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Nicely PN, Yang L, Kim DH, Berry SD. Pre-procedural nursing home length of stay and outcomes of transcatheter aortic valve replacement. J Am Geriatr Soc 2024. [PMID: 39126234 DOI: 10.1111/jgs.19124] [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: 11/13/2023] [Revised: 05/20/2024] [Accepted: 07/04/2024] [Indexed: 08/12/2024]
Abstract
BACKGROUND Older adults with severe aortic stenosis (AS) may receive care in a nursing home (NH) prior to undergoing transcatheter aortic valve replacement (TAVR). NH level of care can be used to stabilize medical conditions, to provide rehabilitation services, or for long-term care services. Our primary objective is to determine whether NH utilization pre-TAVR can be used to stratify patients at risk for higher mortality and poor disposition outcomes at 30 and 365 days post-TAVR. METHODS We conducted a retrospective cohort study among Medicare beneficiaries who spent ≥1 day in an NH 6 months before TAVR (2011-2019). The intensity of NH utilization was categorized as low users (1-30 days), medium users (31-89 days), long-stay NH residents (≥ 100 days, with no more than a 10-day gap in care), and high post-acute rehabilitation patients (≥90 days, with more than a 10-day gap in care). The probabilities of death and disposition were estimated using multinomial logistic regression, adjusting for age, sex, and race. RESULTS Among 15,581 patients, 9908 (63.6%) were low users, 4312 (27.7%) were medium users, 663 (4.3%) were high post-acute care rehab users, and 698 (4.4%) were long-stay NH residents before TAVR. High post-acute care rehabilitation patients were more likely to have dementia, weight loss, falls, and extensive dependence of activities of daily living (ADLs) as compared with low NH users. Mortality was the greatest in high post-acute care rehab users: 5.5% at 30 days, and 36.4% at 365 days. In contrast, low NH users had similar mortality rates compared with long-stay NH residents: 4.8% versus 4.8% at 30 days, and 24.9% versus 27.0% at 365 days. CONCLUSION Frequent bouts of post-acute rehabilitation before TAVR were associated with adverse outcomes, yet this metric may be helpful to determine which patients with severe AS could benefit from palliative and geriatric services.
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Affiliation(s)
- Preston N Nicely
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Laiji Yang
- Hinda and Arthur Marcus Institute for Aging Research and Department of Medicine, Hebrew Senior Life & Harvard Medical School, Boston, Massachusetts, USA
| | - Dae Hyun Kim
- Hinda and Arthur Marcus Institute for Aging Research and Department of Medicine, Hebrew Senior Life & Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Sarah D Berry
- Hinda and Arthur Marcus Institute for Aging Research and Department of Medicine, Hebrew Senior Life & Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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2
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Khan N, Steeds RP, Kyte D, Fabritz L, Collis P, Chua W, Stubbs C, Mehta S, Sun Y, Nulty M, Kirkham K, Cotton JM. Pilot study to evaluate the use of remote patient monitoring to guide the timing of valve intervention in patients with severe asymptomatic aortic stenosis (APRAISE-AS): study protocol for a randomised controlled trial delivered in two tertiary cardiac centres in the UK. BMJ Open 2024; 14:e086587. [PMID: 38858149 PMCID: PMC11168151 DOI: 10.1136/bmjopen-2024-086587] [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: 03/18/2024] [Accepted: 04/03/2024] [Indexed: 06/12/2024] Open
Abstract
INTRODUCTION Aortic stenosis (AS) is common affecting >13% of adults over the age of 75 years. In people who develop symptoms, without valve replacement, prognosis is dismal with mortality as high as 50% at 1 year. In asymptomatic patients, the timing of valve intervention is less well defined and a strategy of watchful waiting is recommended. Many, however, may develop symptoms and attribute this to age related decline, rather than worsening AS. Timely intervention in asymptomatic severe AS is critical, since delayed intervention often results in poor outcomes. Proactive surveillance of symptoms, quality of life and functional capacity should enable timely identification of people who will benefit from aortic valve replacement. There are no data however, to support the clinical and cost effectiveness of such an approach in a healthcare setting in the UK. The aim of this pilot trial is to test the feasibility of a full-scale randomised controlled trial (RCT) to determine the utility of proactive surveillance in people with asymptomatic severe AS to guide the timing of intervention. METHODS AND ANALYSIS APRAISE-AS is a multi-centre, non-blinded, two-arm, parallel group randomised controlled trial of up to 66 participants aged >18 years with asymptomatic severe AS. Participants will be randomised to either standard care or standard care supplemented with the APRAISE-AS intervention. Primary outcomes will capture; adherence to and participant acceptability of the intervention, recruitment and retention rates, and completeness of data collection. The findings will be used to inform the sample size and most appropriate outcome measure(s) for a full-scale RCT and health economic evaluation. ETHICS AND DISSEMINATION Ethical approval was granted by the Black Country REC, reference: 22/WM/0214. Results will be submitted for publication in peer-reviewed journals and disseminated at local, regional and national meetings where appropriate. TRIAL REGISTRATION NUMBER ISRCTN19413194 registered on 14.07.2023.
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Affiliation(s)
- Nazish Khan
- Department of Cardiology (QEHB), University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Richard P Steeds
- Department of Cardiology (QEHB), University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Derek Kyte
- School of Allied Health and Community, University of Worcester, Worcester, UK
- Centre for Patient Reported Outcomes Research, Institute for Applied Health Research, University of Birmingham, Birmingham, UK
| | - Larissa Fabritz
- Department of Cardiology (QEHB), University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- University Center of Cardiovascular Sciences & Department of Cardiology, University Heart and Vascular Center, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | - Philip Collis
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Winnie Chua
- Department of Cardiology (QEHB), University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Clive Stubbs
- Birmingham Clinical Trials Unit, Institute for Applied Health Research, University of Birmingham, Birmingham, UK
| | - Samir Mehta
- Birmingham Clinical Trials Unit, Institute for Applied Health Research, University of Birmingham, Birmingham, UK
| | - Yongzhong Sun
- Birmingham Clinical Trials Unit, Institute for Applied Health Research, University of Birmingham, Birmingham, UK
| | - Mary Nulty
- Birmingham Clinical Trials Unit, Institute for Applied Health Research, University of Birmingham, Birmingham, UK
| | - Katie Kirkham
- Birmingham Clinical Trials Unit, Institute for Applied Health Research, University of Birmingham, Birmingham, UK
| | - James M Cotton
- Department of Cardiology, The Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
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3
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Noto K, Uchida S, Kinoshita H, Takekawa D, Kushikata T, Hirota K. Predictive model for post-induction hypotension in patients undergoing transcatheter aortic valve implantation: a retrospective observational study. JA Clin Rep 2024; 10:33. [PMID: 38787499 PMCID: PMC11126397 DOI: 10.1186/s40981-024-00717-0] [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: 02/27/2024] [Revised: 04/26/2024] [Accepted: 05/19/2024] [Indexed: 05/25/2024] Open
Abstract
PURPOSE Post-induction hypotension (PIH) is an independent risk factor for prolonged postoperative stay and hospital death. Patients undergoing transcatheter aortic valve implantation (TAVI) are prone to develop PIH. This study aimed to develop a predictive model for PIH in patients undergoing TAVI. METHODS This single-center retrospective observational study included 163 patients who underwent TAVI. PIH was defined as at least one measurement of systolic arterial pressure <90 mmHg or at least one incident of norepinephrine infusion at a rate >6 µg/min from anesthetic induction until 20 min post-induction. Multivariate logistic regression analysis was performed to develop a predictive model for PIH in patients undergoing TAVI. RESULTS In total, 161 patients were analyzed. The prevalence of PIH was 57.8%. Multivariable logistic regression analysis showed that baseline mean arterial pressure ≥90 mmHg [adjusted odds ratio (aOR): 0.413, 95% confidence interval (95% CI): 0.193-0.887; p=0.023] and higher doses of fentanyl (per 1-µg/kg increase, aOR: 0.619, 95% CI: 0.418-0.915; p=0.016) and ketamine (per 1-mg/kg increase, aOR: 0.163, 95% CI: 0.062-0.430; p=0.002) for induction were significantly associated with lower risk of PIH. A higher dose of propofol (per 1-mg/kg increase, aOR: 3.240, 95% CI: 1.320-7.920; p=0.010) for induction was significantly associated with higher risk of PIH. The area under the curve (AUC) for this model was 0.802. CONCLUSION The present study developed predictive models for PIH in patients who underwent TAVI. This model may be helpful for anesthesiologists in preventing PIH in patients undergoing TAVI.
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Affiliation(s)
- Kohei Noto
- Department of Anesthesiology, Hirosaki University Graduate School of Medicine, Hirosaki, 036-8562, Japan
| | - Satoshi Uchida
- Department of Anesthesiology, Hirosaki University Graduate School of Medicine, Hirosaki, 036-8562, Japan
| | - Hirotaka Kinoshita
- Department of Anesthesiology, Hirosaki University Graduate School of Medicine, Hirosaki, 036-8562, Japan
| | - Daiki Takekawa
- Department of Anesthesiology, Hirosaki University Graduate School of Medicine, Hirosaki, 036-8562, Japan.
| | - Tetsuya Kushikata
- Department of Anesthesiology, Hirosaki University Graduate School of Medicine, Hirosaki, 036-8562, Japan
| | - Kazuyoshi Hirota
- Department of Anesthesiology, Hirosaki University Graduate School of Medicine, Hirosaki, 036-8562, Japan
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Barzallo D, Torrado J, Benites-Moya CJ, Sturla M, Echarte-Morales J, Scotti A, Kharawala A, Terre JA, Sugiura T, Wiley J, Goldberg Y, Latib A. Acute Hemodynamic Compromise After Transcatheter Aortic Valve Replacement Due to Dynamic Left Ventricle Obstruction: A Systematic Review. Am J Cardiol 2024; 214:125-135. [PMID: 38103763 DOI: 10.1016/j.amjcard.2023.12.005] [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: 08/21/2023] [Revised: 11/08/2023] [Accepted: 12/09/2023] [Indexed: 12/19/2023]
Abstract
Acute hemodynamic compromise after transcatheter aortic valve replacement (TAVR) because of dynamic left ventricle (LV) obstruction (LVO), also known as suicide LV, is an infrequent but severe complication of TAVR that is poorly defined in previous studies. Understanding this complication is essential for its prompt diagnosis and optimal treatment. We conducted a systematic literature review using PubMed, Embase, Web of Science, and Medline databases for studies describing acute hemodynamic compromise after TAVR because of dynamic LVO or suicide LV. Each study was reviewed by 2 authors individually for eligibility, and a third author resolved disagreements. From a total of 506 studies, 25 publications were considered for the final analysis. The majority of patients with this condition were women demonstrating a hypertrophic septum, a small ventricle, and hyperdynamic contractility on pre-TAVR echocardiographic assessment. An intraventricular gradient before TAVR was found in half of the cases. Acute hemodynamic compromise after TAVR because of dynamic LVO manifested mainly as significant hypotension and occurred most often immediately after valve deployment. The LV outflow tract was the most common site of obstruction. Advanced therapies were required in nearly 65% of the cases. In conclusion, acute hemodynamic compromise after TAVR because of dynamic LVO occurred almost invariably in women. Echocardiography before TAVR may offer essential information to anticipate this complication. LV outflow tract obstruction appears to carry the highest risk of developing this phenomenon. Advanced therapies should be promptly considered as a bailout strategy in patients with hemodynamic collapse refractory to medical therapy.
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Affiliation(s)
- Diego Barzallo
- Department of Internal Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, New York.
| | - Juan Torrado
- Department of Cardiology, Montefiore Medical Center, Bronx, New York
| | - Cesar Joel Benites-Moya
- Department of Internal Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Matteo Sturla
- Department of Cardiology, Montefiore Medical Center, Bronx, New York
| | | | - Andrea Scotti
- Department of Cardiology, Montefiore Medical Center, Bronx, New York
| | - Amrin Kharawala
- Department of Internal Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Juan A Terre
- Section of Cardiology, Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana
| | - Tadahisa Sugiura
- Department of Cardiothoracic Surgery, Montefiore Medical Center, Bronx, New York
| | - Jose Wiley
- Section of Cardiology, Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana
| | - Ythan Goldberg
- Section of Structural Echocardiography, Department of Cardiology, Lenox Hill Hospital and Western Region, Northwell Health, New York, New York
| | - Azeem Latib
- Department of Cardiology, Montefiore Medical Center, Bronx, New York
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5
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Paek M, Rinderle T, Resnick R, Bekelman DB. Palliative Care Issues in Aortic Stenosis #467. J Palliat Med 2023; 26:1578-1580. [PMID: 37955887 DOI: 10.1089/jpm.2023.0388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023] Open
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Sasaki M, Sasaki KI, Ishizaki Y, Ushijima S, Kamori-Kurokawa Y, Hamasaki K, Yoshikawa T, Hatada-Katakabe S, Takata Y, Ohtsuka M, Fukumoto Y. Safety and Efficacy of a Bodyweight Exercise Training Program in Symptomatic Patients With Severe Aortic Valve Stenosis. Am J Cardiol 2023; 186:163-169. [PMID: 36273954 DOI: 10.1016/j.amjcard.2022.09.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 09/06/2022] [Accepted: 09/28/2022] [Indexed: 11/01/2022]
Abstract
Conventional exercise therapy including aerobic and resistance training is desirable for cardiovascular disease, whereas it is generally considered contraindicated for symptomatic severe aortic valve stenosis (AS). This study aimed to evaluate the safety and efficacy of bodyweight resistance exercise training (BRET), which is low-intensity exercise training in symptomatic patients with severe AS. A BRET program consisting of 8 exercises was performed 3 times a week by patients with AS with physical therapists. For the 78 symptomatic patients with severe AS, the median aortic valve area and mean transaortic valve pressure gradient were 0.56 cm2 and 48.9 mm Hg, respectively; none showed any harmful changes in blood pressure or heart rate in 11 sessions of the BRET program. There were no adverse events during hospitalization. Meanwhile, Barthel's Index score significantly improved at the time of hospital discharge. In conclusion, the BRET program in this study did not appear to cause harmful changes in hemodynamics during the program or adverse events during hospitalization, and it improved activities of daily living in symptomatic patients with severe AS, allowing doctors and physical therapists to conduct it safely, with less emotional stress, for cardiac rehabilitation for such patients.
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Affiliation(s)
- Motoki Sasaki
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Ken-Ichiro Sasaki
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kurume University School of Medicine, Kurume, Japan.
| | - Yuta Ishizaki
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Shigeki Ushijima
- Division of Rehabilitation, Kurume University Hospital, Kurume, Japan
| | | | - Kumiko Hamasaki
- Division of Rehabilitation, Kurume University Hospital, Kurume, Japan
| | - Takahiro Yoshikawa
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Sachiko Hatada-Katakabe
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Yuki Takata
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Masanori Ohtsuka
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Yoshihiro Fukumoto
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kurume University School of Medicine, Kurume, Japan
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7
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Kammoun I, Sghaier A, Bennour E, Laroussi L, Miled M, Neji H, Ben Halima A, Addad F, Marrakchi S, Kachboura S. Current and new imaging techniques in risk stratification of asymptomatic severe aortic stenosis. Acta Cardiol 2022; 77:288-296. [PMID: 34151729 DOI: 10.1080/00015385.2021.1939513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Aortic stenosis (AS) is one of the most common valvular diseases in clinical practice. The prevalence of calcified AS with moderate or severe stenosis exceeds 2% after 75 years. The optimal timing of intervention for asymptomatic severe AS is uncertain and controversial. Identification of high-risk patients is based on echocardiographic parameters (left ventricular dysfunction, AS severity and progression), hemodynamic response to exercise, pulmonary hypertension, and elevated brain natriuretic peptides. However, early surgical aortic valve replacement (AVR), when compared to the watchful waiting approach, was associated with survival advantage. Moreover, new insights into pathophysiology of AS and advances in imaging modalities were helpful in the management of asymptomatic AS. In this report, we detail the potential role of echocardiography to guide timing of surgery and we discussed the use of early risk features based on recent imaging modalities.
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Affiliation(s)
- Ikram Kammoun
- Cardiology Department, Abderrahmane Mami’s Hospital, Ariana, Tunisia
| | - Ahmed Sghaier
- Cardiology Department, Abderrahmane Mami’s Hospital, Ariana, Tunisia
| | - Emna Bennour
- Cardiology Department, Abderrahmane Mami’s Hospital, Ariana, Tunisia
| | - Lobna Laroussi
- Cardiology Department, Abderrahmane Mami’s Hospital, Ariana, Tunisia
| | - Manel Miled
- Cardiology Department, Abderrahmane Mami’s Hospital, Ariana, Tunisia
| | - Henda Neji
- Radiology Department, Abderrahmane Mami’s Hospital, Ariana, Tunisia
| | - Afef Ben Halima
- Cardiology Department, Abderrahmane Mami’s Hospital, Ariana, Tunisia
| | - Faouzi Addad
- Cardiology Department, Abderrahmane Mami’s Hospital, Ariana, Tunisia
| | - Sonia Marrakchi
- Cardiology Department, Abderrahmane Mami’s Hospital, Ariana, Tunisia
| | - Salem Kachboura
- Cardiology Department, Abderrahmane Mami’s Hospital, Ariana, Tunisia
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8
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Saha B, Wien E, Fancher N, Kahili-Heede M, Enriquez N, Velasco-Hughes A. Heyde's syndrome: a systematic review of case reports. BMJ Open Gastroenterol 2022; 9:bmjgast-2021-000866. [PMID: 35534046 PMCID: PMC9086603 DOI: 10.1136/bmjgast-2021-000866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 03/27/2022] [Indexed: 11/12/2022] Open
Abstract
Objective Heyde’s syndrome (HS), a rare condition characterised by a unique relationship between severe aortic stenosis and angiodysplasia, is often diagnosed late increasing the risk for a prolonged hospital course and mortality in the elderly. The leading hypothesis explaining the aetiology of HS is acquired von Willebrand syndrome (AVWS) but not all studies support this claim. While individual cases of HS have been reported, here we present the first systematic review of case reports and focus on the prevalence of AVWS. Design A systematic search was conducted through PubMed/MEDLINE, CINAHL-EBSCO, Web of Science and Google Scholar since inception. The resulting articles were screened by two independent reviewers based on inclusion criteria that the article must be a case report/series or a letter to the editor in English describing HS in an adult patient. Results Seventy-four articles encompassing 77 cases met the inclusion criteria. The average age was 74.3±9.3 years old with a slight female predominance. The small intestine, especially the jejunum, was the most common location for bleeding origin. Capsule endoscopy and double balloon enteroscopy were superior at identifying bleeding sources than colonoscopy (p=0.0027 and p=0.0095, respectively) and oesophagogastroduodenoscopy (p=0.0006 and p=0.0036, respectively). The mean duration from symptom onset to diagnosis/treatment of HS was 23.8±39 months. Only 27/77 cases provided evidence for AVWS. Surgical and transcutaneous aortic valve replacement (AVR) were superior at preventing rebleeding than non-AVR modalities (p<0.0001). Conclusion Further research is warranted for a stronger understanding and increased awareness of HS, which may hasten diagnosis and optimal management.
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Affiliation(s)
- Bibek Saha
- John A. Burns School of Medicine, University of Hawai'i at Mānoa, Honolulu, Hawaii, USA
| | - Eric Wien
- John A. Burns School of Medicine, University of Hawai'i at Mānoa, Honolulu, Hawaii, USA.,Internal Medicine Residency Program, University of Hawai'i at Mānoa, Honolulu, Hawaii, USA
| | - Nicholas Fancher
- John A. Burns School of Medicine, University of Hawai'i at Mānoa, Honolulu, Hawaii, USA
| | - Melissa Kahili-Heede
- John A. Burns School of Medicine, University of Hawai'i at Mānoa, Honolulu, Hawaii, USA
| | - Nathaniel Enriquez
- John A. Burns School of Medicine, University of Hawai'i at Mānoa, Honolulu, Hawaii, USA.,Internal Medicine Residency Program, University of Hawai'i at Mānoa, Honolulu, Hawaii, USA
| | - Alena Velasco-Hughes
- John A. Burns School of Medicine, University of Hawai'i at Mānoa, Honolulu, Hawaii, USA.,Queen's Medical Group Hospitalist Program, Queen's Medical Center, Honolulu, Hawaii, USA
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9
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Schweiger MJ, Chawla KK, Lotfi A. Severe Aortic Stenosis: More Than an Imaging Diagnosis. Am J Med 2022; 135:566-571. [PMID: 34973961 DOI: 10.1016/j.amjmed.2021.11.022] [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: 11/11/2021] [Revised: 11/24/2021] [Accepted: 11/30/2021] [Indexed: 11/19/2022]
Abstract
The definition of severe aortic stenosis has undergone significant change casting a wider net to avoid missing patients who could benefit from valve replacement. The presence or absence of symptoms remains the key decision-making element; however, individuals presently undergoing evaluation are older, more likely asymptomatic, and have lower gradients. Due to numerous potential measurement errors, attention to detail when performing diagnostic testing and understanding their limitations are necessary to render appropriate treatment. Exercise testing adds useful information for individuals with severe aortic stenosis felt to be asymptomatic. Dobutamine echocardiography, in low flow-low gradient aortic stenosis, distinguishes between a myopathic and valvular cause of left ventricular dysfunction. Evaluation of patients when normotensive minimizes measurement errors. The amount of aortic valve calcification adds useful information when the degree of aortic stenosis is uncertain. A good history and physical integrated with high-quality imaging data allows for appropriate clinical treatment decisions for patients with aortic stenosis. The goal is simultaneously to provide aortic valve replacement for patients in need while avoiding overdiagnosis and performance of unnecessary procedures.
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Affiliation(s)
- Marc J Schweiger
- Department of Cardiology, Baystate Medical Center, Springfield, Mass; Tufts University School of Medicine, Boston, Mass.
| | - Kunal K Chawla
- Department of Cardiology, Baystate Medical Center, Springfield, Mass; University of Massachusetts School of Medicine, Springfield
| | - Amir Lotfi
- Department of Cardiology, Baystate Medical Center, Springfield, Mass; University of Massachusetts School of Medicine, Springfield
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10
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Komoriyama H, Kamiya K, Nagai T, Oyama-Manabe N, Tsuneta S, Kobayashi Y, Kato Y, Sarashina M, Omote K, Konishi T, Sato T, Tsujinaga S, Iwano H, Shingu Y, Wakasa S, Anzai T. Blood flow dynamics with four-dimensional flow cardiovascular magnetic resonance in patients with aortic stenosis before and after transcatheter aortic valve replacement. J Cardiovasc Magn Reson 2021; 23:81. [PMID: 34176516 PMCID: PMC8237445 DOI: 10.1186/s12968-021-00771-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 05/04/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pre- and post-procedural hemodynamic changes which could affect adverse outcomes in aortic stenosis (AS) patients who undergo transcatheter aortic valve replacement (TAVR) have not been well investigated. Four-dimensional (4D) flow cardiovascular magnetic resonance (CMR) enables accurate analysis of blood flow dynamics such as flow velocity, flow pattern, wall shear stress (WSS), and energy loss (EL). We sought to examine the changes in blood flow dynamics of patients with severe AS who underwent TAVR. METHODS We examined 32 consecutive severe AS patients who underwent TAVR between May 2018 and June 2019 (17 men, 82 ± 5 years, median left ventricular ejection fraction 61%, 6 self-expanding valve), after excluding those without CMR because of a contraindication or inadequate imaging from the analyses. We analyzed blood flow patterns, WSS and EL in the ascending aorta (AAo), and those changes before and after TAVR using 4D flow CMR. RESULTS After TAVR, semi-quantified helical flow in the AAo was significantly decreased (1.4 ± 0.6 vs. 1.9 ± 0.8, P = 0.002), whereas vortical flow and eccentricity showed no significant changes. WSS along the ascending aortic circumference was significantly decreased in the left (P = 0.038) and left anterior (P = 0.033) wall at the basal level, right posterior (P = 0.011) and left (P = 0.010) wall at the middle level, and right (P = 0.012), left posterior (P = 0.019) and left anterior (P = 0.028) wall at the upper level. EL in the AAo was significantly decreased (15.6 [10.8-25.1 vs. 25.8 [18.6-36.2]] mW, P = 0.012). Furthermore, a significant negative correlation was observed between EL and effective orifice area index after TAVR (r = - 0.38, P = 0.034). CONCLUSIONS In severe AS patients undergoing TAVR, 4D flow CMR demonstrates that TAVR improves blood flow dynamics, especially when a larger effective orifice area index is obtained.
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Affiliation(s)
- Hirokazu Komoriyama
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita 15, Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Kiwamu Kamiya
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita 15, Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Toshiyuki Nagai
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita 15, Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan.
| | - Noriko Oyama-Manabe
- Department of Diagnostic and Interventional Radiology, Hokkaido University Hospital, Kita 14, Nishi 5, Kita-ku, Sapporo, Hokkaido, 060-8648, Japan
| | - Satonori Tsuneta
- Department of Diagnostic and Interventional Radiology, Hokkaido University Hospital, Kita 14, Nishi 5, Kita-ku, Sapporo, Hokkaido, 060-8648, Japan
| | - Yuta Kobayashi
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita 15, Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Yoshiya Kato
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita 15, Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Miwa Sarashina
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita 15, Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Kazunori Omote
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita 15, Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Takao Konishi
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita 15, Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Takuma Sato
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita 15, Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Shingo Tsujinaga
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita 15, Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Hiroyuki Iwano
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita 15, Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Yasushige Shingu
- Department of Cardiovascular and Thoracic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita 15, Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Satoru Wakasa
- Department of Cardiovascular and Thoracic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita 15, Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Toshihisa Anzai
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita 15, Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
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11
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Bencivenga L, Sepe I, Palaia ME, Komici K, Corbi G, Puzone B, Arcopinto M, Cittadini A, Ferrara N, Femminella GD, Rengo G. Antithrombotic therapy in patients undergoing transcatheter aortic valve replacement: the complexity of the elderly. Eur J Prev Cardiol 2021; 28:87-97. [PMID: 33624104 PMCID: PMC7665487 DOI: 10.1093/eurjpc/zwaa053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 07/03/2020] [Accepted: 08/12/2020] [Indexed: 12/13/2022]
Abstract
Along with epidemiologic transitions of the global population, the burden of aortic stenosis (AS) is rapidly increasing and transcatheter aortic valve replacement (TAVR) has quickly spread; indeed, it is nowadays also employed in treating patients with AS at intermediate operative risk. Nonetheless, the less invasive interventional strategy still carries relevant issues concerning post-procedural optimal antithrombotic strategy, given the current indications provided by guidelines are not completely supported by evidence-based data. Geriatric patients suffer from high bleeding and thromboembolic risks, whose balance is particularly subtle due to the presence of concomitant conditions, such as atrial fibrillation and chronic kidney disease, that make the post-TAVR antithrombotic management particularly insidious. This scenario is further complicated by the lack of specific evidence regarding the 'real-life' complex conditions typical of the geriatric syndromes, thus, the management of such a heterogeneous population, ranging from healthy ageing to frailty, is far from being defined. The aim of the present review is to summarize the critical points and the most updated evidence regarding the post-TAVR antithrombotic approach in the geriatric population, with a specific focus on the most frequent clinical settings.
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Affiliation(s)
| | - Immacolata Sepe
- Department of Translational Medical Sciences, University of Naples “Federico II”, Via Sergio Pansini 5, Naples 80131, Italy
| | - Maria Emiliana Palaia
- Department of Translational Medical Sciences, University of Naples “Federico II”, Via Sergio Pansini 5, Naples 80131, Italy
| | - Klara Komici
- Department of Medicine and Health Sciences, University of Molise, Via Francesco De Sanctis 1, Campobasso 86100, Italy
| | - Graziamaria Corbi
- Department of Medicine and Health Sciences, University of Molise, Via Francesco De Sanctis 1, Campobasso 86100, Italy
| | - Brunella Puzone
- Department of Translational Medical Sciences, University of Naples “Federico II”, Via Sergio Pansini 5, Naples 80131, Italy
| | - Michele Arcopinto
- Department of Translational Medical Sciences, University of Naples “Federico II”, Via Sergio Pansini 5, Naples 80131, Italy
| | - Antonio Cittadini
- Department of Translational Medical Sciences, University of Naples “Federico II”, Via Sergio Pansini 5, Naples 80131, Italy
| | - Nicola Ferrara
- Department of Translational Medical Sciences, University of Naples “Federico II”, Via Sergio Pansini 5, Naples 80131, Italy
- Istituti Clinici Scientifici Maugeri SPA, Società Benefit, IRCCS, Istituto Scientifico di Telese, Via Bagni Vecchi 1, Telese Terme 82037 (BN), Italy
| | - Grazia Daniela Femminella
- Department of Translational Medical Sciences, University of Naples “Federico II”, Via Sergio Pansini 5, Naples 80131, Italy
- Department of Medicine, Imperial College London, South Kensington Campus, London SW7 2AZ, UK
| | - Giuseppe Rengo
- Department of Translational Medical Sciences, University of Naples “Federico II”, Via Sergio Pansini 5, Naples 80131, Italy
- Istituti Clinici Scientifici Maugeri SPA, Società Benefit, IRCCS, Istituto Scientifico di Telese, Via Bagni Vecchi 1, Telese Terme 82037 (BN), Italy
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12
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Transcatheter Aortic Valve Replacement in Rheumatic Aortic Stenosis: A Comprehensive Review. Curr Probl Cardiol 2021; 46:100843. [PMID: 33994024 DOI: 10.1016/j.cpcardiol.2021.100843] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 03/08/2021] [Indexed: 12/31/2022]
Abstract
Rheumatic heart disease (RHD) mainly affects people in developing, low-income countries. However, due to globalization and migration, developed countries are now seeing more cases of RHD. In RHD patients who develop severe symptomatic aortic stenosis, surgical aortic valve replacement remains the treatment of choice. In the past decade, there has been an extension of transcatheter aortic valve replacement (TAVR) to intermediate-risk and lower-risk patients with aortic stenosis. This review suggests the possible utility of TAVR for the treatment of rheumatic aortic stenosis. Rheumatic aortic stenosis has been excluded from major TAVR studies due to the predominantly noncalcific pathology of the rheumatic aortic valve. However, there have been case reports and case series showing successful implantation of the valve even in patients with and without significant leaflet calcification. In this review article, we summarize the latest evidence of severe rheumatic aortic stenosis treated with TAVR and discuss the procedure's impact on patient care, safety, and efficacy.
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13
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Mino T, Kimura S, Kitaura A, Iwamoto T, Yuasa H, Chiba Y, Nakao S. Can left ventricular hypertrophy on electrocardiography detect severe aortic valve stenosis? PLoS One 2020; 15:e0241591. [PMID: 33147268 PMCID: PMC7641401 DOI: 10.1371/journal.pone.0241591] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 10/16/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Severe aortic stenosis (AS) is increasing in the aging society and is a serious condition for anesthetic management. However, approximately one-third of patients with severe AS are asymptomatic. Echocardiography is the most reliable method to detect AS, but it takes time and is costly. METHODS Data were obtained retrospectively from patients who underwent surgery and preoperative transthoracic echocardiography (TTE). LVH on ECG was determined by voltage criteria (Sv1 + Rv5 or 6 ≥3.5 mV) and/or the strain pattern in V5 and V6. Severe AS was defined as a mean transaortic pressure gradient ≥40 mmHg or aortic valve area ≤1.0 cm2 by TTE. RESULTS Data for 470 patients aged 28-94 years old were obtained. One hundred and twenty-six patients had severe AS. LVH on ECG by voltage criteria alone was detected in 182 patients, LVH by strain pattern alone was detected in 80 patients and LVH by both was detected in 55 patients. Multivariable logistic analysis revealed that LVH by the strain pattern or voltage criteria, diabetes mellitus, and age were significantly associated with severe AS. The AUC for the ROC curve for LVH by voltage criteria alone was 0.675 and the cut-off value was 3.84 mm V, and the AUC for the ROC for age was 0.675 and the cut-off value was 74 years old. CONCLUSION Our study suggests that patients who are 74 years old or over with LVH on ECG, especially those with DM, should undergo preoperative TTE in order to detect severe AS.
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Affiliation(s)
- Takashi Mino
- Department of Anesthesiology, Kindai University Faculty of Medicine, OsakaSayama, Osaka, Japan
| | - Seishi Kimura
- Department of Anesthesiology, Kindai University Faculty of Medicine, OsakaSayama, Osaka, Japan
| | - Atsuhiro Kitaura
- Department of Anesthesiology, Kindai University Faculty of Medicine, OsakaSayama, Osaka, Japan
| | - Tatsushige Iwamoto
- Department of Anesthesiology, Kindai University Faculty of Medicine, OsakaSayama, Osaka, Japan
| | - Haruyuki Yuasa
- Department of Anesthesiology, Kindai University Faculty of Medicine, OsakaSayama, Osaka, Japan
| | - Yasutaka Chiba
- Clinical Research Center, Kindai University Hospital, OsakaSayama, Osaka, Japan
| | - Shinichi Nakao
- Department of Anesthesiology, Kindai University Faculty of Medicine, OsakaSayama, Osaka, Japan
- * E-mail:
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14
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George I, Salna M, Kobsa S, Deroo S, Kriegel J, Blitzer D, Shea NJ, D’Angelo A, Raza T, Kurlansky P, Takeda K, Takayama H, Bapat V, Naka Y, Smith CR, Bacha E, Argenziano M. The rapid transformation of cardiac surgery practice in the coronavirus disease 2019 (COVID-19) pandemic: insights and clinical strategies from a centre at the epicentre. Eur J Cardiothorac Surg 2020; 58:667-675. [PMID: 32573737 PMCID: PMC7337744 DOI: 10.1093/ejcts/ezaa228] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVES The onset of the coronavirus disease 2019 (COVID-19) pandemic has forced our cardiac surgery programme and hospital to enact drastic measures that has forced us to change how we care for cardiac surgery patients, assist with COVID-19 care and enable support for the hospital in terms of physical resources, providers and resident training. METHODS In this review, we review the cardiovascular manifestations of COVID-19 and describe our system-wide adaptations to the pandemic, including the use of telemedicine, how a severe reduction in operative volume affected our programme, the process of redeployment of staff, repurposing of residents into specific task teams, the creation of operation room intensive care units, and the challenges that we faced in this process. RESULTS We offer a revised set of definitions of surgical priority during this pandemic and how this was applied to our system, followed by specific considerations in coronary/valve, aortic, heart failure and transplant surgery. Finally, we outline a path forward for cardiac surgery for the near future. CONCLUSIONS We recognize that individual programmes around the world will eventually face COVID-19 with varying levels of infection burden and different resources, and we hope this document can assist programmes to plan for the future.
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Affiliation(s)
- Isaac George
- Division of Cardiac, Thoracic and Vascular Surgery, New York Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - Michael Salna
- Division of Cardiac, Thoracic and Vascular Surgery, New York Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - Serge Kobsa
- Division of Cardiac, Thoracic and Vascular Surgery, New York Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - Scott Deroo
- Division of Cardiac, Thoracic and Vascular Surgery, New York Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - Jacob Kriegel
- Division of Cardiac, Thoracic and Vascular Surgery, New York Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - David Blitzer
- Division of Cardiac, Thoracic and Vascular Surgery, New York Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - Nicholas J Shea
- Division of Cardiac, Thoracic and Vascular Surgery, New York Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - Alex D’Angelo
- Division of Cardiac, Thoracic and Vascular Surgery, New York Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - Tasnim Raza
- Division of Cardiac, Thoracic and Vascular Surgery, New York Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - Paul Kurlansky
- Division of Cardiac, Thoracic and Vascular Surgery, New York Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - Koji Takeda
- Division of Cardiac, Thoracic and Vascular Surgery, New York Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - Hiroo Takayama
- Division of Cardiac, Thoracic and Vascular Surgery, New York Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - Vinayak Bapat
- Division of Cardiac, Thoracic and Vascular Surgery, New York Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - Yoshifumi Naka
- Division of Cardiac, Thoracic and Vascular Surgery, New York Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - Craig R Smith
- Division of Cardiac, Thoracic and Vascular Surgery, New York Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - Emile Bacha
- Division of Cardiac, Thoracic and Vascular Surgery, New York Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - Michael Argenziano
- Division of Cardiac, Thoracic and Vascular Surgery, New York Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
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15
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Kellermair J, Saeed S, Ott HW, Kammler J, Blessberger H, Suppan M, Grund M, Kiblboeck D, Urheim S, Chambers JB, Steinwender C. High-molecular-weight von Willebrand Factor multimer ratio differentiates true-severe from pseudo-severe classical low-flow, low-gradient aortic stenosis. Eur Heart J Cardiovasc Imaging 2020; 21:1123-1130. [PMID: 32417907 DOI: 10.1093/ehjci/jeaa056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 03/07/2020] [Indexed: 01/15/2023] Open
Abstract
AIMS Upon high wall shear stress, high-molecular-weight (HMW) von Willebrand Factor (VWF) multimers are degraded, thus, HMW VWF multimer deficiency mirrors haemodynamics at the site of aortic stenosis (AS). The aim of the present study was to analyse the role of HMW VWF multimer ratio for subcategorization of classical low-flow, low-gradient (LF/LG) AS. METHODS AND RESULTS Eighty-three patients with classical LF/LG AS were prospectively recruited and HMW VWF multimer pattern was analysed using a densitometric quantification of western blot bands. Patients were subclassified into true-severe (TS) and pseudo-severe (PS) classical LF/LG AS based on dobutamine stress echocardiography (DSE). Positive and negative predictive values (PPV/NPV) of HMW VWF multimer ratio for diagnosis of the TS subtype were calculated. HMW VWF multimer ratio in TS classical LF/LG AS was significantly decreased compared to PS classical LF/LG AS (0.86 ± 0.27 vs. 1.06 ± 0.09, P < 0.001). HMW VWF multimer deficiency occurred exclusively in the TS subtype with an optimal PPV of 1.000 and NPV of 0.379. HMW VWF multimer ratio showed a strong correlation with mean transvalvular pressure gradients during DSE (r = -0.616; P < 0.001). HMW VWF multimer ratio measured at baseline was higher compared to levels measured after DSE (0.87 ± 0.27 vs. 0.84 ± 0.31; P = 0.031) indicating DSE-induced increased proteolysis. CONCLUSION HMW VWF multimer ratio represents a valuable biomarker for classical LF/LG AS subclassification and mirrors haemodynamics during DSE. HMW VWF multimer ratio identifies the TS subtype without the use of other imaging techniques.
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Affiliation(s)
- Joerg Kellermair
- Department of Cardiology, Kepler University Hospital, Medical Faculty Johannes Kepler University Linz, Krankenhausstrasse 9, 4020 Linz, Austria
| | - Sahrai Saeed
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Helmut W Ott
- Department of Hemostasis and Transfusion Medicine, Ludwig-Maximilians-University, Munich, Germany
| | - Juergen Kammler
- Department of Cardiology, Kepler University Hospital, Medical Faculty Johannes Kepler University Linz, Krankenhausstrasse 9, 4020 Linz, Austria
| | - Hermann Blessberger
- Department of Cardiology, Kepler University Hospital, Medical Faculty Johannes Kepler University Linz, Krankenhausstrasse 9, 4020 Linz, Austria
| | - Markus Suppan
- Department of Cardiology, Klinikum Wels-Grieskirchen, Wels, Austria
| | - Michael Grund
- Department of Cardiology, Kepler University Hospital, Medical Faculty Johannes Kepler University Linz, Krankenhausstrasse 9, 4020 Linz, Austria
| | - Daniel Kiblboeck
- Department of Cardiology, Kepler University Hospital, Medical Faculty Johannes Kepler University Linz, Krankenhausstrasse 9, 4020 Linz, Austria
| | - Stig Urheim
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - John B Chambers
- Cardiothoracic Centre, Guy's and St Thomas' Hospital, London SE1 7EH, UK
| | - Clemens Steinwender
- Department of Cardiology, Kepler University Hospital, Medical Faculty Johannes Kepler University Linz, Krankenhausstrasse 9, 4020 Linz, Austria.,Paracelsus Medical University Salzburg, Strubergasse 21, 5020 Salzburg, Austria
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16
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George I, Salna M, Kobsa S, Deroo S, Kriegel J, Blitzer D, Shea NJ, D'Angelo A, Raza T, Kurlansky P, Takeda K, Takayama H, Bapat V, Naka Y, Smith CR, Bacha E, Argenziano M. The rapid transformation of cardiac surgery practice in the coronavirus disease 2019 (COVID-19) pandemic: Insights and clinical strategies from a center at the epicenter. J Thorac Cardiovasc Surg 2020; 160:937-947.e2. [PMID: 32624303 PMCID: PMC7331531 DOI: 10.1016/j.jtcvs.2020.04.060] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 04/14/2020] [Accepted: 04/18/2020] [Indexed: 02/08/2023]
Abstract
Background The onset of the coronavirus disease 2019 (COVID-19) pandemic has forced our cardiac surgery program and hospital to enact drastic measures that has forced us to change how we care for cardiac surgery patients, assist with COVID-19 care, and enable support for the hospital in terms of physical resources, providers, and resident training. Methods In this review, we review the cardiovascular manifestations of COVID-19 and describe our system-wide adaptations to the pandemic, including the use of telemedicine, how a severe reduction in operative volume affected our program, the process of redeployment of staff, repurposing of residents into specific task teams, the creation of operation room intensive care units, and the challenges that we faced in this process. Results We offer a revised set of definitions of surgical priority during this pandemic and how this was applied to our system, followed by specific considerations in coronary/valve, aortic, heart failure and transplant surgery. Finally, we outline a path forward for cardiac surgery for the near future. Conclusions We recognize that individual programs around the world will eventually face COVID-19 with varying levels of infection burden and different resources, and we hope this document can assist programs to plan for the future.
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Affiliation(s)
- Isaac George
- Division of Cardiac, Thoracic and Vascular Surgery, NewYork Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY.
| | - Michael Salna
- Division of Cardiac, Thoracic and Vascular Surgery, NewYork Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - Serge Kobsa
- Division of Cardiac, Thoracic and Vascular Surgery, NewYork Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - Scott Deroo
- Division of Cardiac, Thoracic and Vascular Surgery, NewYork Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - Jacob Kriegel
- Division of Cardiac, Thoracic and Vascular Surgery, NewYork Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - David Blitzer
- Division of Cardiac, Thoracic and Vascular Surgery, NewYork Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - Nicholas J Shea
- Division of Cardiac, Thoracic and Vascular Surgery, NewYork Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - Alex D'Angelo
- Division of Cardiac, Thoracic and Vascular Surgery, NewYork Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - Tasnim Raza
- Division of Cardiac, Thoracic and Vascular Surgery, NewYork Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - Paul Kurlansky
- Division of Cardiac, Thoracic and Vascular Surgery, NewYork Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - Koji Takeda
- Division of Cardiac, Thoracic and Vascular Surgery, NewYork Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - Hiroo Takayama
- Division of Cardiac, Thoracic and Vascular Surgery, NewYork Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - Vinayak Bapat
- Division of Cardiac, Thoracic and Vascular Surgery, NewYork Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - Yoshifumi Naka
- Division of Cardiac, Thoracic and Vascular Surgery, NewYork Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - Craig R Smith
- Division of Cardiac, Thoracic and Vascular Surgery, NewYork Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - Emile Bacha
- Division of Cardiac, Thoracic and Vascular Surgery, NewYork Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - Michael Argenziano
- Division of Cardiac, Thoracic and Vascular Surgery, NewYork Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
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17
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George I, Salna M, Kobsa S, Deroo S, Kriegel J, Blitzer D, Shea NJ, D'Angelo A, Raza T, Kurlansky P, Takeda K, Takayama H, Bapat V, Naka Y, Smith CR, Bacha E, Argenziano M. The Rapid Transformation of Cardiac Surgery Practice in the Coronavirus Disease 2019 (COVID-19) Pandemic: Insights and Clinical Strategies From a Center at the Epicenter. Ann Thorac Surg 2020; 110:1108-1118. [PMID: 32591132 PMCID: PMC7309733 DOI: 10.1016/j.athoracsur.2020.04.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 04/22/2020] [Indexed: 02/08/2023]
Abstract
Background The onset of the coronavirus disease 2019 (COVID-19) pandemic has forced our cardiac surgery program and hospital to enact drastic measures that has forced us to change how we care for cardiac surgery patients, assist with COVID-19 care, and enable support for the hospital in terms of physical resources, providers, and resident training. Methods In this review, we review the cardiovascular manifestations of COVID-19 and describe our system-wide adaptations to the pandemic, including the use of telemedicine, how a severe reduction in operative volume affected our program, the process of redeployment of staff, repurposing of residents into specific task teams, the creation of operation room intensive care units, and the challenges that we faced in this process. Results We offer a revised set of definitions of surgical priority during this pandemic and how this was applied to our system, followed by specific considerations in coronary/valve, aortic, heart failure and transplant surgery. Finally, we outline a path forward for cardiac surgery for the near future. Conclusions We recognize that individual programs around the world will eventually face COVID-19 with varying levels of infection burden and different resources, and we hope this document can assist programs to plan for the future.
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Affiliation(s)
- Isaac George
- Division of Cardiac, Thoracic, and Vascular Surgery, New York Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York.
| | - Michael Salna
- Division of Cardiac, Thoracic, and Vascular Surgery, New York Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York
| | - Serge Kobsa
- Division of Cardiac, Thoracic, and Vascular Surgery, New York Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York
| | - Scott Deroo
- Division of Cardiac, Thoracic, and Vascular Surgery, New York Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York
| | - Jacob Kriegel
- Division of Cardiac, Thoracic, and Vascular Surgery, New York Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York
| | - David Blitzer
- Division of Cardiac, Thoracic, and Vascular Surgery, New York Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York
| | - Nicholas J Shea
- Division of Cardiac, Thoracic, and Vascular Surgery, New York Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York
| | - Alex D'Angelo
- Division of Cardiac, Thoracic, and Vascular Surgery, New York Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York
| | - Tasnim Raza
- Division of Cardiac, Thoracic, and Vascular Surgery, New York Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York
| | - Paul Kurlansky
- Division of Cardiac, Thoracic, and Vascular Surgery, New York Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York
| | - Koji Takeda
- Division of Cardiac, Thoracic, and Vascular Surgery, New York Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York
| | - Hiroo Takayama
- Division of Cardiac, Thoracic, and Vascular Surgery, New York Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York
| | - Vinayak Bapat
- Division of Cardiac, Thoracic, and Vascular Surgery, New York Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York
| | - Yoshifumi Naka
- Division of Cardiac, Thoracic, and Vascular Surgery, New York Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York
| | - Craig R Smith
- Division of Cardiac, Thoracic, and Vascular Surgery, New York Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York
| | - Emile Bacha
- Division of Cardiac, Thoracic, and Vascular Surgery, New York Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York
| | - Michael Argenziano
- Division of Cardiac, Thoracic, and Vascular Surgery, New York Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York
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18
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Tribouilloy C, Rusinaru D, Bohbot Y, Maréchaux S, Vanoverschelde JL, Enriquez-Sarano M. How Should Very Severe Aortic Stenosis Be Defined in Asymptomatic Individuals? J Am Heart Assoc 2019; 8:e011724. [PMID: 30712451 PMCID: PMC6405579 DOI: 10.1161/jaha.118.011724] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
See Article by Kanamori et al.
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Affiliation(s)
- Christophe Tribouilloy
- 1 Pôle Coeur-Thorax-Vaisseaux Department of Cardiology University Hospital Amiens Amiens France.,2 EA 7517 MP3CV Jules Verne University of Picardie Amiens France
| | - Dan Rusinaru
- 1 Pôle Coeur-Thorax-Vaisseaux Department of Cardiology University Hospital Amiens Amiens France.,2 EA 7517 MP3CV Jules Verne University of Picardie Amiens France
| | - Yohann Bohbot
- 1 Pôle Coeur-Thorax-Vaisseaux Department of Cardiology University Hospital Amiens Amiens France.,2 EA 7517 MP3CV Jules Verne University of Picardie Amiens France
| | - Sylvestre Maréchaux
- 2 EA 7517 MP3CV Jules Verne University of Picardie Amiens France.,3 Groupement des Hôpitaux de l'Institut Catholique de Lille Hopital Saint Philibert Lomme France
| | - Jean-Louis Vanoverschelde
- 4 Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique Université Catholique de Louvain Brussels Belgium
| | - Maurice Enriquez-Sarano
- 5 Division of Cardiovascular Diseases and Internal Medicine Mayo Medical School Rochester MN
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Maréchaux S, Rusinaru D, Altes A, Pasquet A, Vanoverschelde JL, Tribouilloy C. Prognostic Value of Low Flow in Patients With High Transvalvular Gradient Severe Aortic Stenosis and Preserved Left Ventricular Ejection Fraction: A Multicenter Study. Circ Cardiovasc Imaging 2019; 12:e009299. [PMID: 31597467 DOI: 10.1161/circimaging.119.009299] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Grading of severe (aortic valve area ≤1 cm2) aortic stenosis with preserved left ventricular ejection fraction is based on a classification depending on flow (normal flow versus low flow) and pressure gradient (low gradient versus high gradient). The aim of the present study was to compare the outcome of patients with normal flow high gradient and low flow high gradient severe aortic stenosis (SAS) with no or minimal symptoms. METHODS This multicenter study enrolled 983 consecutive patients (mean age 75±11 years, 459 women) with asymptomatic or minimally symptomatic HG (mean pressure gradient ≥40 mm Hg) SAS with preserved left ventricular ejection fraction. Low flow was defined by Doppler echocardiography as a stroke volume index <30 mL/m2 (n=131) or a stroke volume <55 mL (n=136). The end point was all-cause mortality. RESULTS During a median follow-up period of 48 (45-52) months, 225 patients (23%) died. The 60-month mortality was higher in low flow high gradient SAS compared with normal flow high gradient SAS (36±5% versus 22±2% and 38±5% versus 21±2% for stroke volume index and stroke volume, respectively, both P<0.0001). After adjustment for outcome predictors including aortic valve replacement as time-dependent covariate, low flow high gradient SAS displayed considerable mortality risk during follow up compared with normal flow high gradient SAS (adjusted HR 2.17 [1.51-3.13]; P<0.0001 for stroke volume index <30 mL/m2 and adjusted HR 1.86 [1.29-2.68]; P=0.001, for stroke volume <55 mL). The prognostic impact of low flow was consistent in subgroups of patients. CONCLUSIONS Asymptomatic or minimally symptomatic patients with low flow high gradient SAS and preserved left ventricular ejection fraction have a considerable increased risk of mortality during follow-up. These patients should be promptly considered for aortic valve replacement.
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Affiliation(s)
- Sylvestre Maréchaux
- GCS-Groupement des Hôpitaux de l'Institut Catholique de Lille (GHICL), Cardiology department and Heart Valve Center, Faculté libre de médecine/Université Catholique de Lille, France (S.M., A.A.).,Centre Universitaire de Recherche en Santé, Laboratoire MP3CV - EA 7517, Université de Picardie, Amiens, France (S.M., D.R., C.T.)
| | - Dan Rusinaru
- Centre Universitaire de Recherche en Santé, Laboratoire MP3CV - EA 7517, Université de Picardie, Amiens, France (S.M., D.R., C.T.).,Department of Cardiology, Amiens University Hospital, France (D.R., C.T.)
| | - Alexandre Altes
- GCS-Groupement des Hôpitaux de l'Institut Catholique de Lille (GHICL), Cardiology department and Heart Valve Center, Faculté libre de médecine/Université Catholique de Lille, France (S.M., A.A.)
| | - Agnès Pasquet
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium (A.P., J.L.V.).,Division of Cardiology, Cliniques Universitaires Saint-Luc, Brussels, Belgium (A.P., J.L.V.)
| | - Jean Louis Vanoverschelde
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium (A.P., J.L.V.).,Division of Cardiology, Cliniques Universitaires Saint-Luc, Brussels, Belgium (A.P., J.L.V.)
| | - Christophe Tribouilloy
- Centre Universitaire de Recherche en Santé, Laboratoire MP3CV - EA 7517, Université de Picardie, Amiens, France (S.M., D.R., C.T.).,Department of Cardiology, Amiens University Hospital, France (D.R., C.T.)
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