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Tastet L, Ali M, Pibarot P, Capoulade R, Øvrehus KA, Arsenault M, Haujir A, Bédard É, Diederichsen ACP, Dahl JS, Clavel MA. Grading of Aortic Valve Calcification Severity and Risk Stratification in Aortic Stenosis. J Am Heart Assoc 2024; 13:e035605. [PMID: 39023065 DOI: 10.1161/jaha.123.035605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Accepted: 06/03/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND Thresholds of aortic valve calcification (AVC) to define hemodynamically moderate aortic stenosis (AS) from mild are lacking. We aimed to establish a novel grading classification of AVC as quantified by computed tomography and determine its prognostic value. METHODS AND RESULTS This study included 915 patients with at least mild AS (mean age 70±12 years, 30% women) from a multicenter prospective registry. All patients underwent Doppler-echocardiography and noncontrast computed tomography within 3 months. Primary end point was the occurrence of all-cause death. Receiver operating characteristic curves analyses were used to determine the sensitivity and specificity of sex-specific thresholds of AVC to identify hemodynamically moderate AS. Optimal thresholds (ie, with best sensitivity/specificity) of AVC to distinguish moderate (aortic valve area 1.0-1.5 cm2 and mean gradient 20-39 mm Hg) from mild AS (aortic valve area >1.5 cm2 and mean gradient <20 mm Hg) were AVC ≥360 arbitrary units in women and ≥1037 arbitrary units in men. Based on the guidelines' thresholds for severe AS and the new thresholds in our study for moderate AS, 312 (34%) patients had mild, 253 (28%) moderate, and 350 (38%) severe AVC. During a mean follow-up of 5.6±3.9 years, 183 (27%) deaths occurred. In Cox multivariable models, AVC remained associated with an increased risk of death (adjusted hazard ratio per grade increase, 1.94 [95% CI, 1.53-2.56]; P<0.001). CONCLUSIONS A novel grading classification of anatomic AS severity based on sex-specific thresholds of AVC provides significant prognostic value for predicting mortality. These findings support the complementarity of computed tomography-calcium scoring to Doppler-echocardiography to corroborate AS severity and enhance risk stratification in patients with AS.
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Affiliation(s)
- Lionel Tastet
- Institut universitaire de cardiologie et de pneumologie de Québec Université Laval Québec City Québec Canada
- Division of Cardiovascular Medicine University of California San Francisco CA USA
| | - Mulham Ali
- Department of Cardiology Odense University Hospital Odense Denmark
| | - Philippe Pibarot
- Institut universitaire de cardiologie et de pneumologie de Québec Université Laval Québec City Québec Canada
| | - Romain Capoulade
- Nantes Université, CHU Nantes, CNRS, INSERM, l'institut du thorax Nantes France
| | | | - Marie Arsenault
- Institut universitaire de cardiologie et de pneumologie de Québec Université Laval Québec City Québec Canada
| | - Amal Haujir
- Department of Cardiology Odense University Hospital Odense Denmark
| | - Élisabeth Bédard
- Institut universitaire de cardiologie et de pneumologie de Québec Université Laval Québec City Québec Canada
| | | | - Jordi S Dahl
- Department of Cardiology Odense University Hospital Odense Denmark
| | - Marie-Annick Clavel
- Institut universitaire de cardiologie et de pneumologie de Québec Université Laval Québec City Québec Canada
- Department of Cardiology Odense University Hospital Odense Denmark
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Elkaryoni A, Huded CP, Saad M, Altibi AM, Chhatriwalla AK, Abbott JD, Arnold SV. Normal-Flow Low-Gradient Aortic Stenosis: Comparing the U.S. and European Guidelines. JACC Cardiovasc Imaging 2024; 17:926-936. [PMID: 38703172 DOI: 10.1016/j.jcmg.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 02/12/2024] [Accepted: 03/06/2024] [Indexed: 05/06/2024]
Abstract
Patients with normal-flow low-gradient (NFLG) severe aortic stenosis present both diagnostic and management challenges, with debate about the whether this represents true severe stenosis and the need for valve replacement. Studies exploring the natural history without intervention have shown similar outcomes of patients with NFLG severe aortic stenosis to those with moderate aortic stenosis and better outcomes after valve replacement than those with low-flow low-gradient severe aortic stenosis. Most studies (all observational) have shown that aortic valve replacement was associated with a survival benefit vs surveillance. Based on available data, the European Society of Cardiology/European Association for Cardio-Thoracic Surgery guidelines and European Association of Cardiovascular Imaging/American Society of Echocardiography suggest that these patients are more likely to have moderate aortic stenosis. This clinical entity is not mentioned in the American Heart Association/American College of Cardiology guidelines. Here we review the definition of NFLG severe aortic stenosis, potential diagnostic algorithms and points of error, the data supporting different management strategies, and the differing guidelines and outline the unanswered questions in the diagnosis and management of these challenging patients.
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Affiliation(s)
- Ahmed Elkaryoni
- Division of Cardiology, Warren Alpert Medical School of Brown University, Lifespan Cardiovascular Institute, Providence, Rhode Island, USA.
| | - Chetan P Huded
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Marwan Saad
- Division of Cardiology, Warren Alpert Medical School of Brown University, Lifespan Cardiovascular Institute, Providence, Rhode Island, USA
| | - Ahmed M Altibi
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Adnan K Chhatriwalla
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - J Dawn Abbott
- Division of Cardiology, Warren Alpert Medical School of Brown University, Lifespan Cardiovascular Institute, Providence, Rhode Island, USA
| | - Suzanne V Arnold
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri, USA
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3
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Chong A, Sen J, Reyaldeen R, Wahi S, Huynh Q, Wang WYS, Marwick TH. Prognostication and Interventional Guidance Using Acceleration-Ejection Time Ratio in Undifferentiated Paradoxical Low-Flow Low-Gradient Aortic Stenosis. JACC Cardiovasc Imaging 2024:S1936-878X(24)00227-4. [PMID: 39152958 DOI: 10.1016/j.jcmg.2024.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 05/20/2024] [Accepted: 05/23/2024] [Indexed: 08/19/2024]
Abstract
BACKGROUND Studies in paradoxical low-flow low-gradient aortic stenosis (PLFAS) have demonstrated conflicting outcomes with variable survival advantage from aortic valve replacement (AVR). PLFAS is a heterogeneous composition of patients with uncertainty regarding true stenosis severity that continues to confound decision-making for AVR. OBJECTIVES The purpose of this study was to investigate the utility of the Doppler acceleration (AT) to ejection (ET) time ratio (AT:ET) for prediction of prognosis and benefit from AVR in undifferentiated PLFAS. METHODS Patients with echocardiographic findings of PLFAS (aortic valve area <1.0 cm2 or indexed aortic valve area <0.6 cm2/m2, mean gradient <40 mm Hg, indexed stroke volume <35 mL/m2, and left ventricular ejection fraction ≥50%) were identified and grouped according to an AT:ET cutoff of 0.35. The primary outcome was a 5-year composite of cardiac mortality or AVR. Secondary outcomes included the individual components of the primary endpoint and all-cause mortality at 5 years. Effect of AVR was analyzed in the AT:ET <0.35 and ≥0.35 groups. RESULTS A total of 171 PLFAS patients (median age 77.0 years, 57% women) were followed for a median of 8.9 years. AT:ET ≥0.35 was an independent predictor of the primary outcome (HR: 4.77 [95% CI: 2.94-7.75]; P < 0.001) with incremental value over standard indices of stenosis severity (net reclassification improvement: 0.57 [95% CI: 0.14-0.84]). AT:ET ≥0.35 also remained predictive of increased cardiac death (HR: 2.91 [95% CI: 1.47-5.76]; P = 0.002) and AVR (HR: 8.45 [95% CI: 4.16-17.1]; P < 0.001), respectively, following competing risk analysis. No difference in all-cause mortality was observed. AVR in the AT:ET ≥0.35 group was associated with significant reductions in 5-year cardiac (HR: 0.09 [95% CI: 0.02-0.36]; P < 0.001) and all-cause mortality (HR: 0.16 [95% CI: 0.07-0.38]; P < 0.001). No improvement in survival from AVR was demonstrated in AT:ET <0.35 patients. CONCLUSIONS AT:ET ≥0.35 in PLFAS predicts poorer outcomes and/or need for AVR. In undifferentiated PLFAS patients, AT:ET may have a potential role in improving patient selection for prognostic AVR.
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Affiliation(s)
- Adrian Chong
- Princess Alexandra Hospital, Brisbane, Australia; Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Jonathan Sen
- Princess Alexandra Hospital, Brisbane, Australia; Baker Heart and Diabetes Institute, Melbourne, Australia; Department of Cardiometabolic Health, University of Melbourne, Melbourne, Australia
| | | | - Sudhir Wahi
- Princess Alexandra Hospital, Brisbane, Australia; Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Quan Huynh
- Baker Heart and Diabetes Institute, Melbourne, Australia; Monash University Alfred Health, Melbourne, Australia
| | - William Y S Wang
- Princess Alexandra Hospital, Brisbane, Australia; Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Thomas H Marwick
- Baker Heart and Diabetes Institute, Melbourne, Australia; Department of Cardiometabolic Health, University of Melbourne, Melbourne, Australia.
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4
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Lee SH, Yoon SJ, Sun BJ, Kim HM, Kim HY, Lee S, Shim CY, Kim EK, Cho DH, Park JB, Seo JS, Son JW, Kim IC, Lee SH, Heo R, Lee HJ, Park JH, Song JM, Lee SC, Kim H, Kang DH, Ha JW, Kim KH. 2023 Korean Society of Echocardiography position paper for diagnosis and management of valvular heart disease, part I: aortic valve disease. J Cardiovasc Imaging 2024; 32:11. [PMID: 39061115 PMCID: PMC11282617 DOI: 10.1186/s44348-024-00019-0] [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: 09/06/2023] [Accepted: 11/24/2023] [Indexed: 07/28/2024] Open
Abstract
This manuscript represents the official position of the Korean Society of Echocardiography on valvular heart diseases. This position paper focuses on the clinical management of valvular heart diseases with reference to the guidelines recently published by the American College of Cardiology/American Heart Association and the European Society of Cardiology. The committee tried to reflect the recently published results on the topic of valvular heart diseases and Korean data by a systematic literature search based on validity and relevance. In part I of this article, we will review and discuss the current position of aortic valve disease in Korea.
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Affiliation(s)
- Sun Hwa Lee
- Division of Cardiology, Department of Internal Medicine, Jeonbuk National University Medical School, Jeonbuk National University Hospital, Jeonju, Republic of Korea
| | - Se-Jung Yoon
- Division of Cardiology, National Health Insurance Service Ilsan Hospital, Goyang, Republic of Korea
| | - Byung Joo Sun
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hyue Mee Kim
- Division of Cardiology, Department of Internal Medicine, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Republic of Korea
| | - Hyung Yoon Kim
- Department of Cardiovascular Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Sahmin Lee
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Chi Young Shim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Eun Kyoung Kim
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Heart Vascular Stroke Institute, Samsung Medical Center, Seoul, Republic of Korea
| | - Dong-Hyuk Cho
- Division of Cardiology, Department of Internal Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Jun-Bean Park
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jeong-Sook Seo
- Division of Cardiology, Department of Internal Medicine, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Jung-Woo Son
- Division of Cardiology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - In-Cheol Kim
- Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
| | - Sang-Hyun Lee
- Division of Cardiology, Pusan National Yangsan Hospital, Pusan National University School of Medicine, Busan, Republic of Korea
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National Yangsan Hospital, Busan, Republic of Korea
| | - Ran Heo
- Division of Cardiology, Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Hyun-Jung Lee
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jae-Hyeong Park
- Division of Cardiology, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Republic of Korea
- Regional Cardiocerebrovascular Center, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Jong-Min Song
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang-Chol Lee
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Heart Vascular Stroke Institute, Samsung Medical Center, Seoul, Republic of Korea
| | - Hyungseop Kim
- Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
| | - Duk-Hyun Kang
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jong-Won Ha
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kye Hun Kim
- Department of Cardiovascular Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea.
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Springhetti P, Abdoun K, Clavel MA. Sex Differences in Aortic Stenosis: From the Pathophysiology to the Intervention, Current Challenges, and Future Perspectives. J Clin Med 2024; 13:4237. [PMID: 39064275 PMCID: PMC11278486 DOI: 10.3390/jcm13144237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2024] [Revised: 07/16/2024] [Accepted: 07/17/2024] [Indexed: 07/28/2024] Open
Abstract
Calcific aortic stenosis (AS) is a major cause of morbidity and mortality in high-income countries. AS presents sex-specific features impacting pathophysiology, outcomes, and management strategies. In women, AS often manifests with a high valvular fibrotic burden, small valvular annuli, concentric left ventricular (LV) remodeling/hypertrophy, and, frequently, supernormal LV ejection fraction coupled with diastolic dysfunction. Paradoxical low-flow low-gradient AS epitomizes these traits, posing significant challenges post-aortic valve replacement due to limited positive remodeling and significant risk of patient-prosthesis mismatch. Conversely, men present more commonly with LV dilatation and dysfunction, indicating the phenotype of classical low-flow low-gradient AS, i.e., with decreased LV ejection fraction. However, these distinctions have not been fully incorporated into guidelines for AS management. The only treatment for AS is aortic valve replacement; women are frequently referred late, leading to increased heart damage caused by AS. Therefore, it is important to reassess surgical planning and timing to minimize irreversible cardiac damage in women. The integrity and the consideration of sex differences in the management of AS is critical. Further research, including sufficient representation of women, is needed to investigate these differences and to develop individualized, sex-specific management strategies.
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Affiliation(s)
- Paolo Springhetti
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, QC G1V 4G5, Canada; (P.S.); (K.A.)
- Department of Medicine, Division of Cardiology, University of Verona, 37129 Verona, Italy
| | - Kathia Abdoun
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, QC G1V 4G5, Canada; (P.S.); (K.A.)
| | - Marie-Annick Clavel
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, QC G1V 4G5, Canada; (P.S.); (K.A.)
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Gać P, Jaworski A, Grajnert F, Kicman K, Trejtowicz-Sutor A, Witkowski K, Poręba M, Poręba R. Aortic Valve Calcium Score: Applications in Clinical Practice and Scientific Research-A Narrative Review. J Clin Med 2024; 13:4064. [PMID: 39064103 PMCID: PMC11277735 DOI: 10.3390/jcm13144064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2024] [Revised: 06/29/2024] [Accepted: 07/08/2024] [Indexed: 07/28/2024] Open
Abstract
In this narrative review, we investigate the essential role played by the computed tomography Aortic Valve Calcium Score (AVCS) in the cardiovascular diagnostic landscape, with a special focus on its implications for clinical practice and scientific research. Calcific aortic valve stenosis is the most prevalent type of aortic stenosis (AS) in industrialized countries, and due to the aging population, its prevalence is increasing. While transthoracic echocardiography (TTE) remains the gold standard, AVCS stands out as an essential complementary tool in evaluating patients with AS. The advantage of AVCS is its independence from flow; this allows for a more precise evaluation of patients with discordant findings in TTE. Further clinical applications of AVCS include in the assessment of patients before transcatheter aortic valve replacement (TAVR), as it helps in predicting outcomes and provides prognostic information post-TAVR. Additionally, we describe different AVCS thresholds regarding gender and the anatomical variations of the aortic valve. Finally, we discuss various scientific studies where AVCS was applied. As AVCS has some limitations, due to the pathophysiologies of AS extending beyond calcification and gender differences, scientists strive to validate contrast-enhanced AVCS. Furthermore, research on developing radiation-free methods of measuring calcium content is ongoing.
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Affiliation(s)
- Paweł Gać
- Centre of Diagnostic Imaging, 4th Military Hospital, Rudolfa Weigla 5, 50-981 Wrocław, Poland; (P.G.); (A.T.-S.); (K.W.)
- Department of Population Health, Division of Environmental Health and Occupational Medicine, Wroclaw Medical University, J. Mikulicza-Radeckiego 7, 50-345 Wrocław, Poland
| | - Arkadiusz Jaworski
- Healthcare Team “County Hospital” in Sochaczew, Batalionow Chlopskich 3/7, 96-500 Sochaczew, Poland
| | - Filip Grajnert
- 4th Military Hospital, Rudolfa Weigla 5, 50-981 Wrocław, Poland;
| | - Katarzyna Kicman
- Healthcare Team “County Hospital” in Sochaczew, Batalionow Chlopskich 3/7, 96-500 Sochaczew, Poland
| | - Agnieszka Trejtowicz-Sutor
- Centre of Diagnostic Imaging, 4th Military Hospital, Rudolfa Weigla 5, 50-981 Wrocław, Poland; (P.G.); (A.T.-S.); (K.W.)
| | - Konrad Witkowski
- Centre of Diagnostic Imaging, 4th Military Hospital, Rudolfa Weigla 5, 50-981 Wrocław, Poland; (P.G.); (A.T.-S.); (K.W.)
| | - Małgorzata Poręba
- Department of Paralympic Sports, Wroclaw University of Health and Sport Sciences, Witelona 25a, 51-617 Wrocław, Poland
| | - Rafał Poręba
- Department of Internal and Occupational Diseases, Hypertension and Clinical Oncology, Wroclaw Medical University, Borowska 213, 50-556 Wrocław, Poland;
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Mogensen NSB, Ali M, Carter-Storch R, Annabi MS, Grenier-Delaney J, Møller JE, Øvrehus KA, Pellikka PA, Pibarot P, Clavel MA, Dahl JS. Dobutamine Stress Echocardiography in Low-Gradient Aortic Stenosis. J Am Soc Echocardiogr 2024:S0894-7317(24)00345-6. [PMID: 38972614 DOI: 10.1016/j.echo.2024.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Revised: 05/21/2024] [Accepted: 06/08/2024] [Indexed: 07/09/2024]
Abstract
IMPORTANCE Guidelines recommend the use of dobutamine stress echocardiography (DSE) in patients with low-gradient aortic stenosis (AS) and left ventricular ejection fraction (LVEF) <50%. However, a paucity of DSE data exists when LVEF >35%. OBJECTIVE To examine the diagnostic accuracy of DSE in patients with low-gradient AS with a wide range of LVEF and to examine the interaction between the diagnostic accuracy of DSE and LVEF. DESIGN, SETTING, AND PARTICIPANTS Patients with mean gradient <40 mm Hg, aortic valve area <1.0 cm2, and stroke volume index ≤35 mL/m2 undergoing DSE and cardiac computer tomography (C-CT) were identified from 3 prospectively collected patient cohorts and stratified according to LVEF: LVEF<35%, LVEF 35% to 50%, and LVEF>50%. EXPOSURE Dobutamine stress echocardiography and C-CT were performed on patients with low-gradient AS. MAIN OUTCOMES AND MEASURES Severe AS was defined as aortic valve calcification score ≥2,000 arbitrary units (AU) among men and ≥1,200 AU for women on C-CT. RESULTS Of 221 patients included in the study, 78 (35%) presented with LVEF <35%, 67 (30%) with LVEF 35% to 50%, and 76 (34%) with LVEF >50%. Mean-gradient and aortic valve peak velocity during DSE showed significant diagnostic heterogeneity between LVEF groups, being most precise when LVEF <35% (both areas under the curve [AUC] = 0.90), albeit with optimal thresholds of 30 mm Hg and 377 cm/sec and a limited diagnostic yield in patients with LVEF ≥35% (AUC = 0.67 and 0.66 in LVEF 35% to 50% and AUC = 0.65 and 0.60 in LVEF ≥50%). Using guideline thresholds led to a sensitivity/specificity of 49%/84% for all patients with LVEF <50%. CONCLUSION AND RELEVANCE While DSE is safe and leads to an increase in stroke volume in patients with low-gradient AS regardless of LVEF, the association between DSE gradients and AS severity assessed by C-CT demonstrates important heterogeneity depending on LVEF, with the highest accuracy in patients with LVEF <35%.
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Affiliation(s)
- Nils Sofus Borg Mogensen
- Department of Cardiology, Odense University Hospital, Odense, Denmark; Institut Universitaire de Cardiologie et de Pneumologie de Québec (Québec Heart and Lung Institute), Laval University, Québec, Québec, Canada; Clinical Institute, University of Southern Denmark, Odense, Denmark.
| | - Mulham Ali
- Department of Cardiology, Odense University Hospital, Odense, Denmark; Clinical Institute, University of Southern Denmark, Odense, Denmark
| | | | - Mohamed-Salah Annabi
- Institut Universitaire de Cardiologie et de Pneumologie de Québec (Québec Heart and Lung Institute), Laval University, Québec, Québec, Canada
| | - Jasmine Grenier-Delaney
- Institut Universitaire de Cardiologie et de Pneumologie de Québec (Québec Heart and Lung Institute), Laval University, Québec, Québec, Canada
| | - Jacob Eifer Møller
- Department of Cardiology, Odense University Hospital, Odense, Denmark; Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | | | | | - Philippe Pibarot
- Institut Universitaire de Cardiologie et de Pneumologie de Québec (Québec Heart and Lung Institute), Laval University, Québec, Québec, Canada
| | - Marie-Annick Clavel
- Institut Universitaire de Cardiologie et de Pneumologie de Québec (Québec Heart and Lung Institute), Laval University, Québec, Québec, Canada; Clinical Institute, University of Southern Denmark, Odense, Denmark
| | - Jordi Sanchez Dahl
- Department of Cardiology, Odense University Hospital, Odense, Denmark; Clinical Institute, University of Southern Denmark, Odense, Denmark; Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
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Lopes V, Almeida PC, Moreira N, Ferreira LA, Teixeira R, Donato P, Gonçalves L. Computed tomography imaging in preprocedural planning of transcatheter valvular heart interventions. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2024; 40:1163-1181. [PMID: 38780710 DOI: 10.1007/s10554-024-03140-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Accepted: 05/13/2024] [Indexed: 05/25/2024]
Abstract
Cardiac Computed Tomography (CCT) has become a reliable imaging modality in cardiology providing robust information on the morphology and structure of the heart with high temporal and isotropic spatial resolution. For the past decade, there has been a paradigm shift in the management of valvular heart disease since previously unfavorable candidates for surgery are now provided with less-invasive interventions. Transcatheter heart valve interventions provide a real alternative to medical and surgical management and are often the only treatment option for valvular heart disease patients. Successful transcatheter valve interventions rely on comprehensive multimodality imaging assessment. CCT is the mainstay imaging technique for preprocedural planning of these interventions. CCT is critical in guiding patient selection, choice of procedural access, device selection, procedural guidance, as well as allowing postprocedural follow-up of complications. This article aims to review the current evidence of the role of CCT in the preprocedural planning of patients undergoing transcatheter valvular interventions.
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Affiliation(s)
- Vanessa Lopes
- Cardiology Department, Hospitais da Universidade de Coimbra, Unidade Local de Saúde de Coimbra, Coimbra, Portugal.
| | - Pedro Carvalho Almeida
- Medical Imaging Department, Hospitais da Universidade de Coimbra, Unidade Local de Saúde de Coimbra, Coimbra, Portugal
| | - Nádia Moreira
- Cardiology Department, Hospitais da Universidade de Coimbra, Unidade Local de Saúde de Coimbra, Coimbra, Portugal
| | - Luís Amaral Ferreira
- Medical Imaging Department, Hospitais da Universidade de Coimbra, Unidade Local de Saúde de Coimbra, Coimbra, Portugal
| | - Rogério Teixeira
- Cardiology Department, Hospitais da Universidade de Coimbra, Unidade Local de Saúde de Coimbra, Coimbra, Portugal
- Faculty of Medicine, Univ Coimbra, Coimbra, Portugal
| | - Paulo Donato
- Medical Imaging Department, Hospitais da Universidade de Coimbra, Unidade Local de Saúde de Coimbra, Coimbra, Portugal
- Faculty of Medicine, Univ Coimbra, Coimbra, Portugal
- Univ Coimbra, Coimbra Institute for Biomedical Imaging and Translation Research (CIBIT), Coimbra, Portugal
- Clinical Academic Center of Coimbra (CACC), Coimbra, Portugal
| | - Lino Gonçalves
- Cardiology Department, Hospitais da Universidade de Coimbra, Unidade Local de Saúde de Coimbra, Coimbra, Portugal
- Faculty of Medicine, Univ Coimbra, Coimbra, Portugal
- Clinical Academic Center of Coimbra (CACC), Coimbra, Portugal
- Coimbra Institute for Clinical and Biomedical Research (iCBR), Faculty of Medicine, Univ Coimbra, Coimbra, Portugal
- Center for Innovative Biomedicine and Biotechnology (CIBB), Univ Coimbra, Coimbra, Portugal
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9
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Marrero N, Jha K, Razavi AC, Boakye E, Anchouche K, Dzaye O, Budoff MJ, Tsai MY, Shah SJ, Rotter JI, Guo X, Yao J, Blumenthal RS, Thanassoulis G, Post WS, Blaha MJ, Whelton SP. Identifying People at High Risk for Severe Aortic Stenosis: Aortic Valve Calcium Versus Lipoprotein(a) and Low-Density Lipoprotein Cholesterol. Circ Cardiovasc Imaging 2024; 17:e016372. [PMID: 38889215 DOI: 10.1161/circimaging.123.016372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 04/11/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND Aortic valve calcification (AVC), Lp(a) [lipoprotein(a)], and low-density lipoprotein cholesterol (LDL-C) are associated with severe aortic stenosis (AS). We aimed to determine which of these risk factors were most strongly associated with the risk of incident severe AS. METHODS A total of 6792 participants from the MESA study (Multi-Ethnic Study of Atherosclerosis) had computed tomography-quantified AVC, Lp(a), and LDL-C values at MESA visit 1 (2000-2002). We calculated the absolute event rate of incident adjudicated severe AS per 1000 person-years and performed multivariable adjusted Cox proportional hazards regression. RESULTS The mean age was 62 years old, and 47% were women. Over a median 16.7-year follow-up, the rate of incident severe AS increased exponentially with higher AVC, regardless of Lp(a) or LDL-C values. Participants with AVC=0 had a very low rate of severe AS even with elevated Lp(a) ≥50 mg/dL (<0.1/1000 person-years) or LDL-C ≥130 mg/dL (0.1/1000 person-years). AVC >0 was strongly associated with severe AS when Lp(a) <50 mg/dL hazard ratio (HR) of 33.8 (95% CI, 16.4-70.0) or ≥50 mg/dL HR of 61.5 (95% CI, 7.7-494.2) and when LDL-C <130 mg/dL HR of 31.1 (95% CI, 14.4-67.1) or ≥130 mg/dL HR of 50.2 (95% CI, 13.2-191.9). CONCLUSIONS AVC better identifies people at high risk for severe AS compared with Lp(a) or LDL-C, and people with AVC=0 have a very low long-term rate of severe AS regardless of Lp(a) or LDL-C level. These results suggest AVC should be the preferred prognostic risk marker to identify patients at high risk for severe AS, which may help inform participant selection for future trials testing novel strategies to prevent severe AS.
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Affiliation(s)
| | - Kunal Jha
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins School of Medicine, Baltimore, MD (K.J., A.C.R., E.B., O.D., R.S.B., W.S.P., M.J.B., S.P.W.)
- University of Louisville, Division of Cardiology, KY (K.J.)
| | - Alexander C Razavi
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins School of Medicine, Baltimore, MD (K.J., A.C.R., E.B., O.D., R.S.B., W.S.P., M.J.B., S.P.W.)
- Center for Heart Disease Prevention, Emory School of Medicine, Atlanta, GA (A.C.R.)
| | - Ellen Boakye
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins School of Medicine, Baltimore, MD (K.J., A.C.R., E.B., O.D., R.S.B., W.S.P., M.J.B., S.P.W.)
| | - Khalil Anchouche
- Preventive and Genomic Cardiology, Department of Medicine, McGill University, and the McGill University Health Center Research Institute, Montréal, Québec, Canada (K.A., G.T.)
| | - Omar Dzaye
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins School of Medicine, Baltimore, MD (K.J., A.C.R., E.B., O.D., R.S.B., W.S.P., M.J.B., S.P.W.)
| | - Matthew J Budoff
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins School of Medicine, Baltimore, MD (K.J., A.C.R., E.B., O.D., R.S.B., W.S.P., M.J.B., S.P.W.)
| | - Michael Y Tsai
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis (M.Y.T.)
| | - Sanjiv J Shah
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S.)
| | - Jerome I Rotter
- Department of Pediatrics, The Institute for Translational Genomics and Population Sciences (J.I.R., X.G., J.Y.), The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA
| | - Xiuqing Guo
- Department of Pediatrics, The Institute for Translational Genomics and Population Sciences (J.I.R., X.G., J.Y.), The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA
| | - Jie Yao
- Department of Pediatrics, The Institute for Translational Genomics and Population Sciences (J.I.R., X.G., J.Y.), The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA
| | - Roger S Blumenthal
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins School of Medicine, Baltimore, MD (K.J., A.C.R., E.B., O.D., R.S.B., W.S.P., M.J.B., S.P.W.)
| | - George Thanassoulis
- Preventive and Genomic Cardiology, Department of Medicine, McGill University, and the McGill University Health Center Research Institute, Montréal, Québec, Canada (K.A., G.T.)
| | - Wendy S Post
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins School of Medicine, Baltimore, MD (K.J., A.C.R., E.B., O.D., R.S.B., W.S.P., M.J.B., S.P.W.)
| | - Michael J Blaha
- Department of Medicine (M.J.B.), The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA
| | - Seamus P Whelton
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins School of Medicine, Baltimore, MD (K.J., A.C.R., E.B., O.D., R.S.B., W.S.P., M.J.B., S.P.W.)
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10
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Ferrante EA, Cudrici CD, Rashidi M, Fu YP, Huffstutler R, Carney K, Chen MY, St Hilaire C, Smith K, Bagheri H, Katz JD, Ferreira CR, Gahl WA, Boehm M, Brofferio A. Pilot study to evaluate the safety and effectiveness of etidronate treatment for arterial calcification due to deficiency of CD73 (ACDC). Vasc Med 2024; 29:245-255. [PMID: 38568107 DOI: 10.1177/1358863x241235669] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
BACKGROUND Arterial calcification due to deficiency of CD73 (ACDC; OMIM 211800) is a rare genetic disease resulting in calcium deposits in arteries and small joints causing claudication, resting pain, severe joint pain, and deformities. Currently, there are no standard treatments for ACDC. Our previous work identified etidronate as a potential targeted ACDC treatment, using in vitro and in vivo disease models with patient-derived cells. In this study, we test the safety and effectiveness of etidronate in attenuating the progression of lower-extremity arterial calcification and vascular blood flow based on the computed tomography (CT) calcium score and ankle-brachial index (ABI). METHODS Seven adult patients with a confirmed genetic diagnosis of ACDC were enrolled in an open-label, nonrandomized, single-arm pilot study for etidronate treatment. They took etidronate daily for 14 days every 3 months and were examined at the NIH Clinical Center bi-annually for 3 years. They received a baseline evaluation as well as yearly follow up after treatment. Study visits included imaging studies, exercise tolerance tests with ABIs, clinical blood and urine testing, and full dental exams. RESULTS Etidronate treatment appeared to have slowed the progression of further vascular calcification in lower extremities as measured by CT but did not have an effect in reversing vascular and/or periarticular joint calcifications in our small ACDC cohort. CONCLUSIONS Etidronate was found to be safe and well tolerated by our patients and, despite the small sample size, appeared to show an effect in slowing the progression of calcification in our ACDC patient cohort.(ClinicalTrials.gov Identifier NCT01585402).
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Affiliation(s)
- Elisa A Ferrante
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Cornelia D Cudrici
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Mahmood Rashidi
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Yi-Ping Fu
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Rebecca Huffstutler
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Katherine Carney
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Marcus Y Chen
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Cynthia St Hilaire
- Departments of Medicine and Bioengineering, Vascular Medicine Institute, University of Pittsburg, PA, USA
| | - Kevin Smith
- Clinical Center Nursing Department, Hatfield Clinical Center at the National Institutes of Health, Bethesda, MD, USA
| | - Hadi Bagheri
- Radiology and Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, MD, USA
| | - James D Katz
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Carlos R Ferreira
- National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA
| | - William A Gahl
- National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA
| | - Manfred Boehm
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Alessandra Brofferio
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
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11
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González-García A, Pazos-López P, Calvo-Iglesias FE, Matajira-Chía TM, Bilbao-Quesada R, Blanco-González E, González-Ríos C, Castiñeira-Busto M, Barreiro-Pérez M, Íñiguez-Romo A. Diagnostic Challenges in Aortic Stenosis. J Cardiovasc Dev Dis 2024; 11:162. [PMID: 38921662 PMCID: PMC11203729 DOI: 10.3390/jcdd11060162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Revised: 05/15/2024] [Accepted: 05/16/2024] [Indexed: 06/27/2024] Open
Abstract
Aortic stenosis (AS) is the most prevalent degenerative valvular disease in western countries. Transthoracic echocardiography (TTE) is considered, nowadays, to be the main imaging technique for the work-up of AS due to high availability, safety, low cost, and excellent capacity to evaluate aortic valve (AV) morphology and function. Despite the diagnosis of AS being considered straightforward for a very long time, based on high gradients and reduced aortic valve area (AVA), many patients with AS represent a real dilemma for cardiologist. On the one hand, the acoustic window may be inadequate and the TTE limited in some cases. On the other hand, a growing body of evidence shows that patients with low gradients (due to systolic dysfunction, concentric hypertrophy or coexistence of another valve disease such as mitral stenosis or regurgitation) may develop severe AS (low-flow low-gradient severe AS) with a similar or even worse prognosis. The use of complementary imaging techniques such as transesophageal echocardiography (TEE), multidetector computed tomography (MDTC), or cardiac magnetic resonance (CMR) plays a key role in such scenarios. The aim of this review is to summarize the diagnostic challenges associated with patients with AS and the advantages of a comprehensive multimodality cardiac imaging (MCI) approach to reach a precise grading of the disease, a crucial factor to warrant an adequate management of patients.
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Affiliation(s)
- André González-García
- Department of Cardiology, Hospital Alvaro Cunqueiro, Complexo Hospitalario Universitario de Vigo, 36312 Vigo, Spain; (F.E.C.-I.); (T.M.M.-C.); (R.B.-Q.); (E.B.-G.); (C.G.-R.); (M.C.-B.); (M.B.-P.); (A.Í.-R.)
| | - Pablo Pazos-López
- Department of Cardiology, Hospital Alvaro Cunqueiro, Complexo Hospitalario Universitario de Vigo, 36312 Vigo, Spain; (F.E.C.-I.); (T.M.M.-C.); (R.B.-Q.); (E.B.-G.); (C.G.-R.); (M.C.-B.); (M.B.-P.); (A.Í.-R.)
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12
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Broncano J, Hanneman K, Ghoshhajra B, Rajiah PS. Cardiac Computed Tomography of Native Cardiac Valves. Radiol Clin North Am 2024; 62:399-417. [PMID: 38553177 DOI: 10.1016/j.rcl.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
Valvular heart disease (VHD) is a significant clinical problem associated with high morbidity and mortality. Although not being the primary imaging modality in VHD, cardiac computed tomography (CCT) provides relevant information about its morphology, function, severity grading, and adverse cardiac remodeling assessment. Aortic valve calcification quantification is necessary for grading severity in cases of low-flow/low-gradient aortic stenosis. Moreover, CCT details significant information necessary for adequate percutaneous treatment planning. CCT may help to detail the etiology of VHD as well as to depict other less frequent causes of valvular disease, such as infective endocarditis, valvular neoplasms, or other cardiac pseudomasses.
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Affiliation(s)
- Jordi Broncano
- Cardiothoracic Imaging Unit, Radiology Department, Hospital San Juan de Dios, HT Medica, Avenida El Brillante Nº 36, Córdoba 14012, Spain.
| | - Kate Hanneman
- Department of Medical Imaging, Toronto General Hospital, Peter Munk Cardiac Center, University Health Network (UHN), University of Toronto, 1 PMB-298, 585 University Avenue, Toronto, Ontario M5G2N2, Canada
| | - Brian Ghoshhajra
- Cardiovascular Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charles River Plaza East, 165 Cambridge Street, Boston, MA 02114, USA
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13
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Powers A, Ali M, Lavoie N, Haujir A, Mogensen NSB, Ludwig S, Øvrehus KA, Tastet L, Rhéaume C, Schofer N, Dahl JS, Clavel MA. Aortic Valve Calcification Density Measured by MDCT in the Assessment of Aortic Stenosis Severity. Circ Cardiovasc Imaging 2024; 17:e016267. [PMID: 38771899 DOI: 10.1161/circimaging.123.016267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 03/25/2024] [Indexed: 05/23/2024]
Abstract
BACKGROUND Aortic valve calcification (AVC) indexation to the aortic annulus (AA) area measured by Doppler echocardiography (AVCdEcho) provides powerful prognostic information in patients with aortic stenosis (AS). However, the indexation by AA measured by multidetector computed tomography (AVCdCT) has never been evaluated. The aim of this study was to compare AVC, AVCdCT, and AVCdEcho with regard to hemodynamic correlations and clinical outcomes in patients with AS. METHODS Data from 889 patients, mainly White, with calcific AS who underwent Doppler echocardiography and multidetector computed tomography within the same episode of care were retrospectively analyzed. AA was measured both by Doppler echocardiography and multidetector computed tomography. AVCdCT severity thresholds were established using receiver operating characteristic curve analyses in men and women separately. The primary end point was the occurrence of all-cause mortality. RESULTS Correlations between gradient/velocity and AVCd were stronger (both P≤0.005) using AVCdCT (r=0.68, P<0.001 and r=0.66, P<0.001) than AVC (r=0.61, P<0.001 and r=0.60, P<0.001) or AVCdEcho (r=0.61, P<0.001 and r=0.59, P<0.001). AVCdCT thresholds for the identification of severe AS were 334 Agatston units (AU)/cm2 for women and 467 AU/cm2 for men. On a median follow-up of 6.62 (6.19-9.69) years, AVCdCT ratio was superior to AVC ratio and AVCdEcho ratio to predict all-cause mortality in multivariate analyses (hazard ratio [HR], 1.59 [95% CI, 1.26-2.00]; P<0.001 versus HR, 1.53 [95% CI, 1.11-1.65]; P=0.003 versus HR, 1.27 [95% CI, 1.11-1.46]; P<0.001; all likelihood test P≤0.004). AVCdCT ratio was superior to AVC ratio and AVCdEcho ratio to predict survival under medical treatment in multivariate analyses (HR, 1.80 [95% CI, 1.27-1.58]; P<0.001 compared with HR, 1.55 [95% CI, 1.13-2.10]; P=0.007; HR, 1.28 [95% CI, 1.03-1.57]; P=0.01; all likelihood test P<0.03). AVCdCT ratio predicts mortality in all subgroups of patients with AS. CONCLUSIONS AVCdCT appears to be equivalent or superior to AVC and AVCdEcho to assess AS severity and predict all-cause mortality. Thus, it should be used to evaluate AS severity in patients with nonconclusive echocardiographic evaluations with or without low-flow status. AVCdCT thresholds of 300 AU/cm2 for women and 500 AU/cm2 for men seem to be appropriate to identify severe AS. Further studies are needed to validate these thresholds, especially in diverse populations.
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Affiliation(s)
- Andréanne Powers
- Institut Universitaire de Cardiologie et Pneumologie de Québec (Quebec Heart & Lung Institute), Université Laval, Canada (A.P., N.L., N.S.B.M., L.T., C.R., M.-A.C.)
| | - Mulham Ali
- Faculty of Medicine, University of Southern Denmark, Odense (M.A., A.H., N.S.B.M., K.A.Ø., J.S.D., M.-A.C.)
| | - Nicolas Lavoie
- Institut Universitaire de Cardiologie et Pneumologie de Québec (Quebec Heart & Lung Institute), Université Laval, Canada (A.P., N.L., N.S.B.M., L.T., C.R., M.-A.C.)
| | - Amal Haujir
- Faculty of Medicine, University of Southern Denmark, Odense (M.A., A.H., N.S.B.M., K.A.Ø., J.S.D., M.-A.C.)
| | - Nils Sofus Borg Mogensen
- Institut Universitaire de Cardiologie et Pneumologie de Québec (Quebec Heart & Lung Institute), Université Laval, Canada (A.P., N.L., N.S.B.M., L.T., C.R., M.-A.C.)
- Faculty of Medicine, University of Southern Denmark, Odense (M.A., A.H., N.S.B.M., K.A.Ø., J.S.D., M.-A.C.)
| | - Sebastian Ludwig
- Department of Cardiology, University Heart & Vascular Center Hamburg, Germany (S.L., N.S.)
- German Center for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Lübeck, Hamburg, Germany (S.L., N.S.)
- Cardiovascular Research Foundation, New York, NY (S.L.)
| | - Kristian Altern Øvrehus
- Faculty of Medicine, University of Southern Denmark, Odense (M.A., A.H., N.S.B.M., K.A.Ø., J.S.D., M.-A.C.)
| | - Lionel Tastet
- Institut Universitaire de Cardiologie et Pneumologie de Québec (Quebec Heart & Lung Institute), Université Laval, Canada (A.P., N.L., N.S.B.M., L.T., C.R., M.-A.C.)
| | - Catherine Rhéaume
- Institut Universitaire de Cardiologie et Pneumologie de Québec (Quebec Heart & Lung Institute), Université Laval, Canada (A.P., N.L., N.S.B.M., L.T., C.R., M.-A.C.)
| | - Niklas Schofer
- Department of Cardiology, University Heart & Vascular Center Hamburg, Germany (S.L., N.S.)
- German Center for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Lübeck, Hamburg, Germany (S.L., N.S.)
| | - Jordi Sanchez Dahl
- Faculty of Medicine, University of Southern Denmark, Odense (M.A., A.H., N.S.B.M., K.A.Ø., J.S.D., M.-A.C.)
| | - Marie-Annick Clavel
- Institut Universitaire de Cardiologie et Pneumologie de Québec (Quebec Heart & Lung Institute), Université Laval, Canada (A.P., N.L., N.S.B.M., L.T., C.R., M.-A.C.)
- Faculty of Medicine, University of Southern Denmark, Odense (M.A., A.H., N.S.B.M., K.A.Ø., J.S.D., M.-A.C.)
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14
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Laohachewin D, Ruile P, Breitbart P, Minners J, Jander N, Soschynski M, Schlett CL, Neumann FJ, Westermann D, Hein M. Quantification of Aortic Valve Calcification in Contrast-Enhanced Computed Tomography. J Clin Med 2024; 13:2386. [PMID: 38673658 PMCID: PMC11051576 DOI: 10.3390/jcm13082386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 04/09/2024] [Accepted: 04/16/2024] [Indexed: 04/28/2024] Open
Abstract
Background: The goal of our study is to evaluate a method to quantify aortic valve calcification (AVC) in contrast-enhanced computed tomography for patients with suspected severe aortic stenosis pre-interventionally. Methods: A total of sixty-five patients with aortic stenosis underwent both a native and a contrast-enhanced computed tomography (CECT) scan of the aortic valve (45 in the training cohort and 20 in the validation cohort) using a standardized protocol. Aortic valve calcification was semi-automatically quantified via the Agatston score method for the native scans and was used as a reference. For contrast-enhanced computed tomography, a calcium threshold of the Hounsfield units of the aorta plus four times the standard deviation was used. Results: For the quantification of aortic valve calcification in contrast-enhanced computed tomography, a conversion formula (691 + 1.83 x AVCCECT) was derived via a linear regression model in the training cohort. The validation in the second cohort showed high agreement for this conversion formula with no significant proportional bias (Bland-Altman, p = 0.055) and with an intraclass correlation coefficient in the validation cohort of 0.915 (confidence interval 95% 0.786-0.966) p < 0.001. Conclusions: Calcium scoring in patients with aortic valve stenosis can be performed using contrast-enhanced computed tomography with high validity. Using a conversion factor led to an excellent agreement, thereby obviating an additional native computed tomography scan. This might contribute to a decrease in radiation exposure.
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Affiliation(s)
- Danai Laohachewin
- Department of Cardiology and Angiology, Medical Center—University of Freiburg, Faculty of Medicine, Suedring 15, 79189 Bad Krozingen, Germany
| | - Philipp Ruile
- Department of Cardiology and Angiology, Medical Center—University of Freiburg, Faculty of Medicine, Suedring 15, 79189 Bad Krozingen, Germany
| | - Philipp Breitbart
- Department of Cardiology and Angiology, Medical Center—University of Freiburg, Faculty of Medicine, Suedring 15, 79189 Bad Krozingen, Germany
| | - Jan Minners
- Department of Cardiology and Angiology, Medical Center—University of Freiburg, Faculty of Medicine, Suedring 15, 79189 Bad Krozingen, Germany
| | - Nikolaus Jander
- Department of Cardiology and Angiology, Medical Center—University of Freiburg, Faculty of Medicine, Suedring 15, 79189 Bad Krozingen, Germany
| | - Martin Soschynski
- Department of Diagnostic and Interventional Radiology, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Straße 55, 79106 Freiburg, Germany
| | - Christopher L. Schlett
- Department of Diagnostic and Interventional Radiology, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Straße 55, 79106 Freiburg, Germany
| | - Franz-Josef Neumann
- Department of Cardiology and Angiology, Medical Center—University of Freiburg, Faculty of Medicine, Suedring 15, 79189 Bad Krozingen, Germany
| | - Dirk Westermann
- Department of Cardiology and Angiology, Medical Center—University of Freiburg, Faculty of Medicine, Suedring 15, 79189 Bad Krozingen, Germany
| | - Manuel Hein
- Department of Cardiology and Angiology, Medical Center—University of Freiburg, Faculty of Medicine, Suedring 15, 79189 Bad Krozingen, Germany
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15
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Ye Z, Clavel MA, Foley TA, Pibarot P, Enriquez-Sarano M, Michelena HI. Computed tomography calcium scoring in aortic stenosis: bicuspid versus tricuspid morphology. Heart 2024; 110:594-602. [PMID: 37903555 DOI: 10.1136/heartjnl-2023-323281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 09/28/2023] [Indexed: 11/01/2023] Open
Abstract
OBJECTIVE CT aortic valve calcium score (AVCscore) and density (AVCdensity) thresholds have been recommended for aortic stenosis (AS) severity assessment in tricuspid aortic valve (TAV). We aimed to compare AVCscore and AVCdensity in bicuspid aortic valve (BAV) versus TAV. METHODS Retrospective single-centre study of patients with echocardiographic AS-severity and CT-AVC assessments within 6 months, and left ventricular ejection fraction ≥50%, all referred for clinical AS evaluation.Severe AS was defined as aortic valve area (AVA) ≤1 cm2 or indexed AVA ≤0.6cm2/m2 plus mean gradient ≥40 mm Hg or peak velocity ≥4 m/s. AVC was assessed by Agatston method. RESULTS Of the 1957 patients, 328 had BAV and 1629 had TAV, age 65±11 vs 80±9 years (p<0.001), men 65% vs 56% (p=0.006), respectively. BAV morphology was associated with higher AVCscore and AVCdensity independent of age, comorbidities and AS severity (p<0.001) in men only (sex and BAV interaction p<0.001). In patients with severe AS, mean AVCscore and AVCdensity were higher in BAV-men than that in TAV-men (both p<0.001), but similar in BAV-women and TAV-women (both p≥0.4). Such patterns remained the same after adjustment for clinical covariates and AS severity. Best thresholds for severe AS diagnosis in BAV-men were 2916 AU by AVCscore and 600 AU/cm2 by AVCdensity which were higher than the guideline-recommended thresholds, while thresholds in BAV-women (1036 AU and 282 AU/cm2) were similar to guideline-recommended ones. CONCLUSION Valve calcification in AS differs according to valve morphology and sex. BAV-men with severe AS exhibit greater AVCscore and AVCdensity than TAV-men. This presents a diagnostic challenge to the current guidelines, which needs confirmation in larger studies.
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Affiliation(s)
- Zi Ye
- Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Philippe Pibarot
- Cardiology, Quebec Heart and Lung Institute, Quebec, Quebec, Canada
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16
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Jander N, Minners J. Towards a gender-specific and morphology-specific assessment of aortic valve stenosis severity. Heart 2024; 110:543-544. [PMID: 38086613 DOI: 10.1136/heartjnl-2023-323499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/24/2024] Open
Affiliation(s)
- Nikolaus Jander
- University Heart Center Freiburg Bad Krozingen, Bad Krozingen, Germany
| | - Jan Minners
- University Heart Center Freiburg Bad Krozingen, Bad Krozingen, Germany
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Carter-Storch R, Le Nezet E, Ali M, Powers A, Haujir A, Demers K, Couture C, Dumont É, Trahan S, Pagé S, Dagenais F, Pibarot P, Dahl JS, Clavel MA. Angiotensin II Receptor Blockers Are Associated With Reduced Valvular Fibrosis in Women With Aortic Stenosis. Can J Cardiol 2024:S0828-282X(24)00270-8. [PMID: 38518892 DOI: 10.1016/j.cjca.2024.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Revised: 03/13/2024] [Accepted: 03/15/2024] [Indexed: 03/24/2024] Open
Abstract
BACKGROUND Angiotensin receptor blockers (ARBs) may slow down the progression of aortic stenosis (AS) through their antifibrotic effect. Women present more valvular fibrosis than men, so ARBs may have more effect in females. Our aim was to assess the impact of ARBs on the remodelling of the aortic valve in men and women. METHODS We included patients who had an aortic valve replacement with or without coronary bypass grafting from 2006 to 2013. Patients with missing echocardiographic or histologic data were excluded. Warren-Yong and fibrosis scores of the explanted valves were performed. Patients were divided into 4 phenotypes according to their Warren-Yong and fibrosis scores: mild calcification/fibrosis, severe calcification/fibrosis group, predominant fibrosis group, predominant calcification group. RESULTS Among the 1321 included patients, the vast majority (89%) has severe AS. Patients in the predominant fibrosis group, compared with the predominant calcium group, were more often female (39% vs 31%; P = 0.008) with bicuspid valves (44% vs 34%; P = 0.002), and less often used ARBs (25% vs 30%; P = 0.046). Female sex was independently associated with being in the predominant fibrosis group (odds ratio 1.45, 95% confidence interval 1.08-1.95; P = 0.01), with a significant interaction between female sex and ARBs. Women taking ARBs compared with women not taking ARBs had significantly lower fibrosis scores (P < 0.001). This difference was not seen in men. CONCLUSIONS In this large series of patients with moderate-severe AS, among the women there was a negative association between intake of ARBs and valvular fibrosis. Thus, the possible effects of ARBs may be sex specific, with a larger therapeutic role in women.
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Affiliation(s)
- Rasmus Carter-Storch
- Institut Universitaire de Cardiologie et de Pneumologie, Université Laval, Québec, Québec, Canada; Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Emma Le Nezet
- Institut Universitaire de Cardiologie et de Pneumologie, Université Laval, Québec, Québec, Canada
| | - Mulham Ali
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Andréanne Powers
- Institut Universitaire de Cardiologie et de Pneumologie, Université Laval, Québec, Québec, Canada
| | - Amal Haujir
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Karolanne Demers
- Institut Universitaire de Cardiologie et de Pneumologie, Université Laval, Québec, Québec, Canada
| | - Christian Couture
- Institut Universitaire de Cardiologie et de Pneumologie, Université Laval, Québec, Québec, Canada
| | - Éric Dumont
- Institut Universitaire de Cardiologie et de Pneumologie, Université Laval, Québec, Québec, Canada
| | - Sylvain Trahan
- Institut Universitaire de Cardiologie et de Pneumologie, Université Laval, Québec, Québec, Canada
| | - Sylvain Pagé
- Institut Universitaire de Cardiologie et de Pneumologie, Université Laval, Québec, Québec, Canada
| | - François Dagenais
- Institut Universitaire de Cardiologie et de Pneumologie, Université Laval, Québec, Québec, Canada
| | - Philippe Pibarot
- Institut Universitaire de Cardiologie et de Pneumologie, Université Laval, Québec, Québec, Canada
| | - Jordi S Dahl
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Marie-Annick Clavel
- Institut Universitaire de Cardiologie et de Pneumologie, Université Laval, Québec, Québec, Canada; Department of Cardiology, Odense University Hospital, Odense, Denmark.
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Sartoretti T, Mergen V, Dzaferi A, Allmendinger T, Manka R, Alkadhi H, Eberhard M. Effect of temporal resolution on calcium scoring: insights from photon-counting detector CT. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2024:10.1007/s10554-024-03070-6. [PMID: 38389028 DOI: 10.1007/s10554-024-03070-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 02/13/2024] [Indexed: 02/24/2024]
Abstract
To intra-individually investigate the variation of coronary artery calcium (CAC), aortic valve calcium (AVC), and mitral annular calcium (MAC) scores and the presence of blur artifacts as a function of temporal resolution in patients undergoing non-contrast cardiac CT on a dual-source photon counting detector (PCD) CT. This retrospective, IRB-approved study included 70 patients (30 women, 40 men, mean age 78 ± 9 years) who underwent ECG-gated cardiac non-contrast CT with PCD-CT (gantry rotation time 0.25 s) prior to transcatheter aortic valve replacement. Each scan was reconstructed at a temporal resolution of 66 ms using the dual-source information and at 125 ms using the single-source information. Average heart rate and heart rate variability were calculated from the recorded ECG. CAC, AVC, and MAC were quantified according to the Agatston method on images with both temporal resolutions. Two readers assessed blur artifacts using a 4-point visual grading scale. The influence of average heart rate and heart rate variability on calcium quantification and blur artifacts of the respective structures were analyzed by linear regression analysis. Mean heart rate and heart rate variability during data acquisition were 76 ± 17 beats per minute (bpm) and 4 ± 6 bpm, respectively. CAC scores were smaller on 66 ms (median, 511; interquartile range, 220-978) than on 125 ms reconstructions (538; 203-1050, p < 0.001). Median AVC scores [2809 (2009-3952) versus 3177 (2158-4273)] and median MAC scores [226 (0-1284) versus 251 (0-1574)] were also significantly smaller on 66ms than on 125ms reconstructions (p < 0.001). Reclassification of CAC and AVC risk categories occurred in 4% and 11% of cases, respectively, whereby the risk category was always overestimated on 125ms reconstructions. Image blur artifacts were significantly less on 66ms as opposed to 125 ms reconstructions (p < 0.001). Intra-individual analyses indicate that temporal resolution significantly impacts on calcium scoring with cardiac CT, with CAC, MAC, and AVC being overestimated at lower temporal resolution because of increased motion artifacts eventually leading to an overestimation of patient risk.
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Affiliation(s)
- Thomas Sartoretti
- Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Victor Mergen
- Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Amina Dzaferi
- Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | | | - Robert Manka
- Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
- Department of Cardiology, University Heart Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Hatem Alkadhi
- Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Matthias Eberhard
- Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.
- Radiology, Spital Interlaken, Spitäler fmi AG, Unterseen, Switzerland.
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19
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Alaour B, Nakase M, Pilgrim T. Combined Significant Aortic Stenosis and Mitral Regurgitation: Challenges in Timing and Type of Intervention. Can J Cardiol 2024; 40:235-249. [PMID: 37931671 DOI: 10.1016/j.cjca.2023.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 11/01/2023] [Accepted: 11/02/2023] [Indexed: 11/08/2023] Open
Abstract
In this narrative review, we aim to summarize the literature surrounding the assessment and management of the common, yet understudied combination of aortic stenosis (AS) and mitral regurgitation (MR), the components of which are complexly inter-related and interdependent from diagnostic, prognostic, and therapeutic perspectives. The hemodynamic interdependency of AS and MR confounds the assessment of the severity of each valve disease, thus underscoring the importance of a multimodal approach integrating valvular and extravalvular indicators of severity. A large body of literature suggests that baseline MR is associated with reduced survival post aortic valve (AV) intervention and that regression of MR post-AV intervention confers a mortality benefit. Functional MR is more likely to regress after AV intervention than primary MR. The respective natural courses of the 2 valve diseases are not synchronized; therefore, significant AS and MR at or above the respective threshold for intervention might not coincide. Surgery is primarily a 1-stop-shop procedure because of a considerable perioperative risk of repeat interventions, whereas transcatheter treatment modalities allow for a more tailored timing of intervention with reassessment of concomitant MR after AV replacement and a potential staged intervention in the absence of MR regression. In summary, AS and MR, when combined, are interlaced into a complex hemodynamic, diagnostic, and prognostic synergy, with important therapeutic implications. Contemporary approaches should consider stepwise intervention by exploiting the advantage of transcatheter options. However, evidence is needed to demonstrate the efficacy of different timing and therapeutic options.
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Affiliation(s)
- Bashir Alaour
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Masaaki Nakase
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thomas Pilgrim
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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20
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Liu T, Li M, Long D, Yang J, Zhao X, Li C, Wang W, Jiang C, Tang R. Predictive value of valvular calcification for the recurrence of persistent atrial fibrillation after radiofrequency catheter ablation. Clin Cardiol 2024; 47:e24176. [PMID: 37934927 PMCID: PMC10826787 DOI: 10.1002/clc.24176] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 09/25/2023] [Accepted: 10/16/2023] [Indexed: 11/09/2023] Open
Abstract
BACKGROUND Valvular calcification (VC) is an independent risk factor for cardiovascular diseases. The relationship between VC and atrial fibrillation is not clear. HYPOTHESIS We treated the aortic valve, mitral valve, and tricuspid valve as a whole and considered the possible association between VC and recurrence of persistent atrial fibrillation (PsAF) after radiofrequency catheter ablation (RFCA). METHODS This study involved 2687 PsAF patients who underwent RFCA. Data were collected to explore the relationship between VC and outcome. VC was defined by echocardiography in aortic valve, mitral valve, or tricuspid valve. After 1 year follow-up, subgroup analysis, mixed model regression analysis, and score system analysis were performed. The external validation of 133 patients demonstrated the accuracy of this clinical prediction model. RESULTS Overall, 2687 inpatients were assigned to the recurrence group (n = 682) or the no recurrence group (n = 2005) with or without VC. Compared to patients with no recurrence, the incidence of VC was higher in recurrence patients. Recurrence was present in 18.5%, 34.9%, 39.3%, and 52.0% of the four groups, which met VC numbers of 0, 1, 2, and 3, respectively. After adjustment for potential confounding factors, VC was an independent risk factor for AF recurrence in several models. For multivariable logistic regression, a scoring system was established based on the regression coefficient. The receiver operating characteristic area of the scoring system was 0.787 in the external validation cohort. CONCLUSIONS VC was an independent risk factor for AF recurrence in PsAF after RFCA. The scoring system may be a useful clinical tool to assess AF recurrence.
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Affiliation(s)
- Tong Liu
- Department of Cardiology, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen HospitalCapital Medical UniversityBeijingChina
| | - Meng‐Meng Li
- Department of Cardiology, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen HospitalCapital Medical UniversityBeijingChina
| | - De‐Yong Long
- Department of Cardiology, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen HospitalCapital Medical UniversityBeijingChina
| | - Jie Yang
- Department of Cardiology, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen HospitalCapital Medical UniversityBeijingChina
| | - Xin Zhao
- Department of Cardiology, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen HospitalCapital Medical UniversityBeijingChina
| | - Chang‐Yi Li
- Department of Cardiology, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen HospitalCapital Medical UniversityBeijingChina
| | - Wei Wang
- Department of Cardiology, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen HospitalCapital Medical UniversityBeijingChina
| | - Chen‐Xi Jiang
- Department of Cardiology, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen HospitalCapital Medical UniversityBeijingChina
| | - Ri‐Bo Tang
- Department of Cardiology, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen HospitalCapital Medical UniversityBeijingChina
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21
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Niemi HJ, Suihko S, Kylmälä M, Rajala H, Syväranta S, Kivistö S, Lommi J. Impact of Atrial Fibrillation on the Symptoms and Echocardiographic Evaluation of Patients With Aortic Stenosis. Am J Cardiol 2024; 211:122-129. [PMID: 37949341 DOI: 10.1016/j.amjcard.2023.11.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 10/23/2023] [Accepted: 11/04/2023] [Indexed: 11/12/2023]
Abstract
Atrial fibrillation (AF) is common in patients with aortic stenosis (AS) and complicates the assessment of AS severity. The overlapping of symptoms in these 2 conditions may postpone valve replacement. This study aimed to evaluate the effect of AF on the severity assessment of AS and its impact on symptoms and quality of life (QoL). Patients with severe AS were prospectively recruited. Echocardiography, symptom questionnaires, and RAND-36 QoL assessment were performed preoperatively and 3 months postoperatively. The aortic valve calcium score (AVC) was measured using computed tomography. Of the 279 patients, 74 (26.5%) had AF. Patients with AF had lower mean gradients and 45.9% had a low-gradient phenotype, with a mean gradient <40 mm Hg, compared with 22.4% of those without AF (p <0.001). The AVC measurements revealed severe valve calcification equally in patients with or without AF (85.7% vs 87.7%, p = 0.78). Patients with AF were more symptomatic at baseline, with 50.0% versus 27.3% in New York Heart Association class III or higher (p <0.001), and after intervention. Patients with AF had more residual dyspnea (27.3% vs 12.0%, p = 0.007) and exercise intolerance (36.4% vs 17.0%, p = 0.002). The QoL improved significantly in both groups but was worse at baseline in patients with AF and remained impaired after intervention. In conclusion, low-gradient AS phenotype is overrepresented in patients with AF, but they have equally severe stenosis determined using AVC, despite the lower gradients. Patients with AF have more symptoms and worse QoL, but they improve significantly after intervention. In patients with AF, multimodality imaging is important in the assessment of AS severity.
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Affiliation(s)
- Heikki J Niemi
- Departments of Cardiology, Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland.
| | - Satu Suihko
- Departments of Cardiology, Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
| | - Minna Kylmälä
- Departments of Cardiology, Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
| | - Helena Rajala
- Departments of Cardiology, Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
| | - Suvi Syväranta
- Radiology, HUS Diagnostic Center, Helsinki University Hospital, Helsinki, Finland
| | - Sari Kivistö
- Radiology, HUS Diagnostic Center, Helsinki University Hospital, Helsinki, Finland
| | - Jyri Lommi
- Departments of Cardiology, Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
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22
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Lorenzatti D, Piña P, Daich J, Scotti A, Perez-Cervera J, Miranda R, Feinberg AJ, Halliburton SS, Ivanc TB, Schenone AL, Kuno T, Latib A, Dey D, Pibarot P, Dweck MR, Garcia MJ, Slipczuk L. Diagnostic accuracy of virtual non-contrast CT for aortic valve stenosis severity evaluation. J Cardiovasc Comput Tomogr 2024; 18:50-55. [PMID: 38314547 DOI: 10.1016/j.jcct.2023.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 10/13/2023] [Indexed: 02/06/2024]
Abstract
BACKGROUND Computed tomography aortic valve calcium (AVC) score has accepted value for diagnosing and predicting outcomes in aortic stenosis (AS). Multi-energy CT (MECT) allows virtual non-contrast (VNC) reconstructions from contrast scans. We aim to compare the VNC-AVC score to the true non-contrast (TNC)-AVC score for assessing AS severity. METHODS We prospectively included patients undergoing a MECT for transcatheter aortic valve replacement (TAVR) planning. TNC-AVC was acquired before contrast, and VNC-AVC was derived from a retrospectively gated contrast-enhanced scan. The Agatston scoring method was used for quantification, and linear regression analysis to derive adjusted-VNC values. RESULTS Among 109 patients (55% female) included, 43% had concordant severe and 14% concordant moderate AS. TNC scan median dose-length product was 116 mGy∗cm. The median TNC-AVC was 2,107 AU (1,093-3,372), while VNC-AVC was 1,835 AU (1293-2,972) after applying the coefficient (1.46) and constant (743) terms. A strong correlation was demonstrated between methods (r = 0.93; p < 0.001). Using accepted thresholds (>1,300 AU for women and >2,000 AU for men), 65% (n = 71) of patients had severe AS by TNC-AVC and 67% (n = 73) by adjusted-VNC-AVC. After estimating thresholds for adjusted-VNC (>1,564 AU for women and >2,375 AU for men), 56% (n = 61) had severe AS, demonstrating substantial agreement with TNC-AVC (κ = 0.77). CONCLUSIONS MECT-derived VNC-AVC showed a strong correlation with TNC-AVC. After adjustment, VNC-AVC demonstrated substantial agreement with TNC-AVC, potentially eliminating the requirement for an additional scan and enabling reductions in both radiation exposure and acquisition time.
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Affiliation(s)
- Daniel Lorenzatti
- Division of Cardiology, Montefiore Medical Center/Albert Einstein College of Medicine. Bronx, NY, USA
| | - Pamela Piña
- Division of Cardiology, Montefiore Medical Center/Albert Einstein College of Medicine. Bronx, NY, USA; Division of Cardiology, CEDIMAT, Santo Domingo, Dominican Republic
| | - Jonathan Daich
- Division of Cardiology, Montefiore Medical Center/Albert Einstein College of Medicine. Bronx, NY, USA
| | - Andrea Scotti
- Division of Cardiology, Montefiore Medical Center/Albert Einstein College of Medicine. Bronx, NY, USA
| | | | - Rita Miranda
- Division of Cardiology, Montefiore Medical Center/Albert Einstein College of Medicine. Bronx, NY, USA
| | - Ari J Feinberg
- Division of Cardiology, Montefiore Medical Center/Albert Einstein College of Medicine. Bronx, NY, USA
| | | | - Thomas B Ivanc
- CT Clinical Science, Philips Healthcare, Cleveland, OH, USA
| | - Aldo L Schenone
- Division of Cardiology, Montefiore Medical Center/Albert Einstein College of Medicine. Bronx, NY, USA
| | - Toshiki Kuno
- Division of Cardiology, Montefiore Medical Center/Albert Einstein College of Medicine. Bronx, NY, USA
| | - Azeem Latib
- Division of Cardiology, Montefiore Medical Center/Albert Einstein College of Medicine. Bronx, NY, USA
| | - Damini Dey
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Philippe Pibarot
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Université Laval, Québec, Canada
| | - Marc R Dweck
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Mario J Garcia
- Division of Cardiology, Montefiore Medical Center/Albert Einstein College of Medicine. Bronx, NY, USA
| | - Leandro Slipczuk
- Division of Cardiology, Montefiore Medical Center/Albert Einstein College of Medicine. Bronx, NY, USA.
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23
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Kalisz K, Moore A, Chaturvedi A, Rajiah PS. Multimodality Imaging in Planning of Complex TAVR Procedures. Semin Roentgenol 2024; 59:57-66. [PMID: 38388097 DOI: 10.1053/j.ro.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 10/01/2023] [Accepted: 10/09/2023] [Indexed: 02/24/2024]
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24
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Thong EHE, Kong WKF, Poh KK, Wong R, Chai P, Sia CH. Multimodal Cardiac Imaging in the Assessment of Patients Who Have Suffered a Cardioembolic Stroke: A Review. J Cardiovasc Dev Dis 2023; 11:13. [PMID: 38248883 PMCID: PMC10816708 DOI: 10.3390/jcdd11010013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 12/21/2023] [Accepted: 12/27/2023] [Indexed: 01/23/2024] Open
Abstract
Cardioembolic strokes account for 20-25% of all ischaemic strokes, with their incidence increasing with age. Cardiac imaging plays a crucial role in identifying cardioembolic causes of stroke, with early and accurate identification affecting treatment, preventing recurrence, and reducing stroke incidence. Echocardiography serves as the mainstay of cardiac evaluation. Transthoracic echocardiography (TTE) is the first line in the basic evaluation of structural heart disorders, valvular disease, vegetations, and intraventricular thrombus. It can be used to measure chamber size and systolic/diastolic function. Trans-oesophageal echocardiography (TOE) yields better results in identifying potential cardioembolic sources of stroke and should be strongly considered, especially if TTE does not yield adequate results. Cardiac computed tomography and cardiac magnetic resonance imaging provide better soft tissue characterisation, high-grade anatomical information, spatial and temporal visualisation, and image reconstruction in multiple planes, especially with contrast. These techniques are useful in cases of inconclusive echocardiograms and can be used to detect and characterise valvular lesions, thrombi, fibrosis, cardiomyopathies, and aortic plaques. Nuclear imaging is not routinely used, but it can be used to assess left-ventricular perfusion, function, and dimensions and may be useful in cases of infective endocarditis. Its use should be considered on a case-by-case basis. The accuracy of each imaging modality depends on the likely source of cardioembolism, and the choice of imaging approach should be tailored to individual patients.
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Affiliation(s)
| | - William K. F. Kong
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore; (W.K.F.K.); (K.-K.P.); (R.W.); (P.C.)
| | - Kian-Keong Poh
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore; (W.K.F.K.); (K.-K.P.); (R.W.); (P.C.)
| | - Raymond Wong
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore; (W.K.F.K.); (K.-K.P.); (R.W.); (P.C.)
| | - Ping Chai
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore; (W.K.F.K.); (K.-K.P.); (R.W.); (P.C.)
| | - Ching-Hui Sia
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore; (W.K.F.K.); (K.-K.P.); (R.W.); (P.C.)
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25
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Denis RL, Hasan RK, Post WS, Resar JR, Zimmerman SL, Czarny MJ. Racial Differences in Aortic Valve Calcium Volume Among Patients With Severe Aortic Stenosis Who Underwent Transcatheter Aortic Valve Replacement. Am J Cardiol 2023; 208:116-117. [PMID: 37832207 PMCID: PMC10842499 DOI: 10.1016/j.amjcard.2023.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 09/06/2023] [Indexed: 10/15/2023]
Abstract
“No difference observed in aortic valve calcium volume in patients with severe AS undergoing TAVR.”
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Affiliation(s)
- Rimsky L Denis
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rani K Hasan
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Wendy S Post
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jon R Resar
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Stefan L Zimmerman
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Matthew J Czarny
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.
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26
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Patel KP, Lin A, Kumar N, Esposito G, Grodecki K, Lloyd G, Mathur A, Baumbach A, Mullen MJ, Williams MC, Newby DE, Treibel TA, Dweck MR, Dey D. Influence of cusp morphology and sex on quantitative valve composition in severe aortic stenosis. Eur Heart J Cardiovasc Imaging 2023; 24:1653-1660. [PMID: 37339331 DOI: 10.1093/ehjci/jead142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 04/09/2023] [Accepted: 06/02/2023] [Indexed: 06/22/2023] Open
Abstract
AIMS Aortic stenosis is characterized by fibrosis and calcification of the valve, with a higher proportion of fibrosis observed in women. Stenotic bicuspid aortic valves progress more rapidly than tricuspid valves, which may also influence the relative composition of the valve. We aimed to investigate the influence of cusp morphology on quantitative aortic valve composition quantified from contrast-enhanced computed tomography angiography in severe aortic stenosis. METHODS AND RESULTS Patients undergoing transcatheter aortic valve implantation with bicuspid and tricuspid valves were propensity matched 1:1 by age, sex, and comorbidities. Computed tomography angiograms were analysed using semi-automated software to quantify the fibrotic and calcific scores (volume/valve annular area) and the fibro-calcific ratio (fibrotic score/calcific score). The study population (n = 140) was elderly (76 ± 10 years, 62% male) and had a peak aortic jet velocity of 4.1 ± 0.7 m/s. Compared with those with tricuspid valves (n = 70), patients with bicuspid valves (n = 70) had higher fibrotic scores [204 (interquartile range 118-267) vs. 144 (99-208) mm3/cm2, P = 0.006] with similar calcific scores (P = 0.614). Women had greater fibrotic scores than men in bicuspid [224 (181-307) vs. 169 (109-247) mm3/cm2, P = 0.042] but not tricuspid valves (P = 0.232). Men had greater calcific scores than women in both bicuspid [203 (124-355) vs. 130 (70-182) mm3/cm2, P = 0.008] and tricuspid [177 (136-249) vs. 100 (62-150) mm3/cm2, P = 0.004] valves. Among both valve types, women had a greater fibro-calcific ratio compared with men [tricuspid 1.86 (0.94-2.56) vs. 0.86 (0.54-1.24), P = 0.001 and bicuspid 1.78 (1.21-2.90) vs. 0.74 (0.44-1.53), P = 0.001]. CONCLUSIONS In severe aortic stenosis, bicuspid valves have proportionately more fibrosis than tricuspid valves, especially in women.
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Affiliation(s)
- Kush P Patel
- Department of Cardiology, Barts Health NHS Trust, London, UK
| | - Andrew Lin
- Department of Cardiology, Barts Health NHS Trust, London, UK
- Departments of Biomedical Sciences and Medicine, Cedars-Sinai Medical Center, Biomedical Imaging Research Institute, 116N Robertson Blvd, Suite 400, Los Angeles, CA 90048, USA
| | - Niraj Kumar
- Department of Cardiology, Barts Health NHS Trust, London, UK
- Institute of Cardiovascular Science, University College London, London, UK
| | - Giulia Esposito
- Department of Cardiology, Barts Health NHS Trust, London, UK
- Institute of Cardiovascular Science, University College London, London, UK
| | - Kajetan Grodecki
- Departments of Biomedical Sciences and Medicine, Cedars-Sinai Medical Center, Biomedical Imaging Research Institute, 116N Robertson Blvd, Suite 400, Los Angeles, CA 90048, USA
- First Department of Cardiology, Medical University of Warsaw, Banacha 1A, 02-097 Warsaw, Poland
| | - Guy Lloyd
- Department of Cardiology, Barts Health NHS Trust, London, UK
| | - Anthony Mathur
- Department of Cardiology, Barts Health NHS Trust, London, UK
- Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Andreas Baumbach
- Department of Cardiology, Barts Health NHS Trust, London, UK
- Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, UK
- Yale University School of Medicine, New Haven, CT, USA
| | | | - Michelle C Williams
- University of Edinburgh/British Heart Foundation Centre for Cardiovascular Science, Edinburgh, UK
| | - David E Newby
- University of Edinburgh/British Heart Foundation Centre for Cardiovascular Science, Edinburgh, UK
| | - Thomas A Treibel
- Department of Cardiology, Barts Health NHS Trust, London, UK
- Institute of Cardiovascular Science, University College London, London, UK
| | - Marc R Dweck
- University of Edinburgh/British Heart Foundation Centre for Cardiovascular Science, Edinburgh, UK
| | - Damini Dey
- Departments of Biomedical Sciences and Medicine, Cedars-Sinai Medical Center, Biomedical Imaging Research Institute, 116N Robertson Blvd, Suite 400, Los Angeles, CA 90048, USA
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Scalia IG, Farina JM, Padang R, Jokerst CE, Pereyra M, Mahmoud AK, Naqvi TZ, Chao CJ, Oh JK, Arsanjani R, Ayoub C. Aortic Valve Calcium Score by Computed Tomography as an Adjunct to Echocardiographic Assessment-A Review of Clinical Utility and Applications. J Imaging 2023; 9:250. [PMID: 37998097 PMCID: PMC10672559 DOI: 10.3390/jimaging9110250] [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: 09/01/2023] [Revised: 10/30/2023] [Accepted: 11/01/2023] [Indexed: 11/25/2023] Open
Abstract
Aortic valve stenosis (AS) is increasing in prevalence due to the aging population, and severe AS is associated with significant morbidity and mortality. Echocardiography remains the mainstay for the initial detection and diagnosis of AS, as well as for grading of severity. However, there are important subgroups of patients, for example, patients with low-flow low-gradient or paradoxical low-gradient AS, where quantification of severity of AS is challenging by echocardiography and underestimation of severity may delay appropriate management and impart a worse prognosis. Aortic valve calcium score by computed tomography has emerged as a useful clinical diagnostic test that is complimentary to echocardiography, particularly in cases where there may be conflicting data or clinical uncertainty about the degree of AS. In these situations, aortic valve calcium scoring may help re-stratify grading of severity and, therefore, further direct clinical management. This review presents the evolution of aortic valve calcium score by computed tomography, its diagnostic and prognostic value, as well as its utility in clinical care.
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Affiliation(s)
- Isabel G. Scalia
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (I.G.S.)
| | - Juan M. Farina
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (I.G.S.)
| | - Ratnasari Padang
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | | | - Milagros Pereyra
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (I.G.S.)
| | - Ahmed K. Mahmoud
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (I.G.S.)
| | - Tasneem Z. Naqvi
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (I.G.S.)
| | - Chieh-Ju Chao
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Jae K. Oh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Reza Arsanjani
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (I.G.S.)
| | - Chadi Ayoub
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (I.G.S.)
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Holste G, Oikonomou EK, Mortazavi BJ, Coppi A, Faridi KF, Miller EJ, Forrest JK, McNamara RL, Ohno-Machado L, Yuan N, Gupta A, Ouyang D, Krumholz HM, Wang Z, Khera R. Severe aortic stenosis detection by deep learning applied to echocardiography. Eur Heart J 2023; 44:4592-4604. [PMID: 37611002 PMCID: PMC11004929 DOI: 10.1093/eurheartj/ehad456] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 06/21/2023] [Accepted: 07/11/2023] [Indexed: 08/25/2023] Open
Abstract
BACKGROUND AND AIMS Early diagnosis of aortic stenosis (AS) is critical to prevent morbidity and mortality but requires skilled examination with Doppler imaging. This study reports the development and validation of a novel deep learning model that relies on two-dimensional (2D) parasternal long axis videos from transthoracic echocardiography without Doppler imaging to identify severe AS, suitable for point-of-care ultrasonography. METHODS AND RESULTS In a training set of 5257 studies (17 570 videos) from 2016 to 2020 [Yale-New Haven Hospital (YNHH), Connecticut], an ensemble of three-dimensional convolutional neural networks was developed to detect severe AS, leveraging self-supervised contrastive pretraining for label-efficient model development. This deep learning model was validated in a temporally distinct set of 2040 consecutive studies from 2021 from YNHH as well as two geographically distinct cohorts of 4226 and 3072 studies, from California and other hospitals in New England, respectively. The deep learning model achieved an area under the receiver operating characteristic curve (AUROC) of 0.978 (95% CI: 0.966, 0.988) for detecting severe AS in the temporally distinct test set, maintaining its diagnostic performance in geographically distinct cohorts [0.952 AUROC (95% CI: 0.941, 0.963) in California and 0.942 AUROC (95% CI: 0.909, 0.966) in New England]. The model was interpretable with saliency maps identifying the aortic valve, mitral annulus, and left atrium as the predictive regions. Among non-severe AS cases, predicted probabilities were associated with worse quantitative metrics of AS suggesting an association with various stages of AS severity. CONCLUSION This study developed and externally validated an automated approach for severe AS detection using single-view 2D echocardiography, with potential utility for point-of-care screening.
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Affiliation(s)
- Gregory Holste
- Department of Electrical and Computer Engineering, The University of Texas at Austin, Austin, TX, USA
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06520-8056, USA
| | - Evangelos K Oikonomou
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06520-8056, USA
| | - Bobak J Mortazavi
- Department of Computer Science & Engineering, Texas A&M University, College Station, TX, USA
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, 195 Church St 5th Floor, New Haven, CT, USA
| | - Andreas Coppi
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06520-8056, USA
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, 195 Church St 5th Floor, New Haven, CT, USA
| | - Kamil F Faridi
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06520-8056, USA
| | - Edward J Miller
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06520-8056, USA
| | - John K Forrest
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06520-8056, USA
| | - Robert L McNamara
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06520-8056, USA
| | - Lucila Ohno-Machado
- Section of Biomedical Informatics and Data Science, Yale School of Medicine, New Haven, CT, USA
| | - Neal Yuan
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
- Division of Cardiology, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Aakriti Gupta
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - David Ouyang
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Division of Artificial Intelligence in Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Harlan M Krumholz
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06520-8056, USA
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, 195 Church St 5th Floor, New Haven, CT, USA
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA
| | - Zhangyang Wang
- Department of Electrical and Computer Engineering, The University of Texas at Austin, Austin, TX, USA
| | - Rohan Khera
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06520-8056, USA
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, 195 Church St 5th Floor, New Haven, CT, USA
- Section of Biomedical Informatics and Data Science, Yale School of Medicine, New Haven, CT, USA
- Section of Health Informatics, Department of Biostatistics, Yale School of Public Health, 60 College St, New Haven, CT, USA
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29
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Dweck MR, Loganath K, Bing R, Treibel TA, McCann GP, Newby DE, Leipsic J, Fraccaro C, Paolisso P, Cosyns B, Habib G, Cavalcante J, Donal E, Lancellotti P, Clavel MA, Otto CM, Pibarot P. Multi-modality imaging in aortic stenosis: an EACVI clinical consensus document. Eur Heart J Cardiovasc Imaging 2023; 24:1430-1443. [PMID: 37395329 DOI: 10.1093/ehjci/jead153] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 06/16/2023] [Indexed: 07/04/2023] Open
Abstract
In this EACVI clinical scientific update, we will explore the current use of multi-modality imaging in the diagnosis, risk stratification, and follow-up of patients with aortic stenosis, with a particular focus on recent developments and future directions. Echocardiography is and will likely remain the key method of diagnosis and surveillance of aortic stenosis providing detailed assessments of valve haemodynamics and the cardiac remodelling response. Computed tomography (CT) is already widely used in the planning of transcutaneous aortic valve implantation. We anticipate its increased use as an anatomical adjudicator to clarify disease severity in patients with discordant echocardiographic measurements. CT calcium scoring is currently used for this purpose; however, contrast CT techniques are emerging that allow identification of both calcific and fibrotic valve thickening. Additionally, improved assessments of myocardial decompensation with echocardiography, cardiac magnetic resonance, and CT will become more commonplace in our routine assessment of aortic stenosis. Underpinning all of this will be widespread application of artificial intelligence. In combination, we believe this new era of multi-modality imaging in aortic stenosis will improve the diagnosis, follow-up, and timing of intervention in aortic stenosis as well as potentially accelerate the development of the novel pharmacological treatments required for this disease.
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Affiliation(s)
- Marc R Dweck
- Centre for Cardiovascular Science, University of Edinburgh, Chancellors Building, Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Krithika Loganath
- Centre for Cardiovascular Science, University of Edinburgh, Chancellors Building, Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Rong Bing
- Centre for Cardiovascular Science, University of Edinburgh, Chancellors Building, Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Thomas A Treibel
- Barts Heart Centre, Bart's Health NHS Trust, W Smithfield, EC1A 7BE, London, UK
- University College London Institute of Cardiovascular Science, 62 Huntley St, WC1E 6DD, London, UK
| | - Gerry P McCann
- Department of Cardiovascular Sciences, University of Leicester, University Rd, Leicester LE1 7RH, UK
- The NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Groby Road, Leicester, LE3 9QP, UK
| | - David E Newby
- Centre for Cardiovascular Science, University of Edinburgh, Chancellors Building, Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Jonathon Leipsic
- Centre for Cardiovascular Innovation, St Paul's and Vancouver General Hospital, 1081 Burrard St Room 166, Vancouver, British Columbia V6Z 1Y6, Canada
| | - Chiara Fraccaro
- Department of Cardiac, Thoracic and Vascular Science and Public Health, Via Giustiniani, 2 - 35128, Padua, Italy
| | - Pasquale Paolisso
- Cardiovascular Center Aalst, OLV Clinic, Moorselbaan 164, 9300 Aalst, Belgium
- Department of Advanced Biomedical Sciences, University of Naples, Federico II, 80125 Naples, Italy
| | - Bernard Cosyns
- Department of Cardiology, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090 Jette, Belgium
| | - Gilbert Habib
- Cardiology Department, Hôpital La Timone, 264 Rue Saint-Pierre, 13005 Marseille, France
| | - João Cavalcante
- Allina Health Minneapolis Heart Institute, Abbott Northwestern Hospital, 800 E 28th St, Minneapolis, MN 55407, USA
| | - Erwan Donal
- Cardiology and CIC, Université Rennes, 2 Rue Henri Le Guilloux, 35033 Rennes, France
| | - Patrizio Lancellotti
- GIGA Cardiovascular Sciences, Department of Cardiology, University of Liège Hospital, CHU Sart Tilman, Liège, Belgium
- Gruppo Villa Maria Care and Research, Corso Giuseppe Garibaldi, 11, 48022 Lugo RA, Italy
| | - Marie-Annick Clavel
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, 2725 Ch Ste-Foy, Québec, QC G1V 4G5, Canada
- Faculté de Médecine-Département de Médecine, Université Laval, Ferdinand Vandry Pavillon, 1050 Av. de la Médecine, Québec City, Quebec G1V 0A6, Canada
| | - Catherine M Otto
- Division of Cardiology, Department of Medicine, University of Washington School of Medicine, 4333 Brooklyn Ave NE Box 359458, Seattle, WA 98195-9458, USA
| | - Phillipe Pibarot
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, 2725 Ch Ste-Foy, Québec, QC G1V 4G5, Canada
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30
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Lakshmanan S, Gimelli A. Cardiovascular Imaging in Clinical Trial Design: A Vision for Sustainability. JACC Case Rep 2023; 24:102048. [PMID: 37869224 PMCID: PMC10589438 DOI: 10.1016/j.jaccas.2023.102048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
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Racz AO, Szabo GT, Papp T, Csippa B, Gyurki D, Kracsko B, Koszegi Z, Kolozsvari R. Potential Clinical Usefulness of Post-Valvular Contrast Densities to Determine the Severity of Aortic Valve Stenosis Using Computed Tomography. J Cardiovasc Dev Dis 2023; 10:412. [PMID: 37887859 PMCID: PMC10607528 DOI: 10.3390/jcdd10100412] [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: 07/30/2023] [Revised: 09/23/2023] [Accepted: 09/26/2023] [Indexed: 10/28/2023] Open
Abstract
BACKGROUND Different methods are established for the changes in aortic valve stenosis with cardiac computed tomography angiography (CCTA), but the effect of the grade of stenosis on contrast densities around the valve has not been investigated. AIMS/METHODS Using the information from flow dynamics in cases of increased velocity through narrowed lumen, the hypothesis was formed that flow changes can alter the contrast densities in stenotic post-valvular regions, and the density changes might correlate with the grade of stenosis. Forty patients with severe aortic stenosis and fifteen with a normal aortic valve were enrolled. With echocardiography, the peak/mean transvalvular gradients, peak transvalvular velocity, and aortic valve opening area were obtained. With CCTA, densities 4-5 mm above the aortic valve; at the junction of the left, right, and noncoronary cusp to the annulus; at the middle level of the left, right, and noncoronary sinuses of Valsalva in the center and the lateral points; at the sinotubular junction; and 4 cm from the sinotubular junction at the midline were measured. First, a comparison of the densities between the normal and stenotic valve was performed, and then possible correlations between echocardiography and CCTA values were investigated in the stenotic group. RESULTS In all CCTA regions, significantly lower-density values were detected among stenotic valve patients compared to the normal aortic valve population. Additionally, in both groups, higher densities were measured in the peri-jet regions than in the lateral ones. Furthermore, a good correlation was found between the aortic valve opening area and the densities in almost all perivalvular areas. With regard to the densities at the junction of the non-coronary leaflet to the fibrotic annulus and at the most lateral point of the right sinus of Valsalva, a high level of correlation was found between all echocardiography and CCTA parameters. Lastly, with receiver operating characteristic curve measurements, area under the curve values were between 0.857 and 0.930. CONCLUSION Certain CCTA density values, especially 4-5mm above the valve opening, can serve as auxiliary information to echocardiography when the severity of aortic valve stenosis is unclear.
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Affiliation(s)
- Agnes Orsolya Racz
- Department of Cardiology and Heart Surgery, University of Debrecen, 4032 Debrecen, Hungary; (A.O.R.); (G.T.S.); (B.K.); (Z.K.)
| | - Gabor Tamas Szabo
- Department of Cardiology and Heart Surgery, University of Debrecen, 4032 Debrecen, Hungary; (A.O.R.); (G.T.S.); (B.K.); (Z.K.)
| | - Tamas Papp
- Department of Radiology, University of Debrecen, 4032 Debrecen, Hungary;
| | - Benjamin Csippa
- Department of Hydrodynamic Systems, University of Technology and Economics, 1111 Budapest, Hungary; (B.C.); (D.G.)
| | - Daniel Gyurki
- Department of Hydrodynamic Systems, University of Technology and Economics, 1111 Budapest, Hungary; (B.C.); (D.G.)
| | - Bertalan Kracsko
- Department of Cardiology and Heart Surgery, University of Debrecen, 4032 Debrecen, Hungary; (A.O.R.); (G.T.S.); (B.K.); (Z.K.)
| | - Zsolt Koszegi
- Department of Cardiology and Heart Surgery, University of Debrecen, 4032 Debrecen, Hungary; (A.O.R.); (G.T.S.); (B.K.); (Z.K.)
- 3rd Department of Internal Medicine, Szabolcs-Szatmar-Bereg County Hospital, 4400 Nyíregyháza, Hungary
| | - Rudolf Kolozsvari
- Department of Cardiology and Heart Surgery, University of Debrecen, 4032 Debrecen, Hungary; (A.O.R.); (G.T.S.); (B.K.); (Z.K.)
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32
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Oh JK, Shen M, Guzzetti E, Tastet L, Loganath K, Botezatu S, Lee SA, Lee S, Kim DH, Song JM, Kang DH, Dweck MR, Pibarot P, Clavel MA, Song JK. Effect of race on pressure recovery adjustment for prevention of aortic stenosis grading discordance. Heart 2023; 109:1550-1557. [PMID: 37147133 DOI: 10.1136/heartjnl-2023-322586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 04/21/2023] [Indexed: 05/07/2023] Open
Abstract
OBJECTIVE We sought to evaluate the potential impact of racial difference (Asians vs Caucasians) on the clinical usefulness of pressure recovery (PR) adjustment for preventing discordant aortic stenosis (AS) grading in patients with severe AS. METHODS Data from 1450 patients (mean age, 70.2±10.6 years; 290 (20%) Caucasians; aortic valve area (AVA), 0.77±0.26 cm2) were retrospectively analysed. PR-adjusted AVA was calculated using a validated equation. Discordant grading of severe AS was defined as AVA of <1.0 cm2 and mean gradient of <40 mm Hg. The frequency of discordant grading was assessed in the overall cohort and the propensity score-matched cohort. RESULTS Before PR adjustment, 1186 patients showed AVA values of <1.0 cm2; after PR adjustment, 170 (14.3%) were reclassified as having moderate AS. PR adjustment decreased the frequency of discordant grading from 31.4% to 14.1% in Caucasians and from 13.8% to 7.9% in Asians. Patients with reclassification to moderate AS after PR adjustment had a significantly lower risk of a composite of aortic valve replacement or all-cause death than did those with severe AS after PR adjustment (HR 0.38; 95% CI 0.31-0.46; p<0.001). In propensity score-matched cohorts (173 pairs), the frequency of discordant grading before PR adjustment was 42.2% and 43.9% in the Caucasian and Asian patients, respectively, which decreased to 21.4% and 20.2%, respectively, after PR adjustment. CONCLUSIONS Clinically relevant PR occurred, regardless of race in patients with moderate to severe AS. Routine PR adjustment may be useful for reconciling discordant AS grading.
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Affiliation(s)
- Jin Kyung Oh
- Division of Cardiology, Department of Internal Medicine, Chungnam National University Sejong Hospital, Chungnam National University College of Medicine, Sejong, Republic of Korea
| | - Mylène Shen
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada
| | - Ezequiel Guzzetti
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada
| | - Lionel Tastet
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada
| | - Krithika Loganath
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Simona Botezatu
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Seung-Ah Lee
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sahmin Lee
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Dae-Hee Kim
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jong-Min Song
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Duk-Hyun Kang
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Marc R Dweck
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Philippe Pibarot
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada
| | - Marie-Annick Clavel
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada
| | - Jae-Kwan Song
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Choi Y, Ahn JM, Yang DH, Koo HJ, Lee SA, Kang DY, Kim JB, Park DW, Kim DH, Choo SJ, Park SJ. Clinical outcomes after aortic valve replacement with severe stenosis of trileaflet aortic valve and low valve calcium score. Heart 2023; 109:1479-1485. [PMID: 37290900 DOI: 10.1136/heartjnl-2023-322435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 05/22/2023] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND Some patients have severe aortic valve stenosis (AS) despite a lower degree of aortic valve calcification (AVC). This study compared the clinical features and prognosis of patients undergoing aortic valve replacement (AVR) for severe AS with a low AVC score compared with those with higher AVC scores. METHODS This study included 1002 Korean patients with symptomatic severe degenerative AS who underwent AVR. We measured AVC score before AVR and defined low AVC as AVC score of <2000 units for male patients and <1300 units for female patients. Patients with bicuspid or rheumatic aortic valve disease were excluded. RESULTS The mean age was 75.6±7.9 years and 487 patients (48.6%) were female. Mean left ventricular ejection fraction was 59.4%±10.4%, and concomitant coronary revascularisation was performed in 96 patients (9.6%). The median aortic valve calcium score was 3122 units (IQR 2249-4289 units) among male patients and 1756 units (IQR 1192-2572) among female patients. A total of 242 patients (24.2%) had low AVC; they were significantly younger (73.5±8.7 years vs 76.3±7.5 years, p<0.001) and were more likely to be female (59.5% vs 45.1%, p<0.001) and on haemodialysis (5.4% vs 1.8%, p=0.006) than those with high AVC. During a follow-up (median: 3.8 years), the patients with low AVC had significantly higher risk of death from any cause (adjusted HR 1.60, 95% CI 1.02 to 2.52, p=0.04), mostly non-cardiac cause. CONCLUSIONS Patients with low AVC exhibit distinct clinical characteristics and a higher risk of long-term mortality compared with those with high AVC.
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Affiliation(s)
- Yeonwoo Choi
- Division of Cardiology, Asan Medical Center, Seoul, South Korea
| | - Jung-Min Ahn
- Division of Cardiology, Asan Medical Center, Seoul, South Korea
| | - Dong Hyun Yang
- Department of Radiology, Asan Medical Center, Seoul, South Korea
| | - Hyun Jung Koo
- Department of Radiology, Asan Medical Center, Seoul, South Korea
| | - Seung-Ah Lee
- Division of Cardiology, Asan Medical Center, Seoul, South Korea
| | - Do-Yoon Kang
- Division of Cardiology, Asan Medical Center, Seoul, South Korea
| | - Joon Bum Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Seoul, South Korea
| | - Duk-Woo Park
- Division of Cardiology, Asan Medical Center, Seoul, South Korea
| | - Dae-Hee Kim
- Division of Cardiology, Asan Medical Center, Seoul, South Korea
| | - Suk Jung Choo
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Seoul, South Korea
| | - Seung-Jung Park
- Division of Cardiology, Asan Medical Center, Seoul, South Korea
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Powers A, Clavel MA. Calcium Scoring to Classify Aortic Valve Stenosis Severity: What Is the Current Data? Curr Cardiol Rep 2023; 25:1095-1101. [PMID: 37505400 DOI: 10.1007/s11886-023-01929-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/20/2023] [Indexed: 07/29/2023]
Abstract
PURPOSE OF REVIEW This review explores current clinical value of aortic valve calcification (AVC) in classifying aortic valve stenosis (AS) severity, refining patient's follow-up, as well as novel and potential applications of this highly accurate marker in improving outcomes for AS patients. AVC limitations and important particularities regarding sex, valve phenotype, and ethnicity will also be addressed. RECENT FINDINGS Sex-specific AVC cut-offs have been included in current guidelines to identify severe AS when echocardiography is inconclusive. AVC is also associated with AS progression and could help refine the timing for patient's follow-up. In patients with AS, Doppler echocardiography is the gold standard for the assessment of AS severity. However, in more than one-third of patients, echocardiographic parameters are discordant, casting shadow on the true severity of the disease. Considering active leaflet calcification is the driving mechanism of AS, quantification of AVC has been shown to be of great interest for distinguishing true-severe from pseudo-severe AS. Moreover, AVC is closely associated with AS progression and outcomes.
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Affiliation(s)
- Andréanne Powers
- Institut Universitaire de Cardiologie et Pneumologie de Québec (Quebec Heart & Lung Institute), Université Laval, Québec, Canada
| | - Marie-Annick Clavel
- Institut Universitaire de Cardiologie et Pneumologie de Québec (Quebec Heart & Lung Institute), Université Laval, Québec, Canada.
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Abdelkhalek M, Daeian M, Chavarria J, Sellers S, Gulsin G, Leipsic J, Sheth T, Keshavarz-Motamed Z. Patterns and Structure of Calcification in Aortic Stenosis: An Approach on Contrast-Enhanced CT Images. JACC Cardiovasc Imaging 2023; 16:1224-1226. [PMID: 37052564 DOI: 10.1016/j.jcmg.2023.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 01/30/2023] [Accepted: 02/16/2023] [Indexed: 04/14/2023]
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Iung B, Pierard L, Magne J, Messika-Zeitoun D, Pibarot P, Baumgartner H. Great debate: all patients with asymptomatic severe aortic stenosis need valve replacement. Eur Heart J 2023; 44:3136-3148. [PMID: 37503668 DOI: 10.1093/eurheartj/ehad355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/29/2023] Open
Affiliation(s)
- Bernard Iung
- Cardiology Department, Bichat Hospital, APHP, Université Paris Cité, 46 rue Henri Huchard, 75018 Paris, France
| | - Luc Pierard
- Department of Cardiology, University of Liege, Avenue de l´Hopital, 11, B-4000 Liege, Belgium
| | - Julien Magne
- Inserm U1094, IRD U270, University Limoges, CHU Limoges, EpiMaCT-Epidemiology of chronic diseases in tropical zone, Institute of Epidemiology and Tropical Neurology, Omega Health, 2 rue du Dr Marcland, 87025 Limoges, France
- CHU Limoges, Centre of Research and Clinical Data, 2 rue Martin Luther King, 87402 Limoges, France
| | - David Messika-Zeitoun
- Division of Cardiology, University of Ottawa Heart Institute, 40, Rue Ruskin Street, Ottawa, Ontario K1Y 4W7, Canada
| | - Philippe Pibarot
- Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart & Lung Institute, Laval University, 2725, Chemin Saite-Foy, Quebec City, Quebec G1V 4G5, Canada
| | - Helmut Baumgartner
- Department of Cardiology III-Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building A1, 48149 Muenster, Germany
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Agricola E, Ancona F, Bartel T, Brochet E, Dweck M, Faletra F, Lancellotti P, Mahmoud-Elsayed H, Marsan NA, Maurovich-Hovart P, Monaghan M, Pontone G, Sade LE, Swaans M, Von Bardeleben RS, Wunderlich N, Zamorano JL, Popescu BA, Cosyns B, Donal E. Multimodality imaging for patient selection, procedural guidance, and follow-up of transcatheter interventions for structural heart disease: a consensus document of the EACVI Task Force on Interventional Cardiovascular Imaging: part 1: access routes, transcatheter aortic valve implantation, and transcatheter mitral valve interventions. Eur Heart J Cardiovasc Imaging 2023; 24:e209-e268. [PMID: 37283275 DOI: 10.1093/ehjci/jead096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 04/05/2023] [Indexed: 06/08/2023] Open
Abstract
Transcatheter therapies for the treatment of structural heart diseases (SHD) have expanded dramatically over the last years, thanks to the developments and improvements of devices and imaging techniques, along with the increasing expertise of operators. Imaging, in particular echocardiography, is pivotal during patient selection, procedural monitoring, and follow-up. The imaging assessment of patients undergoing transcatheter interventions places demands on imagers that differ from those of the routine evaluation of patients with SHD, and there is a need for specific expertise for those working in the cath lab. In the context of the current rapid developments and growing use of SHD therapies, this document intends to update the previous consensus document and address new advancements in interventional imaging for access routes and treatment of patients with aortic stenosis and regurgitation, and mitral stenosis and regurgitation.
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Affiliation(s)
- Eustachio Agricola
- Cardiovascular Imaging Unit, Cardio-Thoracic-Vascular Department, IRCCS San Raffaele Scientific Institute, via Olgettina 60, Milan 20132, Italy
- Vita-Salute San Raffaele University, via Olgettina 58, Milan 20132, Italy
| | - Francesco Ancona
- Cardiovascular Imaging Unit, Cardio-Thoracic-Vascular Department, IRCCS San Raffaele Scientific Institute, via Olgettina 60, Milan 20132, Italy
| | - Thomas Bartel
- Heart & Vascular Institute, Cleveland Clinic Abu Dhabi, 26th Street, Dubai, United Arab Emirates
| | - Eric Brochet
- Cardiology Department, Hopital Bichat, 46 rue Huchard, Paris 75018, France
| | - Marc Dweck
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SB, UK
| | - Francesco Faletra
- Senior SHD Consultant Istituto Cardiocentro Via Tesserete 48, CH-6900 Lugano, Switzerland
- Senior Imaging Consultant ISMETT UPCM Hospital, Discesa dei Giudici, 4, 90133 Palermo, Italy
| | - Patrizio Lancellotti
- Department of Cardiology, University of Liège Hospital, Domaine Universitaire du Sart Tilman, Liège B4000, Belgium
- Gruppo Villa Maria Care and Research, Maria Cecilia Hospital, Cotignola, and Anthea Hospital, Bari, Italy
| | | | - Nina Ajmone Marsan
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | | | - Gianluca Pontone
- Department of Perioperative Cardiology and Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, Milan, Italy
| | - Leyla Elif Sade
- University of Pittsburgh-Heart & Vascular Institute UPMC, 200 Lothrop St Ste E354.2, Pıttsburgh, PA 15213, USA
- Cardiology Department, Baskent University, Ankara, Turkey
| | - Martin Swaans
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | | | - Nina Wunderlich
- Asklepios Klinik Langen Röntgenstrasse 20, Langen 63225, Germany
| | | | - Bogdan A Popescu
- Department of Cardiology, University of Medicine and Pharmacy 'Carol Davila' -Euroecolab, Emergency Institute for Cardiovascular Diseases 'Prof. Dr. C. C. Iliescu', Bucharest, Romania
| | - Bernard Cosyns
- Cardiology Department, Centrum voor Hart en Vaatziekten (CHVZ), Universitair ziekenhuis Brussel, Brussels, Belgium
| | - Erwan Donal
- Cardiologie, CHU de RENNES, LTSI UMR1099, INSERM, Universite´ de Rennes-1, Rennes, France
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Ash J, Sandhu GS, Arriola‐Montenegro J, Agakishiev D, Clavel M, Pibarot P, Duval S, Nijjar PS. Performance of Computed Tomographic Angiography-Based Aortic Valve Area for Assessment of Aortic Stenosis. J Am Heart Assoc 2023; 12:e029973. [PMID: 37581391 PMCID: PMC10492957 DOI: 10.1161/jaha.123.029973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 07/26/2023] [Indexed: 08/16/2023]
Abstract
Background A total of 40% of patients with severe aortic stenosis (AS) have low-gradient AS, raising uncertainty about AS severity. Aortic valve calcification, measured by computed tomography (CT), is guideline-endorsed to aid in such cases. The performance of different CT-derived aortic valve areas (AVAs) is less well studied. Methods and Results Consecutive adult patients with presumed moderate and severe AS based on echocardiography (AVA measured by continuity equation on echocardiography <1.5 cm2) who underwent cardiac CT were identified retrospectively. AVAs, measured by direct planimetry on CT (AVACT) and by a hybrid approach (AVA measured in a hybrid manner with echocardiography and CT [AVAHybrid]), were measured. Sex-specific aortic valve calcification thresholds (≥1200 Agatston units in women and ≥2000 Agatston units in men) were applied to adjudicate severe or nonsevere AS. A total of 215 patients (38.0% women; mean±SD age, 78±8 years) were included: normal flow, 59.5%; and low flow, 40.5%. Among the different thresholds for AVACT and AVAHybrid, diagnostic performance was the best for AVACT <1.2 cm2 (sensitivity, 85%; specificity, 26%; and accuracy, 72%), with no significant difference by flow status. The percentage of patients with correctly classified AS severity (correctly classified severe AS+correctly classified moderate AS) was as follows; AVA measured by continuity equation on echocardiography <1.0 cm2, 77%; AVACT <1.2 cm2, 73%; AVACT <1.0 cm2, 58%; AVAHybrid <1.2 cm2, 59%; and AVAHybrid <1.0 cm2, 45%. AVACT cut points of 1.52 cm2 for normal flow and 1.56 cm2 for low flow, provided 95% specificity for excluding severe AS. Conclusions CT-derived AVAs have poor discrimination for AS severity. Using an AVACT <1.2-cm2 threshold to define severe AS can produce significant error. Larger AVACT thresholds improve specificity.
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Affiliation(s)
- Jerry Ash
- Cardiovascular Division, Department of MedicineUniversity of Minnesota Medical SchoolMinneapolisMN
| | - Gurmandeep S. Sandhu
- Cardiovascular Division, Department of MedicineUniversity of Minnesota Medical SchoolMinneapolisMN
- Department of MedicineUniversity of Minnesota Medical SchoolMinneapolisMN
| | | | - Dzhalal Agakishiev
- Department of MedicineUniversity of Minnesota Medical SchoolMinneapolisMN
| | - Marie‐Annick Clavel
- Institut Universitaire de Cardiologie et de Pneumologie de Québec (Quebec Heart and Lung Institute)Laval UniversityQuebec CityCanada
| | - Philippe Pibarot
- Institut Universitaire de Cardiologie et de Pneumologie de Québec (Quebec Heart and Lung Institute)Laval UniversityQuebec CityCanada
| | - Sue Duval
- Cardiovascular Division, Department of MedicineUniversity of Minnesota Medical SchoolMinneapolisMN
| | - Prabhjot S. Nijjar
- Cardiovascular Division, Department of MedicineUniversity of Minnesota Medical SchoolMinneapolisMN
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Geers J, Bing R. Computed tomographic imaging of patients with native and prosthetic aortic valve stenosis. Heart 2023; 109:1327-1337. [PMID: 36948573 DOI: 10.1136/heartjnl-2022-321660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/24/2023] Open
Affiliation(s)
- Jolien Geers
- Department of Cardiology, CHVZ (Centrum voor Hart- en Vaatziekten), Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Rong Bing
- Edinburgh Heart Centre, Royal Infirmary of Edinburgh, Edinburgh, UK
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Canciello G, Pate S, Sannino A, Borrelli F, Todde G, Grayburn P, Losi MA, Esposito G. Pitfalls and Tips in the Assessment of Aortic Stenosis by Transthoracic Echocardiography. Diagnostics (Basel) 2023; 13:2414. [PMID: 37510158 PMCID: PMC10377988 DOI: 10.3390/diagnostics13142414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 07/17/2023] [Accepted: 07/18/2023] [Indexed: 07/30/2023] Open
Abstract
Aortic stenosis (AS) is a valvular heart disease that significantly contributes to cardiovascular morbidity and mortality worldwide. The condition is characterized by calcification and thickening of the aortic valve leaflets, resulting in a narrowed orifice and increased pressure gradient across the valve. AS typically progresses from a subclinical phase known as aortic sclerosis, where valve calcification occurs without a transvalvular gradient, to a more advanced stage marked by a triad of symptoms: heart failure, syncope, and angina. Echocardiography plays a crucial role in the diagnosis and evaluation of AS, serving as the primary non-invasive imaging modality. However, to minimize misdiagnoses, it is crucial to adhere to a standardized protocol for acquiring echocardiographic images. This is because, despite continuous advances in echocardiographic technology, diagnostic errors still occur during the evaluation of AS, particularly in classifying its severity and hemodynamic characteristics. This review focuses on providing guidance for the imager during the echocardiographic assessment of AS. Firstly, the review will report on how the echo machine should be set to improve image quality and reduce noise and artifacts. Thereafter, the review will report specific emphasis on accurate measurements of left ventricular outflow tract diameter, aortic valve morphology and movement, as well as aortic and left ventricular outflow tract velocities. By considering these key factors, clinicians can ensure consistency and accuracy in the evaluation of AS using echocardiography.
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Affiliation(s)
- Grazia Canciello
- Department of Advanced Biomedical Sciences, Federico II University, 80131 Naples, Italy
| | - Shabnam Pate
- Division of Cardiology, Baylor Scott & White Research Institute, Plano, TX 75204, USA
| | - Anna Sannino
- Department of Advanced Biomedical Sciences, Federico II University, 80131 Naples, Italy
- Division of Cardiology, Baylor Scott & White Research Institute, Plano, TX 75204, USA
| | - Felice Borrelli
- Department of Advanced Biomedical Sciences, Federico II University, 80131 Naples, Italy
| | - Gaetano Todde
- Department of Advanced Biomedical Sciences, Federico II University, 80131 Naples, Italy
| | - Paul Grayburn
- Division of Cardiology, Baylor Scott & White Research Institute, Plano, TX 75204, USA
| | - Maria-Angela Losi
- Department of Advanced Biomedical Sciences, Federico II University, 80131 Naples, Italy
| | - Giovanni Esposito
- Department of Advanced Biomedical Sciences, Federico II University, 80131 Naples, Italy
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Jean G, Mogensen NSB, Clavel MA. Aortic Valvular Stenosis and Heart Failure: Advances in Diagnostic, Management, and Intervention. Heart Fail Clin 2023; 19:273-283. [PMID: 37230643 DOI: 10.1016/j.hfc.2023.02.005] [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: 05/27/2023]
Abstract
Up to 30% of patients with aortic stenosis (AS) present with heart failure (HF) symptoms with either reduced or preserved left ventricular ejection fraction. Many of these patients present with a low-flow state, reduced aortic-valve-area (≤1.0 cm2) with low aortic-mean-gradient and aortic-peak-velocity (<40 mm Hg and <4.0 m/s). Thus, determination of true severity is essential for correct management, and multi-imaging evaluation must be performed. Medical treatment of HF is imperative and should be optimized concurrently with the determination of AS-severity. Finally, AS should be treated according to guidelines, keeping in mind that HF and low-flow increase interventions risks.
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Affiliation(s)
- Guillaume Jean
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval (IUCPQ-UL)/ Québec Heart & Lung Institute, Laval University, 2725 Chemin Sainte-Foy, Québec City, QC G1V 4G5, Canada
| | - Nils Sofus Borg Mogensen
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval (IUCPQ-UL)/ Québec Heart & Lung Institute, Laval University, 2725 Chemin Sainte-Foy, Québec City, QC G1V 4G5, Canada; Department of Cardiology, Odense University Hospital, University of Southern Denmark, J. B. Winsløws Vej 4, 5000 Odense, Denmark
| | - Marie-Annick Clavel
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval (IUCPQ-UL)/ Québec Heart & Lung Institute, Laval University, 2725 Chemin Sainte-Foy, Québec City, QC G1V 4G5, Canada; Department of Cardiology, Odense University Hospital, University of Southern Denmark, J. B. Winsløws Vej 4, 5000 Odense, Denmark.
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Bombace S, Meucci MC, Fortuni F, Ilardi F, Manzo R, Canciello G, Esposito G, Grayburn PA, Losi MA, Sannino A. Beyond Aortic Stenosis: Addressing the Challenges of Multivalvular Disease Assessment. Diagnostics (Basel) 2023; 13:2102. [PMID: 37370999 DOI: 10.3390/diagnostics13122102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 06/12/2023] [Accepted: 06/14/2023] [Indexed: 06/29/2023] Open
Abstract
Aortic stenosis (AS) can often coexist with other valvular diseases or be combined with aortic regurgitation (AR), leading to unique pathophysiological conditions. The combination of affected valves can vary widely, resulting in a lack of standardized diagnostic or therapeutic approaches. Echocardiography is crucial in assessing patients with valvular heart disease (VHD), but careful consideration of the hemodynamic interactions between combined valvular defects is necessary. This is important as it may affect the reliability of commonly used echocardiographic parameters, making the diagnosis challenging. Therefore, a multimodality imaging approach, including computed tomography or cardiac magnetic resonance, is often not just beneficial but crucial. It represents the future of diagnostics in this intricate field due to its unprecedented capacity to quantify and comprehend valvular pathology. The absence of definitive data and guidelines for the therapeutic management of AS in the context of multiple valve lesions makes this condition particularly challenging. As a result, an individualized, case-by-case approach is necessary, guided primarily by the recommendations for the predominant valve lesion. This review aims to summarize the pathophysiology of AS in the context of multiple and mixed valve disease, with a focus on the hemodynamic implications, diagnostic challenges, and therapeutic options.
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Affiliation(s)
| | - Maria Chiara Meucci
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy
| | - Federico Fortuni
- Department of Cardiology, Leiden University Medical Centre, 2333 ZA Leiden, The Netherlands
- Department of Cardiology, San Giovanni Battista Hospital, 06034 Foligno, Italy
| | - Federica Ilardi
- Department of Advanced Biomedical Sciences, Division of Cardiology, Federico II University, 80131 Naples, Italy
| | - Rachele Manzo
- Department of Advanced Biomedical Sciences, Division of Cardiology, Federico II University, 80131 Naples, Italy
| | - Grazia Canciello
- Department of Advanced Biomedical Sciences, Division of Cardiology, Federico II University, 80131 Naples, Italy
| | - Giovanni Esposito
- Department of Advanced Biomedical Sciences, Division of Cardiology, Federico II University, 80131 Naples, Italy
| | - Paul A Grayburn
- Baylor Scott & White Research Institute, Plano, TX 75093, USA
| | - Maria Angela Losi
- Department of Advanced Biomedical Sciences, Division of Cardiology, Federico II University, 80131 Naples, Italy
| | - Anna Sannino
- Department of Advanced Biomedical Sciences, Division of Cardiology, Federico II University, 80131 Naples, Italy
- Baylor Scott & White Research Institute, Plano, TX 75093, USA
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Mergen V, Ghouse S, Sartoretti T, Manka R, Euler A, Kasel AM, Alkadhi H, Eberhard M. Cardiac Virtual Noncontrast Images for Calcium Quantification with Photon-counting Detector CT. Radiol Cardiothorac Imaging 2023; 5:e220307. [PMID: 37404795 PMCID: PMC10316300 DOI: 10.1148/ryct.220307] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 03/29/2023] [Accepted: 05/08/2023] [Indexed: 07/06/2023]
Abstract
Purpose To assess the accuracy of aortic valve calcium (AVC), mitral annular calcium (MAC), and coronary artery calcium (CAC) quantification and risk stratification using virtual noncontrast (VNC) images from late enhancement photon-counting detector CT as compared with true noncontrast images. Materials and Methods This retrospective, institutional review board-approved study evaluated patients undergoing photon-counting detector CT between January and September 2022. VNC images were reconstructed from late enhancement cardiac scans at 60, 70, 80, and 90 keV using quantum iterative reconstruction (QIR) strengths of 2-4. AVC, MAC, and CAC were quantified on VNC images and compared with quantification of AVC, MAC, and CAC on true noncontrast images using Bland-Altman analyses, regression models, intraclass correlation coefficients (ICC), and Wilcoxon tests. Agreement between severe aortic stenosis likelihood categories and CAC risk categories determined from VNC and true noncontrast images was assessed by weighted κ analysis. Results Ninety patients were included (mean age, 80 years ± 8 [SD]; 49 male patients). Scores were similar on true noncontrast images and VNC images at 80 keV for AVC and MAC, regardless of QIR strengths, and VNC images at 70 keV with QIR 4 for CAC (all P > .05). The best results were achieved using VNC images at 80 keV with QIR 4 for AVC (mean difference, 3; ICC = 0.992; r = 0.98) and MAC (mean difference, 6; ICC = 0.998; r = 0.99), and VNC images at 70 keV with QIR 4 for CAC (mean difference, 28; ICC = 0.996; r = 0.99). Agreement between calcification categories was excellent on VNC images at 80 keV for AVC (κ = 0.974) and on VNC images at 70 keV for CAC (κ = 0.967). Conclusion VNC images from cardiac photon-counting detector CT enables patient risk stratification and accurate quantification of AVC, MAC, and CAC.Keywords: Coronary Arteries, Aortic Valve, Mitral Valve, Aortic Stenosis, Calcifications, Photon-counting Detector CT Supplemental material is available for this article © RSNA, 2023.
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Wanchaitanawong W, Kanjanavanit R, Srisuwan T, Wongcharoen W, Phrommintikul A. Diagnostic role of aortic valve calcium scoring in various etiologies of aortic stenosis. Sci Rep 2023; 13:8019. [PMID: 37198243 DOI: 10.1038/s41598-023-34118-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 04/25/2023] [Indexed: 05/19/2023] Open
Abstract
Most of the studies about aortic valve calcium (AVC) score in aortic stenosis (AS) were based on degenerative or bicuspid AS but not rheumatic AS. We aimed to study the diagnostic accuracy of AVC score to determine severe AS in various etiologies. Adult patients diagnosed with mild to severe AS were enrolled. AVC score were identified from multi-detector computed tomography (MDCT) scan. The AVC score was highest in bicuspid AS (3211.9 (IQR (1100.0-4562.4) AU) compared to degenerative AS (1803.7 (IQR (1073.6-2550.6) AU)), and rheumatic AS (875.6 (IQR 453.3-1594.0) AU), p < 0.001. For the ROC curve to identify severe AS, the AVC score performed well in degenerative and bicuspid AS with the area under the ROC curve (AuROC) 0.834 (95% CI, 0.730, 0.938) in degenerative group; and 0.820 (95% CI, 0.687, 0.953) in bicuspid AS. Whereas AVC score had non-significant diagnostic accuracy with AuROC 0.667 (95% CI, 0.357, 0.976) for male and 0.60(95% CI, 0.243, 0.957) for female in rheumatic AS. The cut-off AVC score values to identify severe AS were AVCS > 2028.9AU (male) and > 1082.5AU (female) for degenerative AS, and > 2431.8AU (male) and > 1293.5AU (female) for bicuspid AS. In conclusions, AVC score is the accurate test for assessing severity in patients with degenerative and bicuspid AS but performs poorly in rheumatic AS group.
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Affiliation(s)
- Wisarut Wanchaitanawong
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
| | - Rungsrit Kanjanavanit
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
| | - Tanop Srisuwan
- Department of Radiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Wanwarang Wongcharoen
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
| | - Arintaya Phrommintikul
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand.
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Bahadormanesh N, Tomka B, Abdelkhalek M, Khodaei S, Maftoon N, Keshavarz-Motamed Z. A Doppler-exclusive non-invasive computational diagnostic framework for personalized transcatheter aortic valve replacement. Sci Rep 2023; 13:8033. [PMID: 37198194 PMCID: PMC10192526 DOI: 10.1038/s41598-023-33511-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 04/13/2023] [Indexed: 05/19/2023] Open
Abstract
Given the associated risks with transcatheter aortic valve replacement (TAVR), it is crucial to determine how the implant will affect the valve dynamics and cardiac function, and if TAVR will improve or worsen the outcome of the patient. Effective treatment strategies, indeed, rely heavily on the complete understanding of the valve dynamics. We developed an innovative Doppler-exclusive non-invasive computational framework that can function as a diagnostic tool to assess valve dynamics in patients with aortic stenosis in both pre- and post-TAVR status. Clinical Doppler pressure was reduced by TAVR (52.2 ± 20.4 vs. 17.3 ± 13.8 [mmHg], p < 0.001), but it was not always accompanied by improvements in valve dynamics and left ventricle (LV) hemodynamics metrics. TAVR had no effect on LV workload in 4 patients, and LV workload post-TAVR significantly rose in 4 other patients. Despite the group level improvements in maximum LV pressure (166.4 ± 32.2 vs 131.4 ± 16.9 [mmHg], p < 0.05), only 5 of the 12 patients (41%) had a decrease in LV pressure. Moreover, TAVR did not always improve valve dynamics. TAVR did not necessarily result in a decrease (in 9 out of 12 patients investigated in this study) in major principal stress on the aortic valve leaflets which is one of the main contributors in valve degeneration and, consequently, failure of heart valves. Diastolic stresses increased significantly post-TAVR (34%, 109% and 81%, p < 0.001) for each left, right and non-coronary leaflets respectively. Moreover, we quantified the stiffness and material properties of aortic valve leaflets which correspond with the reduced calcified region average stiffness among leaflets (66%, 74% and 62%; p < 0.001; N = 12). Valve dynamics post-intervention should be quantified and monitored to ensure the improvement of patient conditions and prevent any further complications. Improper evaluation of biomechanical valve features pre-intervention as well as post-intervention may result in harmful effects post-TAVR in patients including paravalvular leaks, valve degeneration, failure of TAVR and heart failure.
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Affiliation(s)
- Nikrouz Bahadormanesh
- Department of Mechanical Engineering, McMaster University, JHE-310, Hamilton, ON, L8S 4L7, Canada
| | - Benjamin Tomka
- Department of Mechanical Engineering, McMaster University, JHE-310, Hamilton, ON, L8S 4L7, Canada
| | | | - Seyedvahid Khodaei
- Department of Mechanical Engineering, McMaster University, JHE-310, Hamilton, ON, L8S 4L7, Canada
| | - Nima Maftoon
- Department of Systems Design Engineering, University of Waterloo, Waterloo, ON, Canada
- Centre for Bioengineering and Biotechnology, University of Waterloo, Waterloo, ON, Canada
| | - Zahra Keshavarz-Motamed
- Department of Mechanical Engineering, McMaster University, JHE-310, Hamilton, ON, L8S 4L7, Canada.
- School of Biomedical Engineering, McMaster University, Hamilton, ON, Canada.
- School of Computational Science and Engineering, McMaster University, Hamilton, ON, Canada.
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Grodecki K, Warniello M, Spiewak M, Kwiecinski J. Advanced Cardiac Imaging in the Assessment of Aortic Stenosis. J Cardiovasc Dev Dis 2023; 10:jcdd10050216. [PMID: 37233183 DOI: 10.3390/jcdd10050216] [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: 04/01/2023] [Revised: 05/10/2023] [Accepted: 05/11/2023] [Indexed: 05/27/2023] Open
Abstract
Aortic stenosis is the most common form of valve disease in the Western world and a major healthcare burden. Although echocardiography remains the central modality for the diagnosis and assessment of aortic stenosis, recently, advanced cardiac imaging with cardiovascular magnetic resonance, computed tomography, and positron emission tomography have provided invaluable pathological insights that may guide the personalized management of the disease. In this review, we discuss applications of these novel non-invasive imaging modalities for establishing the diagnosis, monitoring disease progression, and eventually planning the invasive treatment of aortic stenosis.
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Affiliation(s)
- Kajetan Grodecki
- 1st Department of Cardiology, Medical University of Warsaw, Banacha 1a, 02-097 Warsaw, Poland
| | - Mateusz Warniello
- Department of Interventional Cardiology and Angiology, Institute of Cardiology, Alpejska 42, 04-628 Warsaw, Poland
| | - Mateusz Spiewak
- Magnetic Resonance Unit, Department of Radiology, Institute of Cardiology, Alpejska 42, 04-628 Warsaw, Poland
| | - Jacek Kwiecinski
- Department of Interventional Cardiology and Angiology, Institute of Cardiology, Alpejska 42, 04-628 Warsaw, Poland
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Pestiaux C, Pyka G, Quirynen L, De Azevedo D, Vanoverschelde JL, Lengelé B, Vancraeynest D, Beauloye C, Kerckhofs G. 3D histopathology of stenotic aortic valve cusps using ex vivo microfocus computed tomography. Front Cardiovasc Med 2023; 10:1129990. [PMID: 37180789 PMCID: PMC10167041 DOI: 10.3389/fcvm.2023.1129990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 04/03/2023] [Indexed: 05/16/2023] Open
Abstract
Background Calcific aortic stenosis (AS) is the most prevalent heart valve disease in developed countries. The aortic valve cusps progressively thicken and the valve does not open fully due to the presence of calcifications. In vivo imaging, usually used for diagnosis, does not allow the visualization of the microstructural changes associated with AS. Methods Ex vivo high-resolution microfocus computed tomography (microCT) was used to quantitatively describe the microstructure of calcified aortic valve cusps in full 3D. As case study in our work, this quantitative analysis was applied to normal-flow low-gradient severe AS (NF-LG-SAS), for which the medical prognostic is still highly debated in the current literature, and high-gradient severe AS (HG-SAS). Results The volume proportion of calcification, the size and number of calcified particles and their density composition was quantified. A new size-based classification considering small-sized particles that are not detected with in vivo imaging was defined for macro-, meso- and microscale calcifications. Volume and thickness of aortic valve cusps, including the complete thickness distribution, were also determined. Moreover, changes in the cusp soft tissues were also visualized with microCT and confirmed by scanning electron microscopy images of the same sample. NF-LG-SAS cusps contained lower relative amount of calcifications than HG-SAS. Moreover, the number and size of calcified objects and the volume and thickness of the cusps were also lower in NF-LG-SAS cusps than in HG-SAS. Conclusions The application of high-resolution ex vivo microCT to stenotic aortic valve cusps provided a quantitative description of the general structure of the cusps and of the calcifications present in the cusp soft tissues. This detailed description could help in the future to better understand the mechanisms of AS.
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Affiliation(s)
- Camille Pestiaux
- Mechatronic, Electrical Energy and Dynamic Systems, Institute of Mechanics, Materials and Civil Engineering, UCLouvain, Louvain-la-Neuve, Belgium
- Pole of Morphology, Institute of Experimental and Clinical Research, UCLouvain, Brussels, Belgium
| | - Grzegorz Pyka
- Mechatronic, Electrical Energy and Dynamic Systems, Institute of Mechanics, Materials and Civil Engineering, UCLouvain, Louvain-la-Neuve, Belgium
- Pole of Morphology, Institute of Experimental and Clinical Research, UCLouvain, Brussels, Belgium
| | - Louise Quirynen
- Mechatronic, Electrical Energy and Dynamic Systems, Institute of Mechanics, Materials and Civil Engineering, UCLouvain, Louvain-la-Neuve, Belgium
| | - David De Azevedo
- Pole of Cardiovascular Research, Institute of Experimental and Clinical Research, UCLouvain, Brussels, Belgium
- Division of Cardiology, University Hospital Saint-Luc, Brussels, Belgium
| | - Jean-Louis Vanoverschelde
- Pole of Cardiovascular Research, Institute of Experimental and Clinical Research, UCLouvain, Brussels, Belgium
- Division of Cardiology, University Hospital Saint-Luc, Brussels, Belgium
| | - Benoît Lengelé
- Pole of Morphology, Institute of Experimental and Clinical Research, UCLouvain, Brussels, Belgium
| | - David Vancraeynest
- Pole of Cardiovascular Research, Institute of Experimental and Clinical Research, UCLouvain, Brussels, Belgium
- Division of Cardiology, University Hospital Saint-Luc, Brussels, Belgium
| | - Christophe Beauloye
- Pole of Cardiovascular Research, Institute of Experimental and Clinical Research, UCLouvain, Brussels, Belgium
- Division of Cardiology, University Hospital Saint-Luc, Brussels, Belgium
| | - Greet Kerckhofs
- Mechatronic, Electrical Energy and Dynamic Systems, Institute of Mechanics, Materials and Civil Engineering, UCLouvain, Louvain-la-Neuve, Belgium
- Pole of Morphology, Institute of Experimental and Clinical Research, UCLouvain, Brussels, Belgium
- Department of Materials Engineering, KU Leuven, Heverlee, Belgium
- Prometheus, Division for Skeletal Tissue Engineering, KU Leuven, Leuven, Belgium
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Evertz R, Hub S, Beuthner BE, Backhaus SJ, Lange T, Schulz A, Toischer K, Seidler T, von Haehling S, Puls M, Kowallick JT, Zeisberg EM, Hasenfuß G, Schuster A. Aortic valve calcification and myocardial fibrosis determine outcome following transcatheter aortic valve replacement. ESC Heart Fail 2023. [PMID: 37060191 PMCID: PMC10375183 DOI: 10.1002/ehf2.14307] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 12/03/2022] [Accepted: 01/04/2023] [Indexed: 04/16/2023] Open
Abstract
AIMS There is evidence to suggest that the subtype of aortic stenosis (AS), the degree of myocardial fibrosis (MF), and level of aortic valve calcification (AVC) are associated with adverse cardiac outcome in AS. Because little is known about their respective contribution, we sought to investigate their relative importance and interplay as well as their association with adverse cardiac events following transcatheter aortic valve replacement (TAVR). METHODS AND RESULTS One hundred consecutive patients with severe AS and indication for TAVR were prospectively enrolled between January 2017 and October 2018. Patients underwent transthoracic echocardiography, multidetector computed tomography, and left ventricular endomyocardial biopsies at the time of TAVR. The final study cohort consisted of 92 patients with a completed study protocol, 39 (42.4%) of whom showed a normal ejection fraction (EF) high-gradient (NEFHG) AS, 13 (14.1%) a low EF high-gradient (LEFHG) AS, 25 (27.2%) a low EF low-gradient (LEFLG) AS, and 15 (16.3%) a paradoxical low-flow, low-gradient (PLFLG) AS. The high-gradient phenotypes (NEFHG and LEFHG) showed the largest amount of AVC (807 ± 421 and 813 ± 281 mm3 , respectively) as compared with the low-gradient phenotypes (LEFLG and PLFLG; 503 ± 326 and 555 ± 594 mm3 , respectively, P < 0.05). Conversely, MF was most prevalent in low-output phenotypes (LEFLG > LEFHG > PLFLG > NEFHG, P < 0.05). This was paralleled by a greater cardiovascular (CV) mortality within 600 days after TAVR (LEFLG 28% > PLFLG 26.7% > LEFHG 15.4% > NEFHG 2.5%; P = 0.023). In patients with a high MF burden, a higher AVC was associated with a lower mortality following TAVR (P = 0.045, hazard ratio 0.261, 95% confidence interval 0.07-0.97). CONCLUSIONS MF is associated with adverse CV outcome following TAVR, which is most prevalent in low EF situations. In the presence of large MF burden, patients with large AVC have better outcome following TAVR. Conversely, worse outcome in large MF and relatively little AVC may be explained by a relative prominence of an underlying cardiomyopathy. The better survival rates in large AVC patients following TAVR indicate TAVR induced relief of severe AS-associated pressure overload with subsequently improved outcome.
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Affiliation(s)
- Ruben Evertz
- Department of Cardiology and Pneumology, University Medical Center Göttingen (UMG), Georg August University of Göttingen, Göttingen, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Germany
| | - Sebastian Hub
- Department of Cardiology and Pneumology, University Medical Center Göttingen (UMG), Georg August University of Göttingen, Göttingen, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Germany
| | - Bo Eric Beuthner
- Department of Cardiology and Pneumology, University Medical Center Göttingen (UMG), Georg August University of Göttingen, Göttingen, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Germany
| | - Sören J Backhaus
- Department of Cardiology and Pneumology, University Medical Center Göttingen (UMG), Georg August University of Göttingen, Göttingen, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Germany
| | - Torben Lange
- Department of Cardiology and Pneumology, University Medical Center Göttingen (UMG), Georg August University of Göttingen, Göttingen, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Germany
| | - Alexander Schulz
- Department of Cardiology and Pneumology, University Medical Center Göttingen (UMG), Georg August University of Göttingen, Göttingen, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Germany
| | - Karl Toischer
- Department of Cardiology and Pneumology, University Medical Center Göttingen (UMG), Georg August University of Göttingen, Göttingen, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Germany
| | - Tim Seidler
- Department of Cardiology and Pneumology, University Medical Center Göttingen (UMG), Georg August University of Göttingen, Göttingen, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Germany
| | - Stephan von Haehling
- Department of Cardiology and Pneumology, University Medical Center Göttingen (UMG), Georg August University of Göttingen, Göttingen, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Germany
| | - Miriam Puls
- Department of Cardiology and Pneumology, University Medical Center Göttingen (UMG), Georg August University of Göttingen, Göttingen, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Germany
| | - Johannes T Kowallick
- Department of Diagnostic and Interventional Radiology, University Medical Center Göttingen (UMG), Georg August University of Göttingen, Göttingen, Germany
| | - Elisabeth M Zeisberg
- Department of Cardiology and Pneumology, University Medical Center Göttingen (UMG), Georg August University of Göttingen, Göttingen, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Germany
| | - Gerd Hasenfuß
- Department of Cardiology and Pneumology, University Medical Center Göttingen (UMG), Georg August University of Göttingen, Göttingen, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Germany
| | - Andreas Schuster
- Department of Cardiology and Pneumology, University Medical Center Göttingen (UMG), Georg August University of Göttingen, Göttingen, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Germany
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De Marzo V, Viglino U, Zecchino S, Matos JG, Piredda E, Pigati M, Vercellino M, Crimi G, Balbi M, Seitun S, Porto I. Supra-renal aortic atheroma extent and composition predict acute kidney injury after transcatheter aortic valve replacement: A three-dimensional computed tomography study. Int J Cardiol 2023; 381:8-15. [PMID: 37001646 DOI: 10.1016/j.ijcard.2023.03.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 03/21/2023] [Accepted: 03/24/2023] [Indexed: 04/09/2023]
Abstract
OBJECTIVE Acute kidney injury (AKI) may complicate transcatheter aortic valve replacement (TAVR) and could be linked to atheroembolization associated with catheter manipulation in the supra-renal (SR) aorta. We sought to determine the impact of SR aortic atheroma burden (SR-AAB) and composition, as well as of the aortic valve calcium score (AV-CS), measured at pre-operative multislice computed tomography (PO-MSCT), on AKI-TAVR. METHODS All TAVR-patients 3 January-2018 to December-2020 were included. A three-dimensional analysis of PO-MSCT was performed, calculating percentage SR-AAB (%SR-AAB) as [(absolute SR-AAB volume)*100/vessel volume]. Types of plaque were defined according to Hounsfield unit (HU) intensity ranges. Calcified plaque was subcategorized into 3 strata: low- (351-700 HU), mid- (701-1000 HU), and high‑calcium (>1000 HU, termed 1 K-plaque). RESULTS The study population included 222 patients [mean age 83.3 ± 5.7 years, 95 (42.8%) males], AKI-TAVR occurred in 67/222 (30.2%). Absolute SR-AAB (41.3 ± 16.4 cm3 vs. 32.5 ± 10.7 cm3,p < 0.001) and %SR-AAB (17.6 ± 5.1% vs. 13.9 ± 4.3%,p < 0.001) were significantly higher in patients developing AKI-TAVR. Patients who developed AKI-TAVR had higher mid‑calcium (6.9 ± 3.8% vs. 4.2 ± 3.5%,p < 0.001) and 1 K-plaque (5.4 ± 3.7% vs. 2.4 ± 2.4%,p < 0.001) with no difference in AV-CS (p = 0.691). Adjusted multivariable logistic regression analysis showed that %SR-AAB [OR (x%increase): 1.12, 95%CI: 1.04-1.22,p = 0.006] and %SR-calcified plaque [OR (x%increase): 5.60, 95%CI: 2.50-13.36,p < 0.001] were associated with AKI-TAVR. Finally, 3-knots spline analyses identified %SR-AAB >15.0% and %SR-calcified plaque >7.0% as optimal thresholds to predict an increased risk of AKI-TAVR. CONCLUSIONS Suprarenal aortic atheroma, when highly calcified, is associated with AKI-TAVR. Perioperative-MSCT assessment of aortic atherosclerosis may help in identification of patients at high-risk for AKI-TAVR, who could benefit from higher peri-operative surveillance.
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Affiliation(s)
- Vincenzo De Marzo
- Chair of Cardiovascular Disease, Department of Internal Medicine and Specialties (Di.M.I.), University of Genoa, Italy
| | - Umberto Viglino
- Radiology Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Simone Zecchino
- Chair of Cardiovascular Disease, Department of Internal Medicine and Specialties (Di.M.I.), University of Genoa, Italy
| | - Joao Gavina Matos
- Radiology Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Elisa Piredda
- Chair of Cardiovascular Disease, Department of Internal Medicine and Specialties (Di.M.I.), University of Genoa, Italy
| | - Maria Pigati
- Radiology Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Matteo Vercellino
- Chair of Cardiovascular Disease, Department of Internal Medicine and Specialties (Di.M.I.), University of Genoa, Italy
| | - Gabriele Crimi
- Chair of Cardiovascular Disease, Department of Internal Medicine and Specialties (Di.M.I.), University of Genoa, Italy
| | - Manrico Balbi
- Chair of Cardiovascular Disease, Department of Internal Medicine and Specialties (Di.M.I.), University of Genoa, Italy; Cardiology Unit, Cardiothoracic and Vascular Department, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Sara Seitun
- Radiology Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Italo Porto
- Chair of Cardiovascular Disease, Department of Internal Medicine and Specialties (Di.M.I.), University of Genoa, Italy; Cardiology Unit, Cardiothoracic and Vascular Department, IRCCS Ospedale Policlinico San Martino, Genoa, Italy.
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50
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Paolisso P, Beles M, Belmonte M, Gallinoro E, De Colle C, Mileva N, Bertolone DT, Deschepper C, Spapen J, Brouwers S, Degrieck I, Casselman F, Stockman B, Van Praet F, Penicka M, Collet C, Wyffels E, Vanderheyden M, Barbato E, Bartunek J, Van Camp G. Outcomes in patients with moderate and asymptomatic severe aortic stenosis followed up in heart valve clinics. Heart 2023; 109:634-642. [PMID: 36598073 DOI: 10.1136/heartjnl-2022-321874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 11/17/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Heart valve clinics (HVC) have been introduced to manage patients with valvular heart disease within a multidisciplinary team. OBJECTIVE To determine the outcome benefit of HVC approach compared with standard of care (SOC) for patients with moderate and asymptomatic severe aortic stenosis (mAS and asAS). METHODS Single-centre, observational registry of patients with mAS and asAS with at least one cardiac ambulatory consultation at our Cardiovascular Centre. Based on the outpatient strategy, patients were divided into HVC group, if receiving at least one visit at HVC, and SOC group, if followed by routine cardiac consultations. RESULTS 2129 patients with mAS and asAS were divided into those followed in HVC (n=251) versus SOC group (n=1878). The mean age was 76.5±12.4 years; 919 (43.2%) had asAS. During a follow-up of 4.8±1.8 years, 822 patients (38.6%) died, 307 (14.4%) were hospitalised for heart failure and 596 (28%) underwent aortic valve replacement (AVR). After propensity score matching, the number of consultations per year, exercise stress tests, brain natriuretic peptide (BNP) determinations and CTs were higher in the HVC cohort (p<0.05 for all). A shorter time between indication of AVR and less advanced New York Heart Association class was reported in the HVC cohort (p<0.001 and p=0.032). Compared with SOC, the HVC approach was associated with reduced all-cause mortality (HR=0.63, 95% CI 0.40 to 0.98, p=0.038) and cardiovascular death (p=0.030). At multivariable analysis, the HVC remained an independent predictor of all-cause mortality (HR=0.54, 95% CI 0.34 to 0.85, p=0.007). CONCLUSIONS In patients with mAS and asAS, the HVC approach was associated with more efficient management and outcome benefit compared with SOC.
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Affiliation(s)
- Pasquale Paolisso
- Cardiology Department, Hartcentrum OLV Aalst, Aalst, Belgium
- Department of Advanced Biomedical Sciences, Federico II University Hospital, Napoli, Campania, Italy
| | - Monika Beles
- Cardiology Department, Hartcentrum OLV Aalst, Aalst, Belgium
| | - Marta Belmonte
- Cardiology Department, Hartcentrum OLV Aalst, Aalst, Belgium
- Department of Advanced Biomedical Sciences, Federico II University Hospital, Napoli, Campania, Italy
| | | | - Cristina De Colle
- Cardiology Department, Hartcentrum OLV Aalst, Aalst, Belgium
- Department of Advanced Biomedical Sciences, Federico II University Hospital, Napoli, Campania, Italy
| | - Niya Mileva
- Cardiology Department, Hartcentrum OLV Aalst, Aalst, Belgium
| | - Dario Tino Bertolone
- Cardiology Department, Hartcentrum OLV Aalst, Aalst, Belgium
- Department of Advanced Biomedical Sciences, Federico II University Hospital, Napoli, Campania, Italy
| | | | - Jerrold Spapen
- Cardiology Department, Hartcentrum OLV Aalst, Aalst, Belgium
| | - Sofie Brouwers
- Cardiology Department, Hartcentrum OLV Aalst, Aalst, Belgium
- Department of Experimental Pharmacology, Vrije Universiteit Brussel, Brussel, Belgium
| | - Ivan Degrieck
- Department of Cardiovascular Surgery, Hartcentrum OLV Aalst, Aalst, Belgium
| | - Filip Casselman
- Department of Cardiovascular Surgery, Hartcentrum OLV Aalst, Aalst, Belgium
| | - Bernard Stockman
- Department of Cardiovascular Surgery, Hartcentrum OLV Aalst, Aalst, Belgium
| | - Frank Van Praet
- Department of Cardiovascular Surgery, Hartcentrum OLV Aalst, Aalst, Belgium
| | - Martin Penicka
- Cardiology Department, Hartcentrum OLV Aalst, Aalst, Belgium
| | - Carlos Collet
- Cardiology Department, Hartcentrum OLV Aalst, Aalst, Belgium
| | - Eric Wyffels
- Cardiology Department, Hartcentrum OLV Aalst, Aalst, Belgium
| | | | - Emanuele Barbato
- Cardiology Department, Hartcentrum OLV Aalst, Aalst, Belgium
- Department of Advanced Biomedical Sciences, Federico II University Hospital, Napoli, Campania, Italy
| | - Jozef Bartunek
- Cardiology Department, Hartcentrum OLV Aalst, Aalst, Belgium
| | - Guy Van Camp
- Cardiology Department, Hartcentrum OLV Aalst, Aalst, Belgium
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