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Scarsini R, Gallinoro E, Ancona MB, Portolan L, Paolisso P, Springhetti P, Della Mora F, Mainardi A, Belmonte M, Moroni F, Ferri LA, Bellini B, Russo F, Vella C, Bertolone DT, Pesarini G, Benfari G, Vanderheyden M, Montorfano M, De Bruyne B, Barbato E, Ribichini F. Characterisation of coronary microvascular dysfunction in patients with severe aortic stenosis undergoing TAVI. EUROINTERVENTION 2024; 20:e289-e300. [PMID: 37982178 PMCID: PMC10905195 DOI: 10.4244/eij-d-23-00735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 10/27/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND Microvascular resistance reserve (MRR) is a validated measure of coronary microvascular function independent of epicardial resistances. AIMS We sought to assess whether MRR is associated with adverse cardiac remodelling, a low-flow phenotype and extravalvular cardiac damage (EVCD) in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI). METHODS Invasive thermodilution-based assessment of the coronary microvascular function of the left anterior descending artery was performed in a prospective, multicentre cohort of patients undergoing TAVI. Coronary microvascular dysfunction (CMD) was defined as the lowest MRR tertile of the study cohort. Haemodynamic measurements were performed at baseline and then repeated immediately after TAVI. EVCD and markers of a low-flow phenotype were assessed with echocardiography. RESULTS A total of 134 patients were included in this study. Patients with low MRR were more frequently females, had a lower estimated glomerular filtration rate and a higher rate of atrial fibrillation. MRR was significantly lower in patients with advanced EVCD (median 1.80 [1.26-3.30] vs 2.50 [1.87-3.41]; p=0.038) and in low-flow, low-gradient AS (LF LG-AS) (median 1.85 [1.20-3.04] vs 2.50 [1.87-3.40]; p=0.008). Overall, coronary microvascular function tended to improve after TAVI and, in particular, MRR increased significantly after TAVI in the subgroup with low MRR at baseline. However, MRR was significantly impaired in 38 (28.4%) patients immediately after TAVI. Advanced EVCD (adjusted odds ratio 3.08 [1.22-7.76]; p=0.017) and a low-flow phenotype (adjusted odds ratio 3.36 [1.08-10.47]; p=0.036) were significant predictors of CMD. CONCLUSIONS In this observational, hypothesis-generating study, CMD was associated with extravalvular cardiac damage and a low-flow phenotype in patients with severe AS undergoing TAVI.
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Affiliation(s)
- Roberto Scarsini
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Emanuele Gallinoro
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
- Division of University Cardiology, IRCCS Galeazzi - Sant'Ambrogio Hospital, Milan, Italy
| | - Marco B Ancona
- Interventional Cardiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Leonardo Portolan
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Pasquale Paolisso
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
- Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy
| | - Paolo Springhetti
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Francesco Della Mora
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Andrea Mainardi
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Marta Belmonte
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
- Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy
| | - Francesco Moroni
- Interventional Cardiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Luca A Ferri
- Interventional Cardiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Barbara Bellini
- Interventional Cardiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Filippo Russo
- Interventional Cardiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Ciro Vella
- Interventional Cardiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Dario Tino Bertolone
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
- Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy
| | - Gabriele Pesarini
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Giovanni Benfari
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | | | - Matteo Montorfano
- Interventional Cardiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | | | - Emanuele Barbato
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
| | - Flavio Ribichini
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
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Scisciola L, Paolisso P, Belmonte M, Gallinoro E, Delrue L, Taktaz F, Fontanella RA, Degrieck I, Pesapane A, Casselman F, Puocci A, Franzese M, Van Praet F, Torella M, Marfella R, De Feo M, Bartunek J, Paolisso G, Barbato E, Barbieri M, Vanderheyden M. Myocardial sodium-glucose cotransporter 2 expression and cardiac remodelling in patients with severe aortic stenosis: The BIO-AS study. Eur J Heart Fail 2024; 26:471-482. [PMID: 38247224 DOI: 10.1002/ejhf.3145] [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: 07/03/2023] [Revised: 12/22/2023] [Accepted: 01/08/2024] [Indexed: 01/23/2024] Open
Abstract
AIM Cardiac remodelling plays a major role in the prognosis of patients with aortic stenosis (AS) and could impact the benefits of aortic valve replacement. Our study aimed to evaluate the expression of sodium-glucose cotransporter 2 (SGLT2) gene and protein in patients with severe AS stratified in high gradient (HG) and low flow-low gradient (LF-LG) AS and its association with cardiac functional impairments. METHODS AND RESULTS Gene expression and protein levels of main biomarkers of cardiac fibrosis (galectin-3, sST2, serpin-4, procollagen type I amino-terminal peptide, procollagen type I carboxy-terminal propeptide, collagen, transforming growth factor [TGF]-β), inflammation (growth differentiation factor-15, interleukin-6, nuclear factor-κB [NF-κB]), oxidative stress (superoxide dismutase 1 [SOD1] and 2 [SOD2]), and cardiac metabolism (sodium-hydrogen exchanger, peroxisome proliferator-activated receptor [PPAR]-α, PPAR-γ, glucose transporter 1 [GLUT1] and 4 [GLUT4]) were evaluated in blood samples and heart biopsies of 45 patients with AS. Our study showed SGLT2 gene and protein hyper-expression in patients with LF-LG AS, compared to controls and HG AS (p < 0.05). These differences remained significant even after adjusting for age, gender, body mass index, history of diabetes mellitus, arterial hypertension, and coronary artery disease. SGLT2 gene expression was positively correlated with: (i) TGF-β (r = 0.72, p < 0.001) and collagen (r = 0.73, p < 0.001) as markers of fibrosis; (ii) NF-κB (r = 0.36, p < 0.01) and myocardial interleukin-6 (r = 0.68, p < 0.001) as markers of inflammation: (iii) SOD2 (r = -0.38, p < 0.006) as a marker of oxidative stress; (iv) GLUT4 (r = 0.33, p < 0.02) and PPAR-α (r = 0.36, p < 0.01) as markers of cardiac metabolism. CONCLUSION In patients with LF-LG AS, SGLT2 gene and protein were hyper-expressed in cardiomyocytes and associated with myocardial fibrosis, inflammation, and oxidative stress.
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Affiliation(s)
- Lucia Scisciola
- Department of Advanced Medical and Surgical Science, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - Pasquale Paolisso
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
- Department of Advanced Biomedical Sciences, 'Federico II' University, Naples, Italy
| | - Marta Belmonte
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
- Department of Advanced Biomedical Sciences, 'Federico II' University, Naples, Italy
| | - Emanuele Gallinoro
- IRCCS Ospedale Galeazzi Sant'Ambrogio, Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Leen Delrue
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
| | - Fatemeh Taktaz
- Department of Advanced Medical and Surgical Science, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - Rosaria Anna Fontanella
- Department of Advanced Medical and Surgical Science, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - Ivan Degrieck
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
| | - Ada Pesapane
- Department of Advanced Medical and Surgical Science, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | | | - Armando Puocci
- Department of Advanced Medical and Surgical Science, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - Martina Franzese
- Department of Advanced Medical and Surgical Science, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | | | - Michele Torella
- Department of Translation Medical Science, University of Campania 'Luigi Vanvitelli' and Monaldi Hospital, Naples, Italy
| | - Raffaele Marfella
- Department of Advanced Medical and Surgical Science, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - Marisa De Feo
- Department of Translation Medical Science, University of Campania 'Luigi Vanvitelli' and Monaldi Hospital, Naples, Italy
| | | | - Giuseppe Paolisso
- Department of Advanced Medical and Surgical Science, University of Campania 'Luigi Vanvitelli', Naples, Italy
- UniCamillus, International Medical University, Rome, Italy
| | - Emanuele Barbato
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Michelangela Barbieri
- Department of Advanced Medical and Surgical Science, University of Campania 'Luigi Vanvitelli', Naples, Italy
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Maier J, Lambert T, Senoner T, Dobner S, Hoppe UC, Fellner A, Pfeifer BE, Feuchtner GM, Friedrich G, Semsroth S, Bonaros N, Holfeld J, Müller S, Reinthaler M, Steinwender C, Barbieri F. Impact of route of access and stenosis subtype on outcome after transcatheter aortic valve replacement. Front Cardiovasc Med 2023; 10:1256112. [PMID: 38028449 PMCID: PMC10665844 DOI: 10.3389/fcvm.2023.1256112] [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: 07/10/2023] [Accepted: 10/16/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Previous analyses have reported the outcomes of transcatheter aortic valve replacement (TAVR) for patients with low-flow, low-gradient (LFLG) aortic stenosis (AS), without stratifying according to the route of access. Differences in mortality rates among access routes have been established for high-gradient (HG) patients and hypothesized to be even more pronounced in LFLG AS patients. This study aims to compare the outcomes of patients with LFLG or HG AS following transfemoral (TF) or transapical (TA) TAVR. Methods A total of 910 patients, who underwent either TF or TA TAVR with a median follow-up of 2.22 (IQR: 1.22-4.03) years, were included in this multicenter cohort study. In total, 146 patients (16.04%) suffered from LFLG AS. The patients with HG and LFLG AS were stratified according to the route of access and compared statistically. Results The operative mortality rates of patients with HG and LFLG were found to be comparable following TF access. The operative mortality rate was significantly increased for patients who underwent TA access [odds ratio (OR): 2.91 (1.54-5.48), p = 0.001] and patients with LFLG AS [OR: 2.27 (1.13-4.56), p = 0.02], which could be corroborated in a propensity score-matched subanalysis. The observed increase in the risk of operative mortality demonstrated an additive effect [OR for TA LFLG: 5.45 (2.35-12.62), p < 0.001]. LFLG patients who underwent TA access had significantly higher operative mortality rates (17.78%) compared with TF LFLG (3.96%, p = 0.016) and TA HG patients (6.36%, p = 0.024). Conclusions HG patients experienced a twofold increase in operative mortality rates following TA compared with TF access, while LFLG patients had a fivefold increase in operative mortality rates. TA TAVR appears suboptimal for patients with LFLG AS. Prospective studies should be conducted to evaluate alternative options in cases where TF is not possible.
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Affiliation(s)
- Julian Maier
- Department of Cardiology, Kepler University Hospital, Linz, Austria
- Johannes Kepler University Linz, Medical Faculty, Linz, Austria
- Institute for Cardiovascular and Metabolic Research (ICMR), Johannes Kepler University Linz, Linz, Austria
- Institute of Pharmacology, Center for Physiology and Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Thomas Lambert
- Department of Cardiology, Kepler University Hospital, Linz, Austria
- Johannes Kepler University Linz, Medical Faculty, Linz, Austria
| | - Thomas Senoner
- University Clinic of Internal Medicine III, Medical University Innsbruck, Innsbruck, Austria
| | - Stephan Dobner
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- 3rd Medical Department of Cardiology and Intensive Care Medicine, Clinic Ottakring (former Wilhelminenhospital), Vienna, Austria
| | - Uta Caroline Hoppe
- University Clinic of Internal Medicine II, Paracelsus Medical University, Salzburg, Austria
| | - Alexander Fellner
- Department of Cardiology, Kepler University Hospital, Linz, Austria
- Johannes Kepler University Linz, Medical Faculty, Linz, Austria
| | - Bernhard Erich Pfeifer
- Institute of Clinical Epidemiology, Tirol Kliniken, Innsbruck, Austria
- Division of Digital Medicine and Telehealth, University for Health Sciences, Medical Informatics and Technology (UMIT), Hall in Tirol, Austria
| | | | - Guy Friedrich
- University Clinic of Internal Medicine III, Medical University Innsbruck, Innsbruck, Austria
| | - Severin Semsroth
- Department of Cardiac Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - Nikolaos Bonaros
- Department of Cardiac Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - Johannes Holfeld
- Department of Cardiac Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - Silvana Müller
- University Clinic of Internal Medicine III, Medical University Innsbruck, Innsbruck, Austria
| | - Markus Reinthaler
- Department of Cardiology, Campus Benjamin Franklin, Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt–Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Institute of Active Polymers and Berlin-Brandenburg Center for Regenerative Therapies, Helmholtz-Zentrum Hereon, Teltow, Germany
| | - Clemens Steinwender
- Department of Cardiology, Kepler University Hospital, Linz, Austria
- Johannes Kepler University Linz, Medical Faculty, Linz, Austria
- Institute for Cardiovascular and Metabolic Research (ICMR), Johannes Kepler University Linz, Linz, Austria
| | - Fabian Barbieri
- University Clinic of Internal Medicine III, Medical University Innsbruck, Innsbruck, Austria
- Department of Cardiology, Campus Benjamin Franklin, Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt–Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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Koga M, Izumo M, Yoneyama K, Akashi YJ, Yashima F, Tada N, Yamawaki M, Shirai S, Naganuma T, Yamanaka F, Ueno H, Tabata M, Mizutani K, Takagi K, Watanabe Y, Yamamoto M, Hayashida K. Prognostic Value of Electrocardiographic Left Ventricular Hypertrophy After Transcatheter Aortic Valve Implantation: Insights from the OCEAN-TAVI Registry. Am J Cardiol 2023; 204:130-139. [PMID: 37541149 DOI: 10.1016/j.amjcard.2023.07.101] [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: 04/20/2023] [Revised: 07/13/2023] [Accepted: 07/14/2023] [Indexed: 08/06/2023]
Abstract
Electrocardiogram (ECG) left ventricular hypertrophy (LVH) is associated with the prognosis of patients with aortic stenosis. However, the impact of the presence or absence of ECG-LVH on the clinical outcomes after transcatheter aortic valve implantation (TAVI) is limited. This study aimed to assess the prognostic value of ECG-LVH among patients with aortic stenosis treated by TAVI. A total of 1,667 patients who underwent TAVI were prospectively enrolled into the OCEAN-TAVI (Optimized CathEter vAlvular iNtervention-Transcatheter Aortic Valve Implantation) registry. A total of 1,446 patients (mean age 84 years; 29.9% men) were analyzed. The Sokolow-Lyon index was used to determine the presence of ECG-LVH. LVH was also assessed using transthoracic echocardiography (TTE). We investigated the association between ECG-LVH and all-cause and cardiovascular mortality. This study identified ECG-LVH and TTE-LVH in 743 (51.5%) and 1,242 patients (86.0%), respectively. The Kaplan-Meier analysis revealed that all-cause mortality was significantly higher among patients without ECG-LVH than among those with ECG-LVH (log-rank p <0.001). In the multivariable analysis, the absence of ECG-LVH was independently associated with all-cause mortality (hazard ratio 1.98, 95% confidence interval 1.39 to 2.82, p <0.001), regardless of the presence or absence of TTE-LVH. Furthermore, the presence of TTE-LVH with the absence of ECG-LVH was observed in 575 patients (40%), which was associated with cardiovascular mortality (hazard ratio 2.84, 95% confidence interval 1.56 to 5.17, p <0.001). In conclusion, the absence of ECG-LVH was independently associated with an increased risk of all-cause mortality after TAVI. Risk stratification using both ECG-LVH and TTE-LVH is a useful predictor of adverse clinical outcomes after TAVI.
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Affiliation(s)
- Masashi Koga
- Division of Cardiology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Masaki Izumo
- Division of Cardiology, St. Marianna University School of Medicine, Kawasaki, Japan.
| | - Kihei Yoneyama
- Division of Cardiology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Yoshihiro J Akashi
- Division of Cardiology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Fumiaki Yashima
- Department of Cardiology, Saiseikai Utsunomiya Hospital, Utsunomiya, Japan
| | - Norio Tada
- Department of Cardiology, Sendai Kosei Hospital, Sendai, Japan
| | - Masahiro Yamawaki
- Department of Cardiology, Saiseikai Yokohama City Eastern Hospital, Yokohama, Japan
| | - Shinichi Shirai
- Department of Cardiovascular Medicine, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Toru Naganuma
- Department of Cardiology, New Tokyo Hospital, Matsudo, Japan
| | - Futoshi Yamanaka
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Hiroshi Ueno
- Department of Cardiovascular Medicine, Toyama University Hospital, Toyama, Japan
| | - Minoru Tabata
- Department of Cardiovascular Surgery, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu, Japan
| | - Kazuki Mizutani
- Department of Cardiology, Faculty of Medicine, Kindai University, Osaka, Japan
| | - Kensuke Takagi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Yusuke Watanabe
- Department of Cardiology, Teikyo University School of Medicine, Tokyo, Japan
| | - Masanori Yamamoto
- Department of Cardiology, Toyohashi Heart Center, Toyohashi, Japan; Department of Cardiology, Nagoya Heart Center, Nagoya, Japan
| | - Kentaro Hayashida
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
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5
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Tessari FC, Lopes MAAADM, Campos CM, Rosa VEE, Sampaio RO, Soares FJMM, Lopes RRS, Nazzetta DC, de Brito Jr FS, Ribeiro HB, Vieira MLC, Mathias W, Fernandes JRC, Lopes MP, Rochitte CE, Pomerantzeff PMA, Abizaid A, Tarasoutchi F. Risk prediction in patients with classical low-flow, low-gradient aortic stenosis undergoing surgical intervention. Front Cardiovasc Med 2023; 10:1197408. [PMID: 37378406 PMCID: PMC10291604 DOI: 10.3389/fcvm.2023.1197408] [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: 04/03/2023] [Accepted: 05/22/2023] [Indexed: 06/29/2023] Open
Abstract
Introduction Classical low-flow, low-gradient aortic stenosis (LFLG-AS) is an advanced stage of aortic stenosis, which has a poor prognosis with medical treatment and a high operative mortality after surgical aortic valve replacement (SAVR). There is currently a paucity of information regarding the current prognosis of classical LFLG-AS patients undergoing SAVR and the lack of a reliable risk assessment tool for this particular subset of AS patients. The present study aims to assess mortality predictors in a population of classical LFLG-AS patients undergoing SAVR. Methods This is a prospective study including 41 consecutive classical LFLG-AS patients (aortic valve area ≤1.0 cm2, mean transaortic gradient <40 mmHg, left ventricular ejection fraction <50%). All patients underwent dobutamine stress echocardiography (DSE), 3D echocardiography, and T1 mapping cardiac magnetic resonance (CMR). Patients with pseudo-severe aortic stenosis were excluded. Patients were divided into groups according to the median value of the mean transaortic gradient (≤25 and >25 mmHg). All-cause, intraprocedural, 30-day, and 1-year mortality rates were evaluated. Results All of the patients had degenerative aortic stenosis, with a median age of 66 (60-73) years; most of the patients were men (83%). The median EuroSCORE II was 2.19% (1.5%-4.78%), and the median STS was 2.19% (1.6%-3.99%). On DSE, 73.2% had flow reserve (FR), i.e., an increase in stroke volume ≥20% during DSE, with no significant differences between groups. On CMR, late gadolinium enhancement mass was lower in the group with mean transaortic gradient >25 mmHg [2.0 (0.0-8.9) g vs. 8.5 (2.3-15.0) g; p = 0.034), and myocardium extracellular volume (ECV) and indexed ECV were similar between groups. The 30-day and 1-year mortality rates were 14.6% and 43.8%, respectively. The median follow-up was 4.1 (0.3-5.1) years. By multivariate analysis adjusted for FR, only the mean transaortic gradient was an independent predictor of mortality (hazard ratio: 0.923, 95% confidence interval: 0.864-0.986, p = 0.019). A mean transaortic gradient ≤25 mmHg was associated with higher all-cause mortality rates (log-rank p = 0.038), while there was no difference in mortality regarding FR status (log-rank p = 0.114). Conclusions In patients with classical LFLG-AS undergoing SAVR, the mean transaortic gradient was the only independent mortality predictor in patients with LFLG-AS, especially if ≤25 mmHg. The absence of left ventricular FR had no prognostic impact on long-term outcomes.
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Affiliation(s)
- Fernanda Castiglioni Tessari
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Maria Antonieta Albanez A. de M. Lopes
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
- Department of Hemodynamic, Real Hospital Português, Recife, Brazil
| | - Carlos M. Campos
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
- Department of Hemodynamic, Instituto Prevent Senior, Sao Paulo, Brazil
| | - Vitor Emer Egypto Rosa
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Roney Orismar Sampaio
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | | | - Rener Romulo Souza Lopes
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Daniella Cian Nazzetta
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Fábio Sândoli de Brito Jr
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Henrique Barbosa Ribeiro
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Marcelo L. C. Vieira
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Wilson Mathias
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Joao Ricardo Cordeiro Fernandes
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Mariana Pezzute Lopes
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Carlos E. Rochitte
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Pablo M. A. Pomerantzeff
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Alexandre Abizaid
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Flavio Tarasoutchi
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
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Ciampi Q, Cortigiani L, Rivadeneira Ruiz M, Barbieri A, Manganelli F, Mori F, D’Alfonso MG, Bursi F, Villari B. ABCDEG Stress Echocardiography in Aortic Stenosis. Diagnostics (Basel) 2023; 13:1727. [PMID: 37238211 PMCID: PMC10217228 DOI: 10.3390/diagnostics13101727] [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: 04/19/2023] [Revised: 05/06/2023] [Accepted: 05/10/2023] [Indexed: 05/28/2023] Open
Abstract
Rest and stress echocardiography (SE) plays a pivotal role in the evaluation of valvular heart disease. The use of SE is recommended in valvular heart disease when there is a mismatch between resting transthoracic echocardiography findings and symptoms. In aortic stenosis (AS), rest echocardiographic analysis is a stepwise approach that begins with the evaluation of aortic valve morphology and proceeds to the measurement of the transvalvular aortic gradient and aortic valve area (AVA) using continuity equations or planimetry. The presence of the following three criteria suggests severe AS: AVA < 1.0 cm2, a peak velocity > 4.0 m/s, or a mean gradient > 40 mmHg. However, in approximately one in three cases, we can observe a discordant AVA < 1 cm2 with a peak velocity < 4.0 m/s or a mean gradient <40 mmHg. This is due to reduced transvalvular flow associated with LV systolic dysfunction (LVEF < 50%) defined as "classical" low-flow low-gradient (LFLG) AS or normal LVEF "paradoxical" LFLG AS. SE has an established role in evaluating LV contractile reserve (CR) patients with reduced LVEF. In classical LFLG AS, LV CR distinguished pseudo-severe AS from truly severe AS. Some observational data suggest that long-term prognosis in asymptomatic severe AS may not be as favorable as previously thought, offering a window of opportunity for intervention prior to the onset of symptoms. Therefore, guidelines recommend evaluating asymptomatic AS with exercise stress in physically active patients, particularly those younger than 70 years, and symptomatic classical LFLG severe AS with low-dose dobutamine SE. A comprehensive SE assessment includes evaluating valve function (gradients), the global systolic function of the LV, and pulmonary congestion. This assessment integrates considerations of blood pressure response, chronotropic reserve, and symptoms. StressEcho 2030 is a prospective, large-scale study that employs a comprehensive protocol (ABCDEG) to analyze the clinical and echocardiographic phenotypes of AS, capturing various vulnerability sources which support stress echo-driven treatment strategies.
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Affiliation(s)
- Quirino Ciampi
- Cardiology Division, Fatebenefratelli Hospital, 82100 Benevento, Italy;
| | | | | | - Andrea Barbieri
- Department of Biomedical, Cardiology Division, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, 41121 Modena, Italy;
| | - Fiore Manganelli
- Cardiology Division, San Giuseppe Moscati Hospital, 83100 Avellino, Italy;
| | - Fabio Mori
- Cardiology Division, Careggi Hospital, 50134 Florence, Italy; (F.M.); (M.G.D.)
| | | | - Francesca Bursi
- Department of Health Science, University of Milan, Cardiology Division, San Paolo Hospital, ASST Santi Paolo e Carlo, 20142 Milano, Italy;
| | - Bruno Villari
- Cardiology Division, Fatebenefratelli Hospital, 82100 Benevento, Italy;
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7
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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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8
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Lopes MAAADM, Campos CM, Rosa VEE, Sampaio RO, Morais TC, de Brito Júnior FS, Vieira MLC, Mathias W, Fernandes JRC, de Santis A, Santos LDM, Rochitte CE, Capodanno D, Tamburino C, Abizaid A, Tarasoutchi F. Multimodality imaging methods and systemic biomarkers in classical low-flow low-gradient aortic stenosis: Key findings for risk stratification. Front Cardiovasc Med 2023; 10:1149613. [PMID: 37180790 PMCID: PMC10174252 DOI: 10.3389/fcvm.2023.1149613] [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: 01/22/2023] [Accepted: 04/04/2023] [Indexed: 05/16/2023] Open
Abstract
Objectives The aim of the present study is to assess multimodality imaging findings according to systemic biomarkers, high-sensitivity troponin I (hsTnI) and B-type natriuretic peptide (BNP) levels, in low-flow, low-gradient aortic stenosis (LFLG-AS). Background Elevated levels of BNP and hsTnI have been related with poor prognosis in patients with LFLG-AS. Methods Prospective study with LFLG-AS patients that underwent hsTnI, BNP, coronary angiography, cardiac magnetic resonance (CMR) with T1 mapping, echocardiogram and dobutamine stress echocardiogram. Patients were divided into 3 groups according to BNP and hsTnI levels: Group 1 (n = 17) when BNP and hsTnI levels were below median [BNP < 1.98 fold upper reference limit (URL) and hsTnI < 1.8 fold URL]; Group 2 (n = 14) when BNP or hsTnI were higher than median; and Group 3 (n = 18) when both hsTnI and BNP were higher than median. Results 49 patients included in 3 groups. Clinical characteristics (including risk scores) were similar among groups. Group 3 patients had lower valvuloarterial impedance (P = 0.03) and lower left ventricular ejection fraction (P = 0.02) by echocardiogram. CMR identified a progressive increase of right and left ventricular chamber from Group 1 to Group 3, and worsening of left ventricular ejection fraction (EF) (40 [31-47] vs. 32 [29-41] vs. 26 [19-33]%; p < 0.01) and right ventricular EF (62 [53-69] vs. 51 [35-63] vs. 30 [24-46]%; p < 0.01). Besides, there was a marked increase in myocardial fibrosis assessed by extracellular volume fraction (ECV) (28.4 [24.8-30.7] vs. 28.2 [26.9-34.5] vs. 31.8 [28.9-35.5]%; p = 0.03) and indexed ECV (iECV) (28.7 [21.2-39.1] vs. 28.8 [25.4-39.9] vs. 44.2 [36.4-51.2] ml/m2, respectively; p < 0.01) from Group 1 to Group 3. Conclusions Higher levels of BNP and hsTnI in LFLG-AS patients are associated with worse multi-modality evidence of cardiac remodeling and fibrosis.
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Affiliation(s)
- Maria Antonieta Albanez A. de M. Lopes
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
- Real Hospital Português, Real Cardiologia, Recife, PE, Brazil
| | - Carlos M. Campos
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
- Insituto Prevent Senior, São Paulo, SP, Brazil
| | - Vitor Emer Egypto Rosa
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
- Correspondence: Vitor Emer Egypto Rosa
| | - Roney O. Sampaio
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Thamara C. Morais
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Fábio Sândoli de Brito Júnior
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Marcelo L. C. Vieira
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Wilson Mathias
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Joao Ricardo Cordeiro Fernandes
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Antonio de Santis
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Luciano de Moura Santos
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Carlos E. Rochitte
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Davide Capodanno
- CardioT Division of Cardiology, Policlinico-Vittorio Emanuele Hospital University of Catania, Catania, Italy
| | - Corrado Tamburino
- CardioT Division of Cardiology, Policlinico-Vittorio Emanuele Hospital University of Catania, Catania, Italy
| | - Alexandre Abizaid
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Flavio Tarasoutchi
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
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9
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Fukui M, Annabi MS, Rosa VEE, Ribeiro HB, Stanberry LI, Clavel MA, Rodés-Cabau J, Tarasoutchi F, Schelbert EB, Bergler-Klein J, Bartko PE, Dona C, Mascherbauer J, Dahou A, Rochitte CE, Pibarot P, Cavalcante JL. Comprehensive myocardial characterization using cardiac magnetic resonance associates with outcomes in low gradient severe aortic stenosis. Eur Heart J Cardiovasc Imaging 2022; 24:46-58. [PMID: 35613021 DOI: 10.1093/ehjci/jeac089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 04/21/2022] [Accepted: 04/25/2022] [Indexed: 12/24/2022] Open
Abstract
AIMS This study sought to compare cardiac magnetic resonance (CMR) characteristics according to different flow/gradient patterns of aortic stenosis (AS) and to evaluate their prognostic value in patients with low-gradient AS. METHODS AND RESULTS This international prospective multicentric study included 147 patients with low-gradient moderate to severe AS who underwent comprehensive CMR evaluation of left ventricular global longitudinal strain (LVGLS), extracellular volume fraction (ECV), and late gadolinium enhancement (LGE). All patients were classified as followings: classical low-flow low-gradient (LFLG) [mean gradient (MG) < 40 mmHg and left ventricular ejection fraction (LVEF) < 50%]; paradoxical LFLG [MG < 40 mmHg, LVEF ≥ 50%, and stroke volume index (SVi) < 35 ml/m2]; and normal-flow low-gradient (MG < 40 mmHg, LVEF ≥ 50%, and SVi ≥ 35 ml/m2). Patients with classical LFLG (n = 90) had more LV adverse remodelling including higher ECV, and higher LGE and volume, and worst LVGLS. Over a median follow-up of 2 years, 43 deaths and 48 composite outcomes of death or heart failure hospitalizations occurred. Risks of adverse events increased per tertile of LVGLS: hazard ratio (HR) = 1.50 [95% CI, 1.02-2.20]; P = 0.04 for mortality; HR = 1.45 [1.01-2.09]; P < 0.05 for composite outcome; per tertile of ECV, HR = 1.63 [1.07-2.49]; P = 0.02 for mortality; HR = 1.54 [1.02-2.33]; P = 0.04 for composite outcome. LGE presence also associated with higher mortality, HR = 2.27 [1.01-5.11]; P < 0.05 and composite outcome, HR = 3.00 [1.16-7.73]; P = 0.02. The risk of mortality and the composite outcome increased in proportion to the number of impaired components (i.e. LVGLS, ECV, and LGE) with multivariate adjustment. CONCLUSIONS In this international prospective multicentric study of low-gradient AS, comprehensive CMR assessment provides independent prognostic value that is cumulative and incremental to clinical and echocardiographic characteristics.
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Affiliation(s)
- Miho Fukui
- Cardiovascular Imaging Research Center and Core Lab, Minneapolis Heart Institute Foundation, 920 E 28th Street, Suite 100, 55407 Minneapolis, MN, USA
| | - Mohamed-Salah Annabi
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, Québec, Canada
| | - Vitor E E Rosa
- Heart Institute of Sao Paulo (InCor), University of Sao Paulo, Sao Paulo, Brazil
| | - Henrique B Ribeiro
- Heart Institute of Sao Paulo (InCor), University of Sao Paulo, Sao Paulo, Brazil
| | - Larissa I Stanberry
- Cardiovascular Imaging Research Center and Core Lab, Minneapolis Heart Institute Foundation, 920 E 28th Street, Suite 100, 55407 Minneapolis, MN, USA
| | - Marie-Annick Clavel
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, Québec, Canada
| | - Josep Rodés-Cabau
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, Québec, Canada
| | - Flavio Tarasoutchi
- Heart Institute of Sao Paulo (InCor), University of Sao Paulo, Sao Paulo, Brazil
| | - Erik B Schelbert
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jutta Bergler-Klein
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna General Hospital, Vienna, Austria
| | - Philipp E Bartko
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna General Hospital, Vienna, Austria
| | - Carolina Dona
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna General Hospital, Vienna, Austria
| | - Julia Mascherbauer
- Department of Internal Medicine 3, Karl Landsteiner University of Health Sciences, University Hospital St. Pölten, Krems, Austria
| | | | - Carlos E Rochitte
- Heart Institute of Sao Paulo (InCor), University of Sao Paulo, Sao Paulo, Brazil
| | - Philippe Pibarot
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, Québec, Canada
| | - João L Cavalcante
- Cardiovascular Imaging Research Center and Core Lab, Minneapolis Heart Institute Foundation, 920 E 28th Street, Suite 100, 55407 Minneapolis, MN, USA
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10
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Scarsini R, Pighi M, Mainardi A, Portolan L, Springhetti P, Mammone C, Della Mora F, Fanti D, Tavella D, Gottin L, Bergamini C, Benfari G, Pesarini G, Ribichini FL. Proof of concept study on coronary microvascular function in low flow low gradient aortic stenosis. HEART (BRITISH CARDIAC SOCIETY) 2022; 109:785-793. [PMID: 36598066 DOI: 10.1136/heartjnl-2022-321907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 11/30/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVES We hypothesised that low flow low gradient aortic stenosis (LFLGAS) is associated with more severe coronary microvascular dysfunction (CMD) compared with normal-flow high-gradient aortic stenosis (NFHGAS) and that CMD is related to reduced cardiac performance. METHODS Invasive CMD assessment was performed in 41 consecutive patients with isolated severe aortic stenosis with unobstructed coronary arteries undergoing transcatheter aortic valve implantation (TAVI). The index of microcirculatory resistance (IMR), resistive reserve ratio (RRR) and coronary flow reserve (CFR) were measured in the left anterior descending artery before and after TAVI. Speckle tracking echocardiography was performed to assess cardiac function at baseline and repeated at 6 months. RESULTS IMR was significantly higher in patients with LFLGAS compared with patients with NFHGAS (24.1 (14.6 to 39.1) vs 12.8 (8.6 to 19.2), p=0.002), while RRR was significantly lower (1.4 (1.1 to 2.1) vs 2.6 (1.5 to 3.3), p=0.020). No significant differences were observed in CFR between the two groups. High IMR was associated with low stroke volume index, low cardiac output and reduced peak atrial longitudinal strain (PALS). TAVI determined no significant variation in microvascular function (IMR: 16.0 (10.4 to 26.1) vs 16.6 (10.2 to 25.6), p=0.403) and in PALS (15.9 (9.9 to 26.5) vs 20.1 (12.3 to 26.7), p=0.222). Conversely, left ventricular (LV) global longitudinal strain increased after TAVI (-13.2 (8.4 to 16.6) vs -15.1 (9.4 to 17.8), p=0.047). In LFLGAS, LV systolic function recovered after TAVI in patients with preserved microvascular function but not in patients with CMD. CONCLUSIONS CMD is more severe in patients with LFLGAS compared with NFHGAS and is associated with low-flow state, left atrial dysfunction and reduced cardiac performance.
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Affiliation(s)
- Roberto Scarsini
- Department of Medicine, Division of Cardiology, University of Verona, Verona, Italy .,Department of Medicine, Division of Cardiology, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Veneto, Italy
| | - Michele Pighi
- Department of Medicine, Division of Cardiology, University of Verona, Verona, Italy
| | - Andrea Mainardi
- Department of Medicine, Division of Cardiology, University of Verona, Verona, Italy
| | - Leonardo Portolan
- Department of Medicine, Division of Cardiology, University of Verona, Verona, Italy
| | - Paolo Springhetti
- Department of Medicine, Division of Cardiology, University of Verona, Verona, Italy
| | - Concetta Mammone
- Department of Medicine, Division of Cardiology, University of Verona, Verona, Italy
| | - Francesco Della Mora
- Department of Medicine, Division of Cardiology, University of Verona, Verona, Italy
| | - Diego Fanti
- Department of Medicine, Division of Cardiology, University of Verona, Verona, Italy
| | - Domenico Tavella
- Department of Medicine, Division of Cardiology, University of Verona, Verona, Italy
| | - Leonardo Gottin
- Department of Intensive Care and Anesthesiology, University of Verona, Verona, Italy
| | - Corinna Bergamini
- Department of Medicine, Division of Cardiology, University of Verona, Verona, Italy
| | - Giovanni Benfari
- Department of Medicine, Division of Cardiology, University of Verona, Verona, Italy
| | - Gabriele Pesarini
- Department of Medicine, Division of Cardiology, University of Verona, Verona, Italy
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11
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Yousef S, Amabile A, Ram C, Singh S, Agarwal R, Milewski R, Assi R, Patel PA, Krane M, Geirsson A, Vallabhajosyula P. Direct relationship between transvalvular velocity and cardiac dysfunction, morbidity, and mortality in patients with aortic stenosis. J Card Surg 2022; 37:5052-5062. [PMID: 36378856 DOI: 10.1111/jocs.17199] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 10/29/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Current guidelines recommend intervention in subjects with severe symptomatic aortic stenosis (AS), even though any degree of AS is associated with a higher risk of mortality. We investigated the association between the degree of AS, delineated by transvalvular flow velocity, and patient morbidity and mortality. METHODS Medically managed patients aged 40-95 years with maximum flow velocity (Vmax ) by echocardiography between 2013 and 2018 were stratified into five groups (A-E) based on the 75th, 90th, 97.5th, and the 99th percentiles of Vmax distribution. Patient characteristics, cardiac structural changes, and end-organ disease were compared using Kruskal-Wallis and Cochran-Armitage tests. Mortality over a median of 2.8 (1.52-4.8) years was compared using Kaplan-Meier curves and risk estimates were derived from the Cox model. RESULTS The Vmax was reported in 37,131 patients. There was a steady increase (from Group A towards E) in age, Caucasian race, structural cardiac changes, end-organ morbidities, and all-cause mortality. In reference to Group A, there as an increased risk of mortality in Groups B (hazard ratio [HR] = 1.3; confidence interval [CI]: 1.2-1.35; p < .0001), C (HR = 1.5; CI: 1.4-1.6; p < .0001), and D (HR = 1.8; CI: 1.6-2; p < .0001), with an exponential increase in Group E (HR = 2.5; CI: 2.2-2.8; p < .0001). CONCLUSIONS A direct, strong correlation exists between the degree of AS and cardiac structural changes and mortality. Patients with Vmax ≥ 97.5th percentile (≥3.2 m/s) might benefit from early intervention.
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Affiliation(s)
- Sameh Yousef
- Division of Cardiac Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Andrea Amabile
- Division of Cardiac Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Chirag Ram
- Division of Cardiac Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Saket Singh
- Division of Cardiac Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Ritu Agarwal
- Joint Data Analytics Team, Information Technology Service, Yale University, New Haven, Connecticut, USA
| | - Rita Milewski
- Division of Cardiac Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Roland Assi
- Division of Cardiac Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Prakash A Patel
- Division of Cardiac Anesthesiology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Markus Krane
- Division of Cardiac Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Arnar Geirsson
- Division of Cardiac Surgery, Yale School of Medicine, New Haven, Connecticut, USA
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12
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Kolte D, Bhardwaj B, Lu M, Alu MC, Passeri JJ, Inglessis I, Vlahakes GJ, Garcia S, Cohen DJ, Lindman BR, Kodali S, Thourani VH, Daubert MA, Douglas PS, Jaber W, Pibarot P, Clavel MA, Palacios IF, Leon MB, Smith CR, Mack MJ, Elmariah S. Association Between Early Left Ventricular Ejection Fraction Improvement After Transcatheter Aortic Valve Replacement and 5-Year Clinical Outcomes. JAMA Cardiol 2022; 7:934-944. [PMID: 35895046 PMCID: PMC9330296 DOI: 10.1001/jamacardio.2022.2222] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance In patients with severe aortic stenosis and left ventricular ejection fraction (LVEF) less than 50%, early LVEF improvement after transcatheter aortic valve replacement (TAVR) is associated with improved 1-year mortality; however, its association with long-term clinical outcomes is not known. Objective To examine the association between early LVEF improvement after TAVR and 5-year outcomes. Design, Setting, and Participants This cohort study analyzed patients enrolled in the Placement of Aortic Transcatheter Valves (PARTNER) 1, 2, and S3 trials and registries between July 2007 and April 2015. High- and intermediate-risk patients with baseline LVEF less than 50% who underwent transfemoral TAVR were included in the current study. Data were analyzed from August 2020 to May 2021. Exposures Early LVEF improvement, defined as increase of 10 percentage points or more at 30 days and also as a continuous variable (ΔLVEF between baseline and 30 days). Main Outcomes and Measures All-cause death at 5 years. Results Among 659 included patients with LVEF less than 50%, 468 (71.0%) were male, and the mean (SD) age was 82.4 (7.7) years. LVEF improvement within 30 days following transfemoral TAVR occurred in 216 patients (32.8%) (mean [SD] ΔLVEF, 16.4 [5.7%]). Prior myocardial infarction, diabetes, cancer, higher baseline LVEF, larger left ventricular end-diastolic diameter, and larger aortic valve area were independently associated with lower likelihood of LVEF improvement. Patients with vs without early LVEF improvement after TAVR had lower 5-year all-cause death (102 [50.0%; 95% CI, 43.3-57.1] vs 246 [58.4%; 95% CI, 53.6-63.2]; P = .04) and cardiac death (52 [29.5%; 95% CI, 23.2-37.1] vs 135 [38.1%; 95% CI, 33.1-43.6]; P = .05). In multivariable analyses, early improvement in LVEF (modeled as a continuous variable) was associated with lower 5-year all-cause death (adjusted hazard ratio per 5% increase in LVEF, 0.94 [95% CI, 0.88-1.00]; P = .04) and cardiac death (adjusted hazard ratio per 5% increase in LVEF, 0.90 [95% CI, 0.82-0.98]; P = .02) after TAVR. Restricted cubic spline analysis demonstrated a visual inflection point at ΔLVEF of 10% beyond which there was a steep decline in all-cause mortality with increasing degree of LVEF improvement. There were no statistically significant differences in rehospitalization, New York Heart Association functional class, or Kansas City Cardiomyopathy Questionnaire Overall Summary score at 5 years in patients with vs without early LVEF improvement. In subgroup analysis, the association between early LVEF improvement and 5-year all-cause death was consistent regardless of the presence or absence of coronary artery disease or prior myocardial infarction. Conclusions and Relevance In patients with severe aortic stenosis and LVEF less than 50%, 1 in 3 experience LVEF improvement within 1 month after TAVR. Early LVEF improvement is associated with lower 5-year all-cause and cardiac death.
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Affiliation(s)
- Dhaval Kolte
- Cardiology Division, Massachusetts General Hospital/Harvard Medical School, Boston
| | - Bhaskar Bhardwaj
- Division of Cardiovascular Medicine, University of Missouri, Columbia
| | - Michael Lu
- Edwards Lifesciences, Irvine, California
| | - Maria C Alu
- Cardiovascular Research Foundation, New York, New York.,Division of Cardiology, Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York
| | - Jonathan J Passeri
- Cardiology Division, Massachusetts General Hospital/Harvard Medical School, Boston
| | - Ignacio Inglessis
- Cardiology Division, Massachusetts General Hospital/Harvard Medical School, Boston
| | - Gus J Vlahakes
- Division of Cardiac Surgery, Massachusetts General Hospital/Harvard Medical School, Boston
| | - Santiago Garcia
- Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - David J Cohen
- Cardiovascular Research Foundation, New York, New York.,St. Francis Hospital and Heart Center, Roslyn, New York
| | - Brian R Lindman
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Susheel Kodali
- Cardiovascular Research Foundation, New York, New York.,Division of Cardiology, Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York
| | - Vinod H Thourani
- Department of Cardiovascular Surgery, Piedmont Heart Institute, Atlanta, Georgia
| | - Melissa A Daubert
- Division of Cardiology and Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Pamela S Douglas
- Division of Cardiology and Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Wael Jaber
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Philippe Pibarot
- Department of Medicine, Institut Universitaire de Cardiologie et de Pneumologie de Québec-Université Laval, Quebec City, Quebec, Canada
| | - Marie-Annick Clavel
- Department of Medicine, Institut Universitaire de Cardiologie et de Pneumologie de Québec-Université Laval, Quebec City, Quebec, Canada
| | - Igor F Palacios
- Cardiology Division, Massachusetts General Hospital/Harvard Medical School, Boston
| | - Martin B Leon
- Cardiovascular Research Foundation, New York, New York.,Division of Cardiology, Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York
| | - Craig R Smith
- Cardiovascular Research Foundation, New York, New York.,Division of Cardiology, Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York
| | - Michael J Mack
- Department of Cardiothoracic Surgery, Baylor University Medical Center, Dallas, Texas
| | - Sammy Elmariah
- Cardiology Division, Massachusetts General Hospital/Harvard Medical School, Boston
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13
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Brega C, Calvi S, Pin M, Anderlucci L, Falcone R, Albertini A. Surgical aortic valve replacement for low-gradient aortic stenosis. J Cardiovasc Med (Hagerstown) 2022; 23:338-343. [PMID: 35486684 DOI: 10.2459/jcm.0000000000001292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Low-gradient aortic stenosis is a challenging entity that needs accurate preoperative evaluation. For this high-risk patient population, ad hoc predictive scores are not available and profile risk is currently revealed by the EuroSCOREs. Aims of this study are to verify the suitability of the ES II as predictor of mortality in low-gradient aortic stenosis and to analyse the role of surgery as a treatment. METHODS From June 2013 to August 2019, 414 patients underwent surgical aortic valve replacement for low-gradient aortic stenosis. Mean age was 75.78 ± 6.77 years and 190 were women. The prognostic value of Logistic EuroSCORE and EuroSCORE II were compared by receiver-operating characteristics (ROC) curve analysis. RESULTS In-hospital, 30-day and 1-year mortality rates were respectively 3.4, 2.9 and 4.8% (14, 12 and 20 patients over 414). In-hospital mortality risk calculated by the Additive EuroSCORE was 7.2 ± 2.7%, by the Logistic EuroSCORE was 9 ± 5.2% and by the ES II was 4.13 ± 2.56%. The prognostic values of the EuroSCORE II and of the EuroSCORE were analysed in a ROC curve analysis for the prediction of in-hospital mortality [area under the curve (AUC): 0.62 vs. 0.58], 30-day mortality (AUC: 0.63 vs. 0.64) and 1-year mortality (AUC: 0.79 vs. 0.65). Both scores did not show significant differences with the only exception of 1-year mortality, for which EuroSCORE II had a better predictive ability than the Logistic EuroSCORE (P < 0.05). CONCLUSION In low-gradient aortic stenosis undergoing surgery, the EuroSCORE II is a strong predictor of 1-year mortality.
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Affiliation(s)
- Carlotta Brega
- Department of Cardiovascular Surgery, Maria Cecilia Hospital, GVM Care & Research, Cotignola
| | - Simone Calvi
- Department of Cardiovascular Surgery, Maria Cecilia Hospital, GVM Care & Research, Cotignola
| | - Maurizio Pin
- Department of Cardiovascular Surgery, Maria Cecilia Hospital, GVM Care & Research, Cotignola
| | - Laura Anderlucci
- Statistical Sciences Department, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Roberta Falcone
- Statistical Sciences Department, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Alberto Albertini
- Department of Cardiovascular Surgery, Maria Cecilia Hospital, GVM Care & Research, Cotignola
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14
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Santangelo G, Rossi A, Toriello F, Badano LP, Messika Zeitoun D, Faggiano P. Diagnosis and Management of Aortic Valve Stenosis: The Role of Non-Invasive Imaging. J Clin Med 2021; 10:jcm10163745. [PMID: 34442039 PMCID: PMC8396987 DOI: 10.3390/jcm10163745] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 08/16/2021] [Accepted: 08/20/2021] [Indexed: 12/13/2022] Open
Abstract
Aortic stenosis is the most common heart valve disease necessitating surgical or percutaneous intervention. Imaging has a central role for the initial diagnostic work-up, the follow-up and the selection of the optimal timing and type of intervention. Referral for aortic valve replacement is currently driven by the severity and by the presence of aortic stenosis-related symptoms or signs of left ventricular systolic dysfunction. This review aims to provide an update of the imaging techniques and seeks to highlight a practical approach to help clinical decision making.
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Affiliation(s)
- Gloria Santangelo
- San Paolo Hospital, Division of Cardiology, Department of Health Sciences, University of Milan, 20142 Milan, Italy;
| | - Andrea Rossi
- Division of Cardiology, Azienda Ospedaliero Universitaria Verona, 37126 Verona, Italy;
| | - Filippo Toriello
- Fondazione IRCCS Ca’ Granda-Ospedale Maggiore Policlinico, Division of Cardiology, Department of Internal Medicine, University of Milan, 20122 Milan, Italy;
| | - Luigi Paolo Badano
- Department of Medicine and Surgery, University of Milano Bicocca, 20126 Milan, Italy;
- Department of Cardiac, Metabolic and Neural Sciences, Istituto Auxologico Italiano, IRCCS, 20149 Milan, Italy
| | - David Messika Zeitoun
- Department of Cardiology, University of Ottawa Heart Institute, Ottawa, ON K1Y 4W7, Canada;
| | - Pompilio Faggiano
- Fondazione Poliambulanza, Cardiovascular Disease Unit, Via Leonida Bissolati, 57, 25100 Brescia, Italy
- Correspondence:
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15
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Abstract
Aortic stenosis is the most common valvular disease requiring valve replacement. Valve replacement therapies have undergone progressive evolution since the 1960s. Over the last 20 years, transcatheter aortic valve replacement has radically transformed the care of aortic stenosis, such that it is now the treatment of choice for many, particularly elderly, patients. This review provides an overview of the pathophysiology, presentation, diagnosis, indications for intervention, and current therapeutic options for aortic stenosis.
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Affiliation(s)
- Marko T Boskovski
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, MA
| | - Thomas G Gleason
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, MA
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16
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Elbaum C, Iacuzio L, Bohbot Y, Civaia F, Dommerc C, Tribouilloy C, Guerin P, Levy F. Non-contrast myocardial T1 global and regional reference values at 3 Tesla cardiac magnetic resonance in aortic stenosis. Arch Cardiovasc Dis 2021; 114:293-304. [PMID: 33716045 DOI: 10.1016/j.acvd.2020.11.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 09/08/2020] [Accepted: 11/30/2020] [Indexed: 10/21/2022]
Abstract
BACKGROUND T1 mapping using cardiac magnetic resonance (CMR) was recently proposed as a promising non-contrast imaging technique for the assessment of diffuse myocardial fibrosis (MF) in aortic stenosis (AS). AIMS To provide reference values for native T1 mapping at 3 Tesla magnetic field strength in subjects with moderate or severe AS and in control subjects; to identify factors associated with the presence of diffuse MF in severe AS; to assess the regional distribution of diffuse MF; and to compare the level of diffuse MF in the different types of AS, stratified by flow and gradient patterns. METHODS Retrospective study based on 160 consecutive patients with moderate (n=11) to severe (n=149) AS and 47 control subjects referred for CMR. RESULTS Mean native T1 increased progressively across controls (1221±23ms), moderate AS (1249±26ms) and severe AS (1273±43ms). T1 times correlated significantly with left ventricular (LV) remodelling (indexed LV mass and LV diastolic volume) and functional LV alterations (global longitudinal strain and LV ejection fraction). Native T1 appears to be elevated in the basal segments of the septum in moderate AS, and to extend to midventricular and apical segments in severe AS. Mean T1 time was higher in classical low-flow/low-gradient AS (1295±62ms) than in the other types of AS (P=0.006). The level of diffuse MF in paradoxical low-flow/low-gradient AS (1280±42ms) was higher than in moderate AS, but similar to that in high-gradient AS (1271±42ms) (P=0.07). CONCLUSIONS Assessment of diffuse MF in AS using T1 mapping is feasible and reproducible in clinical practice. T1 value increases with AS severity, along with morphological and functional LV alterations, particularly in the basal segments of the septum.
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Affiliation(s)
- Clara Elbaum
- Monaco cardiothoracic centre, 11 bis, avenue d'Ostende, 98000 MC, Monaco
| | - Laura Iacuzio
- Monaco cardiothoracic centre, 11 bis, avenue d'Ostende, 98000 MC, Monaco
| | - Yohann Bohbot
- Department of cardiology, University Hospital Amiens, 80054 Amiens, France
| | - Filippo Civaia
- Monaco cardiothoracic centre, 11 bis, avenue d'Ostende, 98000 MC, Monaco
| | - Carine Dommerc
- Monaco cardiothoracic centre, 11 bis, avenue d'Ostende, 98000 MC, Monaco
| | | | - Patrice Guerin
- Monaco cardiothoracic centre, 11 bis, avenue d'Ostende, 98000 MC, Monaco
| | - Franck Levy
- Monaco cardiothoracic centre, 11 bis, avenue d'Ostende, 98000 MC, Monaco.
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17
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Contorni F, Fineschi M, Iadanza A, Santoro A, Mandoli GE, Cameli M. How to deal with low-flow low-gradient aortic stenosis and reduced left ventricle ejection fraction: from literature review to tips for clinical practice. Heart Fail Rev 2021; 27:697-709. [PMID: 33683509 PMCID: PMC8898219 DOI: 10.1007/s10741-021-10090-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/15/2021] [Indexed: 01/01/2023]
Abstract
Low-flow low-gradient aortic stenosis (LFLG AS) with reduced left ventricle ejection fraction (LVEF) is still a diagnostic and therapeutic challenge. The aim of this paper is to review the latest evidences about the assessment of the valvular disease, usually difficult because of the low-flow status, and the therapeutic options. Special emphasis is given to the available diagnostic tools for the characterization of LFLG AS without functional reserve at stress echocardiography and to the factors that clinicians should evaluate to choose between surgical aortic valve repair, transcatheter aortic valve implantation, or medical therapy.
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Affiliation(s)
- F Contorni
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy.
| | - M Fineschi
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - A Iadanza
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - A Santoro
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - G E Mandoli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - M Cameli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
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18
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Busse A, Rajagopal R, Yücel S, Beller E, Öner A, Streckenbach F, Cantré D, Ince H, Weber MA, Meinel FG. Cardiac MRI-Update 2020. Radiologe 2021; 60:33-40. [PMID: 32385547 DOI: 10.1007/s00117-020-00687-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
PURPOSE To review emerging techniques in cardiac magnetic resonance imaging (CMR) and their clinical applications with a special emphasis on new technologies, recent trials, and updated guidelines. TECHNOLOGICAL INNOVATIONS The utility of CMR has expanded with the development of new MR sequences, postprocessing techniques, and artificial intelligence-based technologies, which have substantially increased the spectrum, quality, and reliability of information that can be obtained by CMR. ESTABLISHED AND EMERGING INDICATIONS The CMR modality has become an irreplaceable tool for diagnosis, treatment guidance and follow-up of patients with ischemic heart disease, myocarditis, and cardiomyopathies. Its role has been further strengthened by recent trials and guidelines. Quantitative mapping techniques are increasingly used for tissue characterization and detection of diffuse myocardial changes including myocardial storage diseases. PRACTICAL RECOMMENDATIONS With state-of-the-art CMR sequences, postprocessing techniques and understanding of their interpretation, CMR makes invaluable contributions to provide state-of-the-art diagnostics and care for cardiac patients in a multidisciplinary team.
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Affiliation(s)
- Anke Busse
- Department of Diagnostic and Interventional Radiology, Paediatric Radiology and Neuroradiology, University Medical Center Rostock, Ernst-Heydemann-Str. 6, 18057, Rostock, Germany
| | - Rengarajan Rajagopal
- Department of Cardiovascular Radiology and Endovascular Interventions, All India Institute of Medical Sciences, New Delhi, India
| | - Seyrani Yücel
- Department of Internal Medicine, Division of Cardiology, University Medical Center Rostock, Rostock, Germany
| | - Ebba Beller
- Department of Diagnostic and Interventional Radiology, Paediatric Radiology and Neuroradiology, University Medical Center Rostock, Ernst-Heydemann-Str. 6, 18057, Rostock, Germany
| | - Alper Öner
- Department of Internal Medicine, Division of Cardiology, University Medical Center Rostock, Rostock, Germany
| | - Felix Streckenbach
- Department of Diagnostic and Interventional Radiology, Paediatric Radiology and Neuroradiology, University Medical Center Rostock, Ernst-Heydemann-Str. 6, 18057, Rostock, Germany
| | - Daniel Cantré
- Department of Diagnostic and Interventional Radiology, Paediatric Radiology and Neuroradiology, University Medical Center Rostock, Ernst-Heydemann-Str. 6, 18057, Rostock, Germany
| | - Hüseyin Ince
- Department of Internal Medicine, Division of Cardiology, University Medical Center Rostock, Rostock, Germany
| | - Marc-André Weber
- Department of Diagnostic and Interventional Radiology, Paediatric Radiology and Neuroradiology, University Medical Center Rostock, Ernst-Heydemann-Str. 6, 18057, Rostock, Germany
| | - Felix G Meinel
- Department of Diagnostic and Interventional Radiology, Paediatric Radiology and Neuroradiology, University Medical Center Rostock, Ernst-Heydemann-Str. 6, 18057, Rostock, Germany.
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19
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Guzzetti E, Annabi MS, Pibarot P, Clavel MA. Multimodality Imaging for Discordant Low-Gradient Aortic Stenosis: Assessing the Valve and the Myocardium. Front Cardiovasc Med 2020; 7:570689. [PMID: 33344514 PMCID: PMC7744378 DOI: 10.3389/fcvm.2020.570689] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 10/12/2020] [Indexed: 01/29/2023] Open
Abstract
Aortic stenosis (AS) is a disease of the valve and the myocardium. A correct assessment of the valve disease severity is key to define the need for aortic valve replacement (AVR), but a better understanding of the myocardial consequences of the increased afterload is paramount to optimize the timing of the intervention. Transthoracic echocardiography remains the cornerstone of AS assessment, as it is universally available, and it allows a comprehensive structural and hemodynamic evaluation of both the aortic valve and the rest of the heart. However, it may not be sufficient as a significant proportion of patients with severe AS presents with discordant grading (i.e., an AVA ≤ 1 cm2 and a mean gradient <40 mmHg) which raises uncertainty about the true severity of AS and the need for AVR. Several imaging modalities (transesophageal or stress echocardiography, computed tomography, cardiovascular magnetic resonance, positron emission tomography) exist that allow a detailed assessment of the stenotic aortic valve and the myocardial remodeling response. This review aims to provide an updated overview of these multimodality imaging techniques and seeks to highlight a practical approach to help clinical decision making in the challenging group of patients with discordant low-gradient AS.
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Affiliation(s)
- Ezequiel Guzzetti
- Institut Universitaire de Cardiologie et de Pneumologie de Québec (Quebec Heart & Lung Institute), Quebec, QC, Canada
| | - Mohamed-Salah Annabi
- Institut Universitaire de Cardiologie et de Pneumologie de Québec (Quebec Heart & Lung Institute), Quebec, QC, Canada
| | - Philippe Pibarot
- Institut Universitaire de Cardiologie et de Pneumologie de Québec (Quebec Heart & Lung Institute), Quebec, QC, Canada
| | - Marie-Annick Clavel
- Institut Universitaire de Cardiologie et de Pneumologie de Québec (Quebec Heart & Lung Institute), Quebec, QC, Canada
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20
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Prognostic Value of Computed Tomography-Derived Extracellular Volume in TAVR Patients With Low-Flow Low-Gradient Aortic Stenosis. JACC Cardiovasc Imaging 2020; 13:2591-2601. [PMID: 33129731 DOI: 10.1016/j.jcmg.2020.07.045] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 07/06/2020] [Accepted: 07/09/2020] [Indexed: 01/01/2023]
Abstract
OBJECTIVES The association between extracellular volume (ECV) measured by computed tomography angiography (CTA) and clinical outcomes was evaluated in low-flow low-gradient (LFLG) aortic stenosis (AS) patients undergoing transcatheter aortic valve replacement (TAVR). BACKGROUND Patients with LFLG AS comprise a high-risk group with respect to clinical outcomes. Although ECV, a marker of myocardial fibrosis, is traditionally measured with cardiac magnetic resonance, it can also be measured using cardiac CTA. The authors hypothesized that in LFLG AS, increased ECV may be associated with adverse clinical outcomes. METHODS In 150 LFLG patients with AS who underwent TAVR, ECV was quantified using pre-TAVR CTA. Echocardiographic and clinical information including all-cause death and heart failure rehospitalization (HFH) was obtained from electronic medical records. A Cox proportional hazards model was used to evaluate the association between ECV and death+HFH. RESULTS During a median follow-up of 13.9 months (range 0.07 to 28.9 months), there were 31 death+HFH events (21%). Patients who experienced death+HFH had a greater median Society of Thoracic Surgery score (9.9 vs. 4.7; p < 0.01), lower left ventricular ejection fraction (42.3 ± 20.2% vs. 52.7 ± 17.2%; p < 0.01), lower mean transvalvular gradient (24.9 ± 8.9 mm Hg vs. 28.1 ± 7.3 mm Hg; p = 0.04) and increased mean ECV (35.5 ± 9.6% vs. 29.9 ± 8.2%; p < 0.01) compared with patients who did not experience death+HFH. In a multivariable Cox proportional hazards model, increase in ECV was associated with increase in death+HFH, (hazard ratio per 1% increase: 1.04, 95% confidence interval: 1.01 to 1.09; p < 0.01). CONCLUSIONS In patients with LFLG AS, CTA measured increase in ECV is associated with increased risk of adverse clinical outcomes post-TAVR and may thus serve as a useful noninvasive marker for prognostication.
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21
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Bohbot Y, Renard C, Manrique A, Levy F, Maréchaux S, Gerber BL, Tribouilloy C. Usefulness of Cardiac Magnetic Resonance Imaging in Aortic Stenosis. Circ Cardiovasc Imaging 2020; 13:e010356. [PMID: 32370617 DOI: 10.1161/circimaging.119.010356] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
The objective of this review is to provide an overview of the role of cardiac magnetic resonance (CMR) in aortic stenosis (AS). Although CMR is undeniably the gold standard for assessing left ventricular volume, mass, and function, the assessment of the left ventricular repercussions of AS by CMR is not routinely performed in clinical practice, and its role in evaluating and quantifying AS is not yet well established. CMR is an imaging modality integrating myocardial function and disease, which could be particularly useful in a pathology like AS that should be considered as a global myocardial disease rather than an isolated valve disease. In this review, we discuss the emerging potential of CMR for the diagnosis and prognosis of AS. We detail its utility for studying all aspects of AS, including valve anatomy, flow quantification, left ventricular volumes, mass, remodeling, and function, tissue mapping, and 4-dimensional flow magnetic resonance imaging. We also discuss different clinical situations where CMR could be useful in AS, for example, in low-flow low-gradient AS to confirm the low-flow state and to understand the reason for the left ventricular dysfunction or when there is a suspicion of associated cardiac amyloidosis.
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Affiliation(s)
- Yohann Bohbot
- Department of Cardiology (Y.B., C.T.), Amiens University Hospital, France.,UR UPJV 7517, Jules Verne University of Picardie, Amiens, France (Y.B., S.M., C.T.)
| | - Cédric Renard
- Department of Radiology (C.R.), Amiens University Hospital, France
| | - Alain Manrique
- Department of Nuclear Medicine, CHU Cote de Nacre, Normandy University, Caen, France (A.M.)
| | - Franck Levy
- Department of Cardiology, Centre Cardio-Thoracique De Monaco (F.L.)
| | - Sylvestre Maréchaux
- UR UPJV 7517, Jules Verne University of Picardie, Amiens, France (Y.B., S.M., C.T.).,Groupement des Hôpitaux de l'Institut Catholique de Lille/Faculté libre de médecine, Université Lille Nord de France (S.M.)
| | - Bernhard L Gerber
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium (B.L.G.).,Division of Cardiology, Cliniques Universitaires Saint-Luc, Brussels, Belgium (B.L.G.)
| | - Christophe Tribouilloy
- Department of Cardiology (Y.B., C.T.), Amiens University Hospital, France.,UR UPJV 7517, Jules Verne University of Picardie, Amiens, France (Y.B., S.M., C.T.)
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22
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Lavall D, Kuprat LK, Kandels J, Stöbe S, Hagendorff A, Laufs U. Left ventricular mechanical dispersion in flow-gradient patterns of severe aortic stenosis with narrow QRS complex. Int J Cardiovasc Imaging 2020; 36:605-614. [PMID: 31933102 PMCID: PMC7125243 DOI: 10.1007/s10554-019-01754-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 12/17/2019] [Indexed: 01/10/2023]
Abstract
Patients with severe aortic stenosis are classified according to flow-gradient patterns. We investigated whether left ventricular (LV) mechanical dispersion, a marker of dyssynchrony and predictor of mortality, is associated with low-flow status in aortic stenosis. 316 consecutive patients with aortic stenosis and QRS duration < 120 ms were included in the retrospective analysis. Patients with severe aortic stenosis (aortic valve area ≤ 1.0 cm2) were classified as normal-flow (NF; stroke volume index > 35 ml/m2) high-gradient (HG; mean transvalvular gradient ≥ 40 mmHg) (n = 79), NF low-gradient (LG) (n = 62), low-flow (LF) LG ejection fraction (EF) ≥ 50% (n = 57), and LF LG EF < 50% (n = 23). Patients with moderate aortic stenosis (aortic valve area 1.5–1.0 cm2; n = 95) served as comparison group. Mechanical dispersion (calculated as standard deviation of time from Q/S onset on electrocardiogram to peak longitudinal strain in 17 left ventricular segments) was similar in patients with NF HG (49.4 ± 14.7 ms), NF LG (43.5 ± 12.9 ms), LF LG EF ≥ 50% (47.2 ± 16.3 ms) and moderate aortic stenosis (44.2 ± 15.7 ms). In patients with LF LG EF < 50%, mechanical dispersion was increased (60.8 ± 20.7 ms, p < 0.05 vs. NF HG, NF LG, LF LG EF ≥ 50% and moderate AS). Mechanical dispersion correlated with global longitudinal strain (r = 0.1354, p = 0.0160) and heart rate (r = 0.1587, p = 0.0047), but not with parameters of aortic stenosis. Mechanical dispersion was similar among flow-gradient subgroups of severe aortic stenosis with preserved LVEF, but increased in patients with low-flow low-gradient and reduced LVEF. These findings indicate that mechanical dispersion is rather a marker of systolic myocardial dysfunction than of aortic stenosis.
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Affiliation(s)
- Daniel Lavall
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany.
| | - Linn Kristin Kuprat
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
| | - Joscha Kandels
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
| | - Stephan Stöbe
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
| | - Andreas Hagendorff
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
| | - Ulrich Laufs
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
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Abstract
Over the last 15 years, cardiovascular magnetic resonance (CMR) imaging has progressively evolved to become an indispensable tool in cardiology. It is a non-invasive technique that enables objective and functional assessment of myocardial tissue. Recent innovations in magnetic resonance imaging scanner technology and parallel imaging techniques have facilitated the generation of T1 and T2 parametric mapping to explore tissue characteristics. The emergence of strain imaging has enabled cardiologists to evaluate cardiac function beyond conventional metrics. Significant progress in computer processing capabilities and cloud infrastructure has supported the growth of artificial intelligence in CMR imaging. In this review article, we describe recent advances in T1/T2 mapping, myocardial strain, and artificial intelligence in CMR imaging.
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Affiliation(s)
- Karthik Seetharam
- Division of Cardiology, Icahn School of Medicine at Mount Sinai, Mount Sinai Medical Center, New York, USA
| | - Stamatios Lerakis
- Division of Cardiology, Icahn School of Medicine at Mount Sinai, Mount Sinai Medical Center, New York, USA
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24
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Affiliation(s)
- Rong Bing
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, United Kingdom
| | - Marc R Dweck
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, United Kingdom
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