420 DOI: 10.1161/circimaging.116.005942] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 04/10/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND With improved survival of patients undergoing primary bioprosthetic aortic valve replacement (AVR), reoperation to relieve severe prosthetic aortic stenosis (PAS) is increasing. Timing of redo surgery in asymptomatic/minimally symptomatic patients remains controversial. Left ventricular (LV) global longitudinal strain (GLS) is a marker of subclinical LV dysfunction. In asymptomatic/minimally symptomatic patients with severe PAS undergoing redo AVR, we sought to determine whether LV-GLS provides incremental prognostic use. METHODS AND RESULTS We studied 191 patients with severe bioprosthetic PAS (63±16 years, 58% men) who underwent redo AVR between 2000 and 2012 (excluding mechanical PAS, severe other valve disease transcatheter AVR, and LV ejection fraction <50%). Society of Thoracic Surgeons score was calculated. Standard echocardiography data were obtained. LV-GLS was measured on 2-, 3-, and 4-chamber views using velocity vector imaging. Severe PAS was defined as aortic valve area <0.8 cm2, mean aortic valve gradient ≥40 mm Hg, and dimensionless index <0.25. A composite outcome of death and congestive heart failure admission was recorded. At baseline, mean Society of Thoracic Surgeons score, LV ejection fraction, mean aortic valve gradients, and right ventricular systolic pressure were 7±6, 58±6%, 54±10 mm Hg and 40±14 mm Hg, whereas 50% had >2+ aortic regurgitation. Median LV-GLS was -14.2% (-11.4, -17.1%). At 4.2±3 years, 41 (22%) patients met the composite end point (2.5% deaths and 1% strokes at 30 days postoperatively). On multivariable Cox survival analysis, LV-GLS was independently associated with longer-term composite events (hazard ratio, 1.21; 95% confidence interval, 1.10-1.33), P<0.01. The C statistic for the clinical model (Society of Thoracic Surgeons score, degree of aortic regurgitation, and right ventricular systolic pressure) was 0.64 (95% confidence interval 0.54-0.79), P<0.001. Addition of LV-GLS to the clinical model increased the C statistic significantly to 0.71 (95% confidence interval 0.58-0.81), P<0.001. CONCLUSIONS In asymptomatic/minimally symptomatic patients with severe bioprosthetic PAS undergoing redo AVR, baseline LV-GLS provides incremental prognostic use over established predictors and could potentially aid in surgical timing and risk stratification.
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18
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Pulignano G, Gulizia MM, Baldasseroni S, Bedogni F, Cioffi G, Indolfi C, Romeo F, Murrone A, Musumeci F, Parolari A, Patanè L, Pino PG, Mongiardo A, Spaccarotella C, Di Bartolomeo R, Musumeci G. ANMCO/SIC/SICI-GISE/SICCH Executive Summary of Consensus Document on Risk Stratification in elderly patients with aortic stenosis before surgery or transcatheter aortic valve replacement. Eur Heart J Suppl 2017; 19:D354-D369. [PMID: 28751850 PMCID: PMC5520760 DOI: 10.1093/eurheartj/sux012] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Aortic stenosis is one of the most frequent valvular diseases in developed countries, and its impact on public health resources and assistance is increasing. A substantial proportion of elderly people with severe aortic stenosis is not eligible to surgery because of the advanced age, frailty, and multiple co-morbidities. Transcatheter aortic valve implantation (TAVI) enables the treatment of very elderly patients at high or prohibitive surgical risk considered ineligible for surgery and with an acceptable life expectancy. However, a significant percentage of patients die or show no improvement in quality of life (QOL) in the follow-up. In the decision-making process, it is important to determine: (i) whether and how much frailty of the patient influences the risk of procedures; (ii) how the QOL and the individual patient's survival are influenced by aortic valve disease or from other associated conditions; and (iii) whether a geriatric specialist intervention to evaluate and correct frailty or other diseases with their potential or already manifest disabilities can improve the outcome of surgery or TAVI. Consequently, in addition to risk stratification with conventional tools, a number of factors including multi-morbidity, disability, frailty, and cognitive function should be considered, in order to assess the expected benefit of both surgery and TAVI. The pre-operative optimization through a multidisciplinary approach with a Heart Team can counteract the multiple damage (cardiac, neurological, muscular, respiratory, and kidney) that can potentially aggravate the reduced physiological reserves characteristic of frailty. The systematic application in clinical practice of multidimensional assessment instruments of frailty and cognitive function in the screening and the adoption of specific care pathways should facilitate this task.
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Affiliation(s)
- Giovanni Pulignano
- Cardiology Department 1, Ospedale San Camillo-Forlanini, Via O. Regnoli, 8 00152 Rome, Italy
| | - Michele Massimo Gulizia
- Cardiology Department, Ospedale Garibaldi-Nesima, Azienda di Rilievo Nazionale e Alta Specializzazione "Garibaldi" Catania, Italy
| | | | - Francesco Bedogni
- CCU-Cardiology Unit, IRCCS Policlinico San Donato, San Donato Milanese (Milano), Italy
| | - Giovanni Cioffi
- Cardiology and Medicine Unit, Casa di Cura Villa Bianca, Trento, Italy
| | - Ciro Indolfi
- Cardiology Unit- Campus Universitario, Azienda Ospedaliera Universitaria Mater Domini, Catanzaro, Italy
| | - Francesco Romeo
- Cardiology and Interventional Cardiology Department, Policlinico "Tor Vergata", Rome, Italy
| | - Adriano Murrone
- Cardiology and Cardiovascular Pathophysiology Department, Azienda Ospedaliera di Perugia, Perugia, Italy
| | | | - Alessandro Parolari
- Heart Surgery Unit, Centro Cardiologico Monzino IRCCS, Università degli Studi, Milano, Italy
| | - Leonardo Patanè
- Cardiology Cardiac Surgery Department (Centro Cuore), Centro Clinico Diagnostico G.B. Morgagni, Pedara (Catania), Italy
| | | | - Annalisa Mongiardo
- Cardiology Unit- Campus Universitario, Azienda Ospedaliera Universitaria Mater Domini, Catanzaro, Italy
| | - Carmen Spaccarotella
- Cardiology Unit- Campus Universitario, Azienda Ospedaliera Universitaria Mater Domini, Catanzaro, Italy
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Lancellotti P, Pellikka PA, Budts W, Chaudhry FA, Donal E, Dulgheru R, Edvardsen T, Garbi M, Ha JW, Kane GC, Kreeger J, Mertens L, Pibarot P, Picano E, Ryan T, Tsutsui JM, Varga A. The Clinical Use of Stress Echocardiography in Non-Ischaemic Heart Disease: Recommendations from the European Association of Cardiovascular Imaging and the American Society of Echocardiography. J Am Soc Echocardiogr 2017; 30:101-138. [DOI: 10.1016/j.echo.2016.10.016] [Citation(s) in RCA: 105] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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20
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Abstract
Although echocardiography remains the mainstay imaging technique for the evaluation of patients with valvular heart disease (VHD), innovations in noninvasive imaging in the past few years have provided new insights into the pathophysiology and quantification of VHD, early detection of left ventricular (LV) dysfunction, and advanced prognostic assessment. The severity grading of valve dysfunction has been refined with the use of Doppler echocardiography, cardiac magnetic resonance (CMR), and CT imaging. LV ejection fraction remains an important criterion when deciding whether patients should be referred for surgery. However, echocardiographic strain imaging can now detect impaired LV systolic function before LV ejection fraction reduces, thus provoking the debate on whether patients with severe VHD should be referred for surgery at an earlier stage (before symptom onset). Impaired LV strain correlates with the amount of myocardial fibrosis detected with CMR techniques. Furthermore, accumulating data show that the extent of fibrosis associated with severe VHD has important prognostic implications. The present Review focuses on using these novel imaging modalities to assess pathophysiology, early LV dysfunction, and prognosis of major VHDs, including aortic stenosis, mitral regurgitation, and aortic regurgitation.
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21
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Lancellotti P, Pellikka PA, Budts W, Chaudhry FA, Donal E, Dulgheru R, Edvardsen T, Garbi M, Ha JW, Kane GC, Kreeger J, Mertens L, Pibarot P, Picano E, Ryan T, Tsutsui JM, Varga A. The clinical use of stress echocardiography in non-ischaemic heart disease: recommendations from the European Association of Cardiovascular Imaging and the American Society of Echocardiography. Eur Heart J Cardiovasc Imaging 2016; 17:1191-1229. [DOI: 10.1093/ehjci/jew190] [Citation(s) in RCA: 206] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 08/12/2016] [Indexed: 12/20/2022] Open
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22
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Ali MT, Yucel E, Bouras S, Wang L, Fei HW, Halpern EF, Scherrer-Crosbie M. Myocardial Strain Is Associated with Adverse Clinical Cardiac Events in Patients Treated with Anthracyclines. J Am Soc Echocardiogr 2016; 29:522-527.e3. [DOI: 10.1016/j.echo.2016.02.018] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2015] [Indexed: 12/30/2022]
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Abstract
Calcific aortic stenosis (AS) is the most prevalent heart valve disorder in developed countries. It is characterized by progressive fibro-calcific remodelling and thickening of the aortic valve leaflets that, over years, evolve to cause severe obstruction to cardiac outflow. In developed countries, AS is the third-most frequent cardiovascular disease after coronary artery disease and systemic arterial hypertension, with a prevalence of 0.4% in the general population and 1.7% in the population >65 years old. Congenital abnormality (bicuspid valve) and older age are powerful risk factors for calcific AS. Metabolic syndrome and an elevated plasma level of lipoprotein(a) have also been associated with increased risk of calcific AS. The pathobiology of calcific AS is complex and involves genetic factors, lipoprotein deposition and oxidation, chronic inflammation, osteoblastic transition of cardiac valve interstitial cells and active leaflet calcification. Although no pharmacotherapy has proved to be effective in reducing the progression of AS, promising therapeutic targets include lipoprotein(a), the renin-angiotensin system, receptor activator of NF-κB ligand (RANKL; also known as TNFSF11) and ectonucleotidases. Currently, aortic valve replacement (AVR) remains the only effective treatment for severe AS. The diagnosis and staging of AS are based on the assessment of stenosis severity and left ventricular systolic function by Doppler echocardiography, and the presence of symptoms. The introduction of transcatheter AVR in the past decade has been a transformative therapeutic innovation for patients at high or prohibitive risk for surgical valve replacement, and this new technology might extend to lower-risk patients in the near future.
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Affiliation(s)
- Brian R Lindman
- Cardiovascular Division, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Marie-Annick Clavel
- Québec Heart and Lung Institute, Department of Medicine, Laval University, 2725 Chemin Sainte-Foy, Québec City, Québec G1V 4G5, Canada
| | - Patrick Mathieu
- Québec Heart and Lung Institute, Department of Medicine, Laval University, 2725 Chemin Sainte-Foy, Québec City, Québec G1V 4G5, Canada
| | - Bernard Iung
- Cardiology Department, AP-HP, Bichat Hospital, Paris, France
- Paris-Diderot University, DHU Fire, Paris, France
| | - Patrizio Lancellotti
- University of Liège Hospital, GIGA Cardiovascular Sciences, Department of Cardiology, Heart Valve Clinic and CHU Sart Tilman, Liège, Belgium
- Grupo Villa Maria Care and Research, Anthea Hospital, Bari, Italy
| | - Catherine M Otto
- Division of Cardiology, Department of Medicine, University of Washington School of Medicine, Seattle, USA
| | - Philippe Pibarot
- Québec Heart and Lung Institute, Department of Medicine, Laval University, 2725 Chemin Sainte-Foy, Québec City, Québec G1V 4G5, Canada
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Vamvakidou A, Gurunathan S, Senior R. Novel techniques in stress echocardiography: a focus on the advantages and disadvantages. Expert Rev Cardiovasc Ther 2016; 14:477-94. [DOI: 10.1586/14779072.2016.1135054] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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25
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Dahou A, Clavel MA, Capoulade R, Bartko PE, Magne J, Mundigler G, Bergler-Klein J, Burwash I, Mascherbauer J, Ribeiro HB, O'Connor K, Baumgartner H, Sénéchal M, Dumesnil JG, Rosenhek R, Mathieu P, Larose E, Rodés-Cabau J, Pibarot P. Right ventricular longitudinal strain for risk stratification in low-flow, low-gradient aortic stenosis with low ejection fraction. Heart 2016; 102:548-54. [DOI: 10.1136/heartjnl-2015-308309] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 12/17/2015] [Indexed: 11/03/2022] Open
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26
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Kamperidis V, Delgado V, van Mieghem NM, Kappetein AP, Leon MB, Bax JJ. Diagnosis and management of aortic valve stenosis in patients with heart failure. Eur J Heart Fail 2016; 18:469-81. [DOI: 10.1002/ejhf.466] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Revised: 11/04/2015] [Accepted: 11/19/2015] [Indexed: 11/09/2022] Open
Affiliation(s)
- Vasileios Kamperidis
- Department of Cardiology, Heart and Lung Centrum; Leiden University Medical Centre; Albinusdreef 2 2333 ZA Leiden the Netherlands
- Department of Cardiology; AHEPA University Hospital; Thessaloniki Greece
| | - Victoria Delgado
- Department of Cardiology, Heart and Lung Centrum; Leiden University Medical Centre; Albinusdreef 2 2333 ZA Leiden the Netherlands
| | - Nicolas M. van Mieghem
- Department of Cardiology; Thoraxcenter, Erasmus Medical Centre; Rotterdam the Netherlands
| | - Arie-Pieter Kappetein
- Department of Cardio-Thoracic Surgery; Erasmus Medical Centre; Rotterdam the Netherlands
| | - Martin B. Leon
- Columbia University Medical Center and The Cardiovascular Research Foundation; New York NY USA
| | - Jeroen J. Bax
- Department of Cardiology, Heart and Lung Centrum; Leiden University Medical Centre; Albinusdreef 2 2333 ZA Leiden the Netherlands
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Holmes AA, Taub CC, Garcia MJ, Shan J, Slovut DP. Paradoxical low-flow aortic stenosis is defined by increased ventricular hydraulic load and reduced longitudinal strain. J Cardiovasc Med (Hagerstown) 2015; 18:87-95. [PMID: 26556444 DOI: 10.2459/jcm.0000000000000324] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Patients with paradoxical low-flow severe aortic stenosis (PLF-AS) reportedly have higher left ventricular hydraulic load and more systolic strain dysfunction than patients with normal-flow aortic stenosis. This study investigates the relationship of systolic loading and strain to PLF-AS to further define its pathophysiology. METHODS One hundred and twenty patients (age 79 ± 12 years, 37% men) with an indexed aortic valve area (AVAi) of 0.6 cm/m or less and an ejection fraction of 50% or higher were divided into two groups based on indexed stroke volume (SVi): PLF-AS, SVi ≤ 35 ml/m, N = 46; normal-flow aortic stenosis, SVi > 35 ml/m, N = 74). Valvular and arterial load were assessed using multiple measurements, and strain was assessed using speckle-tracking echocardiography. RESULTS Patients with PLF-AS were found to have more valvular load (lower AVAi, P = 0.028; lower energy loss coefficient, P = 0.001), more arterial load [decreased arterial compliance and increased systemic vascular resistance (SVR), both P < 0.001] and more total hydraulic load [increased valvuloarterial impedance (Zva), P < 0.001]. Transvalvular gradients and arterial pressures were similar. Longitudinal strain was lower in PLF-AS (P < 0.001), but circumferential and rotation strains were similar. On adjusted regression, AVAi, SVR and longitudinal strain were associated with PLF-AS [odds ratio (OR) = 1.34, P = 0.043; OR = 1.31, P = 0.004; OR = 1.34, P = 0.011, respectively]. When SVR and AVAi were replaced with Zva, longitudinal strain and Zva (OR = 1.38, P = 0.015; OR = 1.33, P < 0.001 for both, respectively) were associated with PLF-AS. CONCLUSION Increased hydraulic load, from more severe valvular stenosis and increased vascular resistance, and longitudinal strain impairment are associated with PLF-AS and their interplay is likely fundamental to its pathophysiology.
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Affiliation(s)
- Anthony A Holmes
- aDepartment of Medicine bDivision of Cardiology cDepartment of Cardiovascular and Thoracic Surgery, Montefiore Medical Center, Bronx, New York, USA
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Krishnasamy R, Hawley CM, Stanton T, Pascoe EM, Campbell KL, Rossi M, Petchey W, Tan KS, Beetham KS, Coombes JS, Leano R, Haluska BA, Isbel NM. Left ventricular global longitudinal strain is associated with cardiovascular risk factors and arterial stiffness in chronic kidney disease. BMC Nephrol 2015; 16:106. [PMID: 26187506 PMCID: PMC4506621 DOI: 10.1186/s12882-015-0098-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Accepted: 06/25/2015] [Indexed: 11/29/2022] Open
Abstract
Background Global longitudinal strain (GLS) has emerged as a superior method for detecting left ventricular (LV) systolic dysfunction compared to ejection fraction (EF) on the basis that it is less operator dependent and more reproducible. The 2-dimensional strain (2DS) method is easily measured and integrated into a standard echocardiogram. This study aimed to determine the relationship between GLS and traditional and chronic kidney disease (CKD)-related risk factors of cardiovascular disease (CVD) in patients with CKD. Methods A cross sectional study of patients with moderate CKD stages 3 and 4 (n = 136). Clinical characteristics, anthropometric, biochemical data including markers of inflammation [C-reactive protein (CRP)], uremic toxins [indoxyl sulphate (IS), p-cresyl sulphate (PCS)], and arterial stiffness [pulse wave velocity (PWV)] were measured. Inducible ischemia was detected using exercise stress echocardiogram. GLS was determined from 3 standard apical views using 2-dimensional speckle tracking and EF was measured using Simpson’s rule. Associations between GLS and traditional and CKD-related risk factors were explored using multivariate models. Results The study population parameters included: age 59.4 ± 9.8 years, 58 % male, estimated glomerular filtration rate (eGFR) 44.4 ± 10.1 ml/min/1.73 m2, GLS −18.3 ± 3.6 % and EF 65.8 % ± 7.8 %. This study demonstrated that GLS correlated with diabetes (r = 0.21, p = 0.01), history of heart failure (r = 0.20, p = 0.01), free IS (r = 0.24, p = 0.005) free PCS (r = 0.23, p = 0.007), body mass index (BMI) (r = 0.28, p < 0.001), and PWV (r = 0.24, p = 0.009). Following adjustment for demographic, baseline co-morbidities and laboratory parameters,GLS was independently associated with free IS, BMI and arterial stiffness (R2 for model = 0.30, p < 0.0001). Conclusions In the CKD cohort, LV systolic function assessed using GLS was associated with uremic toxins, obesity and arterial stiffness. Electronic supplementary material The online version of this article (doi:10.1186/s12882-015-0098-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Rathika Krishnasamy
- Department of Renal Medicine, The University of Queensland at Princess Alexandra Hospital, Brisbane, Australia. .,School of Medicine, The University of Queensland, Brisbane, Australia.
| | - Carmel M Hawley
- Department of Renal Medicine, The University of Queensland at Princess Alexandra Hospital, Brisbane, Australia. .,School of Medicine, The University of Queensland, Brisbane, Australia. .,Translational Research Institute, Brisbane, Australia.
| | - Tony Stanton
- Cardiovascular Imaging Research Center, The University of Queensland at Princess Alexandra Hospital, Brisbane, Australia.
| | - Elaine M Pascoe
- School of Medicine, The University of Queensland, Brisbane, Australia. .,Translational Research Institute, Brisbane, Australia.
| | - Katrina L Campbell
- Department of Renal Medicine, The University of Queensland at Princess Alexandra Hospital, Brisbane, Australia. .,School of Medicine, The University of Queensland, Brisbane, Australia. .,Translational Research Institute, Brisbane, Australia.
| | - Megan Rossi
- Department of Renal Medicine, The University of Queensland at Princess Alexandra Hospital, Brisbane, Australia. .,School of Medicine, The University of Queensland, Brisbane, Australia. .,Translational Research Institute, Brisbane, Australia.
| | - William Petchey
- Department of Renal Medicine, Cambridge University Hospital, Cambridge, England.
| | - Ken-Soon Tan
- Department of Renal Medicine, The University of Queensland at Princess Alexandra Hospital, Brisbane, Australia. .,School of Medicine, The University of Queensland, Brisbane, Australia. .,School of Medicine, Griffith University, Brisbane, Australia.
| | - Kassia S Beetham
- School of Human Movement Studies, The University of Queensland, Brisbane, Australia.
| | - Jeff S Coombes
- School of Human Movement Studies, The University of Queensland, Brisbane, Australia.
| | - Rodel Leano
- Cardiovascular Imaging Research Center, The University of Queensland at Princess Alexandra Hospital, Brisbane, Australia.
| | - Brian A Haluska
- Cardiovascular Imaging Research Center, The University of Queensland at Princess Alexandra Hospital, Brisbane, Australia.
| | - Nicole M Isbel
- Department of Renal Medicine, The University of Queensland at Princess Alexandra Hospital, Brisbane, Australia. .,School of Medicine, The University of Queensland, Brisbane, Australia.
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Stress-echocardiography is underused in clinical practice: a nationwide survey in Austria. Wien Klin Wochenschr 2015; 127:514-20. [PMID: 26162465 DOI: 10.1007/s00508-015-0828-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Accepted: 06/06/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND The wide area of application, including coronary artery disease, valvular heart disease, or pulmonary hypertension makes stress echocardiography (SE) a powerful, cost-effective imaging modality in cardiology. The role of this technique in clinical practice in Austria is unknown. METHODS A nationwide survey included all departments for cardiology and/or internal medicine in the years 2008 and 2013. By electronic questionnaire demographics, indication for the test, the numbers of examined cases per year, operators, and various applied techniques of SE were interrogated and completed by telephone interviews. RESULTS Data could be obtained from all 117 departments. In the year 2007 in 58 (50%) and in 2012 57 (49%) departments SE was available in Austrian hospitals. More than 100 SEs per year were performed by only four (7%) units in the year 2007 and by five (8%) in 2012. Physical exercise, dobutamine, and dipyridamole SE were available in 27 (46%), 52 (90%), and six (10%) units in 2007, and in 15 (27%), 52 (91%), and five (9%) units in 2012, respectively. In 2007 41 (71%) and in 2012 26 (46%) echo-labs administered contrast agents during SE. Transesophageal SE and 3D-echo was performed in one (2%) and three (5%) units in 2007, and in six (10%) and four (7%) echo-labs in 2012. CONCLUSIONS This representative survey demonstrates the underuse of SE in clinical practice in Austria. Even in established application fields performance is low, examination frequencies as recommended by the cardiology societies are fulfilled only by a minority of institutions.
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Pokharel P, Fujikura K, Bella JN. Clinical applications and prognostic implications of strain and strain rate imaging. Expert Rev Cardiovasc Ther 2015; 13:853-66. [DOI: 10.1586/14779072.2015.1056163] [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] [Indexed: 01/09/2023]
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Left Ventricular Global Longitudinal Strain (GLS) Is a Superior Predictor of All-Cause and Cardiovascular Mortality When Compared to Ejection Fraction in Advanced Chronic Kidney Disease. PLoS One 2015; 10:e0127044. [PMID: 25978372 PMCID: PMC4433230 DOI: 10.1371/journal.pone.0127044] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Accepted: 04/11/2015] [Indexed: 01/11/2023] Open
Abstract
Background Echocardiographic global longitudinal strain (GLS) is increasingly recognised as a more effective technique than conventional ejection fraction (EF) in detecting subtle changes in left ventricular (LV) function. This study investigated the prognostic value of GLS over EF in patients with advanced Chronic Kidney Disease (CKD). Methods The study included 183 patients (57% male, 63% on dialysis) with CKD stage 4, 5 and 5Dialysis (D). 112 (61%) of patients died in a follow up of 7.8 ± 4.4 years and 41% of deaths were due to cardiovascular (CV) disease. GLS was calculated using 2-dimensional speckle tracking and EF was measured using Simpson’s biplane method. Cox proportional hazard models were used to assess the association of measures of LV function and all- cause and CV mortality. Results The mean GLS at baseline was -13.6 ± 4.3% and EF was 45 ± 11%. GLS was a significant predictor of all-cause [Hazard Ratio (HR) 1.09 95%; Confidence Interval (CI) 1.02–1.16; p = 0.01] and CV mortality (HR 1.16 95%; CI 1.04–1.30; p = 0.008) following adjustment for relevant clinical variables including LV mass index (LVMI) and EF. GLS also had greater predictive power for both all- cause and CV mortality compared to EF. Impaired GLS (>-16%) was associated with a 5.6-fold increased unadjusted risk of CV mortality in patients with preserved EF. Conclusions In this cohort of patients with advanced CKD, GLS is a more sensitive predictor of overall and CV mortality compared to EF. Studies of larger populations in CKD are required to confirm that GLS provides additive prognostic value in patients with preserved EF.
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Călin A, Roşca M, Beladan CC, Enache R, Mateescu AD, Ginghină C, Popescu BA. The left ventricle in aortic stenosis--imaging assessment and clinical implications. Cardiovasc Ultrasound 2015; 13:22. [PMID: 25928763 PMCID: PMC4425891 DOI: 10.1186/s12947-015-0017-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 04/21/2015] [Indexed: 01/07/2023] Open
Abstract
Aortic stenosis has an increasing prevalence in the context of aging population. In these patients non-invasive imaging allows not only the grading of valve stenosis severity, but also the assessment of left ventricular function. These two goals play a key role in clinical decision-making. Although left ventricular ejection fraction is currently the only left ventricular function parameter that guides intervention, current imaging techniques are able to detect early changes in LV structure and function even in asymptomatic patients with significant aortic stenosis and preserved ejection fraction. Moreover, new imaging parameters emerged as predictors of disease progression in patients with aortic stenosis. Although proper standardization and confirmatory data from large prospective studies are needed, these novel parameters have the potential of becoming useful tools in guiding intervention in asymptomatic patients with aortic stenosis and stratify risk in symptomatic patients undergoing aortic valve replacement. This review focuses on the mechanisms of transition from compensatory left ventricular hypertrophy to left ventricular dysfunction and heart failure in aortic stenosis and the role of non-invasive imaging assessment of the left ventricular geometry and function in these patients.
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Affiliation(s)
- Andreea Călin
- Department of Cardiology, University of Medicine and Pharmacy "Carol Davila", Euroecolab, Bucharest, Romania.
| | - Monica Roşca
- Department of Cardiology, University of Medicine and Pharmacy "Carol Davila", Euroecolab, Bucharest, Romania.
| | - Carmen Cristiana Beladan
- Department of Cardiology, University of Medicine and Pharmacy "Carol Davila", Euroecolab, Bucharest, Romania. .,Institute of Cardiovascular Diseases "Prof. Dr. C. C. Iliescu", Sos Fundeni 258 sector 2, 022328, Bucharest, Romania.
| | - Roxana Enache
- Department of Cardiology, University of Medicine and Pharmacy "Carol Davila", Euroecolab, Bucharest, Romania. .,Institute of Cardiovascular Diseases "Prof. Dr. C. C. Iliescu", Sos Fundeni 258 sector 2, 022328, Bucharest, Romania.
| | - Anca Doina Mateescu
- Department of Cardiology, University of Medicine and Pharmacy "Carol Davila", Euroecolab, Bucharest, Romania.
| | - Carmen Ginghină
- Department of Cardiology, University of Medicine and Pharmacy "Carol Davila", Euroecolab, Bucharest, Romania. .,Institute of Cardiovascular Diseases "Prof. Dr. C. C. Iliescu", Sos Fundeni 258 sector 2, 022328, Bucharest, Romania.
| | - Bogdan Alexandru Popescu
- Department of Cardiology, University of Medicine and Pharmacy "Carol Davila", Euroecolab, Bucharest, Romania. .,Institute of Cardiovascular Diseases "Prof. Dr. C. C. Iliescu", Sos Fundeni 258 sector 2, 022328, Bucharest, Romania.
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Cioffi G, Rossi A, Nistri S, Faggiano P. Implementation of diagnosis in asymptomatic patients with aortic stenosis. J Cardiovasc Med (Hagerstown) 2015; 16:303-9. [DOI: 10.2459/jcm.0000000000000021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
OPINION STATEMENT Severe low-gradient (LG) aortic stenosis (AS) [aortic valve area (AVA) ≤ 1.0 cm(2), mean pressure gradient (MG) < 40 mmHg] represents a frequently encountered and challenging clinical dilemma. A systematic approach, which often requires several imaging modalities, should be undertaken to confirm the hemodynamic findings and rule out measurement error. Low-flow conditions often account for the discrepancy and can be present whether the left ventricular ejection fraction (LVEF) is depressed or normal. In patients with classical low-flow (LF), LG AS in which LVEF is reduced (<40-50 %), dobutamine stress echocardiography (DSE) should be used to distinguish patients with true severe AS and pseudo-severe AS, as well as to evaluate for the presence of left ventricular contractile or flow reserve. Surgical or transcatheter aortic valve replacement (AVR) should likely be reserved for those patients with true severe AS. Patient outcome with medical or surgical management generally relates to patient functional capacity, stenosis severity, and left ventricular functional reserve. Patients with severe LG AS with preserved LVEF can have a stroke volume that is either normal (>35 mL/m(2)) or low (<35 mL/m(2)). New data suggest that DSE can identify pseudo-severe AS in up to 30 % of patients with severe LF-LG AS with preserved LVEF. AVR should likely be restricted to those patients with true severe AS, although there is currently little data to support this strategy. Symptomatic patients with severe LG AS with preserved LVEF, whether they have normal or low flow, should be offered AVR. Transcatheter AVR provides an alternative therapeutic option in the high-risk patient.
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Dahou A, Bartko PE, Capoulade R, Clavel MA, Mundigler G, Grondin SL, Bergler-Klein J, Burwash I, Dumesnil JG, Sénéchal M, O’Connor K, Baumgartner H, Pibarot P. Usefulness of Global Left Ventricular Longitudinal Strain for Risk Stratification in Low Ejection Fraction, Low-Gradient Aortic Stenosis. Circ Cardiovasc Imaging 2015; 8:e002117. [DOI: 10.1161/circimaging.114.002117] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Abdellaziz Dahou
- From the Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada (A.D., R.C., M.-A.C., S.L.G., J.G.D., M.S., K.O’C., P.P.); Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria, (P.E.B., G.M., J.B.-K.); University of Ottawa Heart Institute, Ottawa, Ontario, Canada (I.B.); and Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular
| | - Philipp Emanuel Bartko
- From the Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada (A.D., R.C., M.-A.C., S.L.G., J.G.D., M.S., K.O’C., P.P.); Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria, (P.E.B., G.M., J.B.-K.); University of Ottawa Heart Institute, Ottawa, Ontario, Canada (I.B.); and Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular
| | - Romain Capoulade
- From the Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada (A.D., R.C., M.-A.C., S.L.G., J.G.D., M.S., K.O’C., P.P.); Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria, (P.E.B., G.M., J.B.-K.); University of Ottawa Heart Institute, Ottawa, Ontario, Canada (I.B.); and Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular
| | - Marie-Annick Clavel
- From the Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada (A.D., R.C., M.-A.C., S.L.G., J.G.D., M.S., K.O’C., P.P.); Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria, (P.E.B., G.M., J.B.-K.); University of Ottawa Heart Institute, Ottawa, Ontario, Canada (I.B.); and Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular
| | - Gerald Mundigler
- From the Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada (A.D., R.C., M.-A.C., S.L.G., J.G.D., M.S., K.O’C., P.P.); Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria, (P.E.B., G.M., J.B.-K.); University of Ottawa Heart Institute, Ottawa, Ontario, Canada (I.B.); and Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular
| | - Samuel Larue Grondin
- From the Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada (A.D., R.C., M.-A.C., S.L.G., J.G.D., M.S., K.O’C., P.P.); Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria, (P.E.B., G.M., J.B.-K.); University of Ottawa Heart Institute, Ottawa, Ontario, Canada (I.B.); and Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular
| | - Jutta Bergler-Klein
- From the Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada (A.D., R.C., M.-A.C., S.L.G., J.G.D., M.S., K.O’C., P.P.); Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria, (P.E.B., G.M., J.B.-K.); University of Ottawa Heart Institute, Ottawa, Ontario, Canada (I.B.); and Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular
| | - Ian Burwash
- From the Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada (A.D., R.C., M.-A.C., S.L.G., J.G.D., M.S., K.O’C., P.P.); Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria, (P.E.B., G.M., J.B.-K.); University of Ottawa Heart Institute, Ottawa, Ontario, Canada (I.B.); and Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular
| | - Jean G. Dumesnil
- From the Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada (A.D., R.C., M.-A.C., S.L.G., J.G.D., M.S., K.O’C., P.P.); Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria, (P.E.B., G.M., J.B.-K.); University of Ottawa Heart Institute, Ottawa, Ontario, Canada (I.B.); and Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular
| | - Mario Sénéchal
- From the Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada (A.D., R.C., M.-A.C., S.L.G., J.G.D., M.S., K.O’C., P.P.); Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria, (P.E.B., G.M., J.B.-K.); University of Ottawa Heart Institute, Ottawa, Ontario, Canada (I.B.); and Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular
| | - Kim O’Connor
- From the Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada (A.D., R.C., M.-A.C., S.L.G., J.G.D., M.S., K.O’C., P.P.); Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria, (P.E.B., G.M., J.B.-K.); University of Ottawa Heart Institute, Ottawa, Ontario, Canada (I.B.); and Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular
| | - Helmut Baumgartner
- From the Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada (A.D., R.C., M.-A.C., S.L.G., J.G.D., M.S., K.O’C., P.P.); Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria, (P.E.B., G.M., J.B.-K.); University of Ottawa Heart Institute, Ottawa, Ontario, Canada (I.B.); and Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular
| | - Philippe Pibarot
- From the Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada (A.D., R.C., M.-A.C., S.L.G., J.G.D., M.S., K.O’C., P.P.); Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria, (P.E.B., G.M., J.B.-K.); University of Ottawa Heart Institute, Ottawa, Ontario, Canada (I.B.); and Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular
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Hansen KL, Møller-Sørensen H, Pedersen MM, Hansen PM, Kjaergaard J, Lund JT, Nilsson JC, Jensen JA, Nielsen MB. First report on intraoperative vector flow imaging of the heart among patients with healthy and diseased aortic valves. ULTRASONICS 2015; 56:243-250. [PMID: 25128079 DOI: 10.1016/j.ultras.2014.07.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Revised: 07/22/2014] [Accepted: 07/23/2014] [Indexed: 06/03/2023]
Abstract
The vector velocity method Transverse Oscillation (TO) implemented on a conventional ultrasound (US) scanner (ProFocus, BK Medical, Herlev, Denmark) can provide real-time, angle-independent estimates of the cardiac blood flow. During cardiac surgery, epicardial US examination using TO was performed on (A) 3 patients with healthy aortic valve and (B) 3 patients with aortic valve stenosis. In group B, the systolic flow of the ascending aorta had higher velocities, was more aliased and chaotic. The jet narrowed to 44% of the lumen compared to 75% in group A and with a vector concentration, a measure of flow complexity, of 0.41 compared to 0.87 in group A. The two groups had similar secondary flow of the ascending aorta with an average rotation frequency of 4.8 Hz. Simultaneous measurements were obtained with spectral Doppler (SD) and a thermodilution technique (TD). The mean difference in peak systolic velocity compared to SD in group A was 22% and 45% in B, while the mean difference in volume flow compared to TD in group A was 30% and 32% in B. TO can potentially reveal new information of cardiac blood flow, and may become a valuable diagnostic tool in the evaluation of patients with cardiovascular diseases.
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Affiliation(s)
| | - Hasse Møller-Sørensen
- Department of Cardiothoracic Anesthesiology, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Mads Møller Pedersen
- Department of Radiology, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Peter Møller Hansen
- Department of Radiology, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Jesper Kjaergaard
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Jens Teglgaard Lund
- Department of Cardiothoracic Surgery, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Jens Christian Nilsson
- Department of Cardiothoracic Surgery, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Jørgen Arendt Jensen
- Center for Fast Ultrasound Imaging, DTU Elektro, Technical University of Denmark, Denmark
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Salvo GD, Pergola V, Fadel B, Bulbul ZA, Caso P. Strain Echocardiography and Myocardial Mechanics: From Basics to Clinical Applications. J Cardiovasc Echogr 2015; 25:1-8. [PMID: 28465921 PMCID: PMC5353453 DOI: 10.4103/2211-4122.158415] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
The aim of this review is to summarize the recent developments in strain imaging, an evolving technique – from tissue Doppler to 3D echocardiography – for resolving the complex left ventricular mechanics. Following a brief overview of the different used technique to extract myocardial deformation data, the authors summarize the role of the technique in the assessment of cardiac mechanics and its role in the clinical arena.
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Affiliation(s)
- Giovanni Di Salvo
- King Faisal Specialist Hospital and Research Center, Heart Center, Riyadh, Saudi Arabia
| | - Valeria Pergola
- King Faisal Specialist Hospital and Research Center, Heart Center, Riyadh, Saudi Arabia
| | - Bahaa Fadel
- King Faisal Specialist Hospital and Research Center, Heart Center, Riyadh, Saudi Arabia
| | - Ziad Al Bulbul
- King Faisal Specialist Hospital and Research Center, Heart Center, Riyadh, Saudi Arabia
| | - Pio Caso
- Monaldi Hospital Cardiology, Naples, Italy
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Burwash IG. Echocardiographic Evaluation of Aortic Stenosis - Normal Flow and Low Flow Scenarios. Eur Cardiol 2014; 9:92-99. [PMID: 30310493 PMCID: PMC6159432 DOI: 10.15420/ecr.2014.9.2.92] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Accepted: 11/11/2014] [Indexed: 02/07/2023] Open
Abstract
The echocardiographic evaluation of the patient with aortic stenosis (AS) has evolved in recent years, beyond confirming the diagnosis and measuring the resting mean pressure gradient or valve area. New echocardiographic approaches have developed to address the clinical dilemmas related to discordant haemodynamic data, asymptomatic haemodynamically severe AS and low-flow, low-gradient AS in order to better evaluate the disease severity, enhance the risk stratification of patients and provide important prognostic information. This article reviews the echocardiographic evaluation of the AS patient and focuses on the echocardiographic assessment of the haemodynamic severity, the prediction of clinical outcome and the use of echocardiography to guide patient management in the presence of normal flow and low flow scenarios.
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Affiliation(s)
- Ian G Burwash
- University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
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Clavel MA, Pibarot P. Assessment of low-flow, low-gradient aortic stenosis: multimodality imaging is the key to success. EUROINTERVENTION 2014; 10 Suppl U:U52-60. [DOI: 10.4244/eijv10sua8] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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The Role of Biomarkers in Valvular Heart Disease: Focus on Natriuretic Peptides. Can J Cardiol 2014; 30:1027-34. [DOI: 10.1016/j.cjca.2014.07.014] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Revised: 07/10/2014] [Accepted: 07/10/2014] [Indexed: 01/26/2023] Open
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Affiliation(s)
- Philippe Pibarot
- From the Department of Medicine, Québec Heart & Lung Institute, Laval University, Québec, Canada
| | - Jean G. Dumesnil
- From the Department of Medicine, Québec Heart & Lung Institute, Laval University, Québec, Canada
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Bartel T, Müller S. Preserved ejection fraction can accompany low gradient severe aortic stenosis: impact of pathophysiology on diagnostic imaging. Eur Heart J 2013; 34:1862-3. [DOI: 10.1093/eurheartj/eht157] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Wang B, Chen H, Shu X, Hong T, Lai H, Wang C, Cheng L. Emerging role of echocardiographic strain/strain rate imaging and twist in systolic function evaluation and operative procedure in patients with aortic stenosis. Interact Cardiovasc Thorac Surg 2013; 17:384-91. [PMID: 23644729 DOI: 10.1093/icvts/ivt171] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Systolic function of the left ventricle is vital for patients with aortic stenosis. Unfortunately, the most widely used clinical parameter, the left ventricular ejection fraction, is not sensitive enough, especially for patients with left ventricular hypertrophy. Echocardiographic strain/strain rate and twist are emerging parameters for left ventricular systolic and diastolic function evaluation. Aortic stenosis could reduce strain/strain rate while magnifying twist. Furthermore, strain/strain rate correlates well with the prognosis of patients with aortic stenosis. Most importantly the circumferential strain, strain rate and twist also play a role in differentiating cardiac compensation or decompensation. In any case, these parameters could normalize after successful surgical aortic valve replacement or transcatheter aortic valve replacement. Regardless of these advantages, clinical evidence is needed to ensure their usefulness.
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Affiliation(s)
- Bin Wang
- Department of Cardiac Surgery, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai, China
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