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Marigliano AN, Ortiz JT, Casas J, Evangelista A. Aortic Regurgitation: From Valvular to Myocardial Dysfunction. J Clin Med 2024; 13:2929. [PMID: 38792470 PMCID: PMC11122337 DOI: 10.3390/jcm13102929] [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: 04/03/2024] [Revised: 04/30/2024] [Accepted: 05/02/2024] [Indexed: 05/26/2024] Open
Abstract
Chronic aortic regurgitation (AR) leads to volume overload in the left ventricle (LV), which is well tolerated for years. In this condition, the LV usually dilates with minimal reduction in the ejection fraction (EF), even in the absence of symptoms. Echocardiography is the primary imaging test used to quantify AR. However, no single assessment of Doppler measures is accurate and precise in individual patients; therefore, the integration of multiple parameters is necessary. Recent guidelines recommend surgical treatment for severe AR in patients who are symptomatic or have an LVEF < 55% and an end-systolic diameter > 50 mm. Nevertheless, advances in imaging technology have improved the quantification of AR and the assessment of LV subclinical dysfunction. It is widely recognized that patients who undergo aortic valve replacement/repair (AVR) due to symptoms or a low LVEF experience worse outcomes than those undergoing AVR for non-Class I indications. In fact, subclinical irreversible myocardial damage may occur in clinically well-compensated and closely monitored patients while awaiting formal surgical indications. This condition could be prevented by the use of multimodal imaging parameters, in particular longitudinal LV strain and magnetic resonance imaging. In addition, better cut-off values for mortality predictors should be established. This review aims to identify simple models that integrate several echocardiographic and cardiac magnetic resonance-derived parameters to predict the optimal timing of surgical treatment in asymptomatic patients with chronic severe AR.
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Affiliation(s)
- Alba-Nidia Marigliano
- Heart Institute, Teknon Medical Center, 08022 Barcelona, Spain; (A.-N.M.); (J.-T.O.)
| | - José-Tomas Ortiz
- Heart Institute, Teknon Medical Center, 08022 Barcelona, Spain; (A.-N.M.); (J.-T.O.)
| | - Jorge Casas
- Instituto Cedic, Bahía Blanca B8000, Argentina;
| | - Arturo Evangelista
- Heart Institute, Teknon Medical Center, 08022 Barcelona, Spain; (A.-N.M.); (J.-T.O.)
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2
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Saeed M, Bersali A, Darwish A, Qamar F, Maragiannis D, El-Tallawi KC, Malahfji M, Shah DJ. Assessing Regurgitation Severity, Adverse Remodeling, and Fibrosis with CMR in Aortic Regurgitation. Curr Cardiol Rep 2024; 26:413-421. [PMID: 38517604 DOI: 10.1007/s11886-024-02044-3] [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] [Accepted: 03/15/2024] [Indexed: 03/24/2024]
Abstract
PURPOSE OF REVIEW Cardiac magnetic resonance (CMR) is emerging as a valuable imaging modality for the assessment of aortic regurgitation (AR). In this review, we discuss the assessment of AR severity, left ventricular (LV) remodeling, and tissue characterization by CMR while highlighting the latest studies and addressing future research needs. RECENT FINDINGS Recent studies have further established CMR-based thresholds of AR severity and LV remodeling that are associated with adverse clinical outcomes, and lower than current guideline criteria. In addition, tissue profiling with late gadolinium enhancement (LGE) and extracellular volume (ECV) quantification can reliably assess adverse myocardial tissue remodeling which is also associated with adverse outcomes. The strengths and reproducibility of CMR in evaluating ventricular volumes, tissue characteristics, and regurgitation severity position it as an excellent modality in evaluating and following AR patients. Advanced CMR techniques for the detection of tissue remodeling have shown significant potential and merit further investigation.
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Affiliation(s)
- Mujtaba Saeed
- Cardiovascular MRI Laboratory, Division of Cardiovascular Imaging, Houston Methodist DeBakey Heart & Vascular Center, Weill Cornell Medical College, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA
| | - Akila Bersali
- Cardiovascular MRI Laboratory, Division of Cardiovascular Imaging, Houston Methodist DeBakey Heart & Vascular Center, Weill Cornell Medical College, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA
| | - Amr Darwish
- Cardiovascular MRI Laboratory, Division of Cardiovascular Imaging, Houston Methodist DeBakey Heart & Vascular Center, Weill Cornell Medical College, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA
| | - Fatima Qamar
- Cardiovascular MRI Laboratory, Division of Cardiovascular Imaging, Houston Methodist DeBakey Heart & Vascular Center, Weill Cornell Medical College, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA
| | - Dimitrios Maragiannis
- Cardiovascular MRI Laboratory, Division of Cardiovascular Imaging, Houston Methodist DeBakey Heart & Vascular Center, Weill Cornell Medical College, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA
| | - Kinan Carlos El-Tallawi
- Cardiovascular MRI Laboratory, Division of Cardiovascular Imaging, Houston Methodist DeBakey Heart & Vascular Center, Weill Cornell Medical College, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA
| | - Maan Malahfji
- Cardiovascular MRI Laboratory, Division of Cardiovascular Imaging, Houston Methodist DeBakey Heart & Vascular Center, Weill Cornell Medical College, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA
| | - Dipan J Shah
- Cardiovascular MRI Laboratory, Division of Cardiovascular Imaging, Houston Methodist DeBakey Heart & Vascular Center, Weill Cornell Medical College, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA.
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3
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Kočková R, Vojáček J, Bedáňová H, Fila P, Skalský I, Žáková D, Klán M, Míková B, Mědílek K, Tuna M, Fialová M, Dvořáková R, Hlubocká Z, Panovský R, Slabý K, Kelen de Oliveira E, Casselman F, Pěnička M. Rationale and design of the ELEANOR trial early aortic valve surgery versus watchful waiting strategy in severe asymptomatic aortic regurgitation, ACRONYM: ELEANOR. Heliyon 2024; 10:e29470. [PMID: 38638969 PMCID: PMC11024602 DOI: 10.1016/j.heliyon.2024.e29470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 03/17/2024] [Accepted: 04/08/2024] [Indexed: 04/20/2024] Open
Abstract
Background The optimal treatment of patients with severe symptomatic aortic regurgitation (AR) is state-of-the-art surgery. Asymptomatic patients with advanced left ventricular (LV) dilatation and/or impaired ejection fraction should undergo surgical treatment, but there is no guidelines consensus on cut-off values for this recommendation. Multimodality imaging has brought new tools for the accurate selection of asymptomatic patients at risk of early clinical deterioration, however, prospective and randomized data are pending. Cardiac magnetic resonance (CMR)-derived AR quantification along with LV remodeling assessment appears to be the most accurate tool for a selection of such patients at risk. Trial design The objective of our prospective and multicenter study is to determine whether patients at risk of early clinical deterioration as per CMR assessment will benefit from early surgical treatment. The study is designed as a superiority trial to demonstrate that early surgical treatment is safe and more effective than the standard treatment. A total of 217 asymptomatic patients with severe AR, but without current guidelines-based surgical indication, will be enrolled across all centers. We expect 24 % of patients identified as high clinical risk and therefore eligible for 1:1 randomization to early surgical treatment within 3 months or a watchful waiting strategy. Follow-up will be annual. We expect a complete restoration of LV size and function along with improved quality of life and physical performance in a short-term follow-up of 12 months. The primary endpoint will be a composite safety and efficacy with all criteria mandatory: 15 % or larger reduction of baseline CMR-derived LV end-diastolic volume index, LV ejection fraction >50 %, and no major adverse cardiovascular events. The annual follow-up will continue for a minimum of 4 years until the required number of endpoints is achieved to show a statistically significant difference in cardiovascular morbidity and mortality in early surgically treated patients. Conclusion The ELEANOR trial is the first multicenter randomized controlled study to compare early surgical treatment with a watchful waiting strategy in asymptomatic patients with chronic severe AR at high risk of early clinical deterioration as per CMR assessment but without guidelines-based indications for surgical treatment.
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Affiliation(s)
- Radka Kočková
- Na Homolce Hospital, Prague, Czech Republic
- Charles University, Faculty of Medicine in Hradec Králové, Hradec Králové, Czech Republic
| | - Jan Vojáček
- Charles University, Faculty of Medicine in Hradec Králové, Hradec Králové, Czech Republic
- University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Helena Bedáňová
- Centre of Cardiovascular Surgery and Transplantation, Brno, Czech Republic
| | - Petr Fila
- Centre of Cardiovascular Surgery and Transplantation, Brno, Czech Republic
- Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | | | - Daniela Žáková
- Centre of Cardiovascular Surgery and Transplantation, Brno, Czech Republic
| | | | | | - Karel Mědílek
- Charles University, Faculty of Medicine in Hradec Králové, Hradec Králové, Czech Republic
- University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Martin Tuna
- Charles University, Faculty of Medicine in Hradec Králové, Hradec Králové, Czech Republic
- University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Monika Fialová
- University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Radka Dvořáková
- University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Zuzana Hlubocká
- 2nd Department of Internal Cardiovascular Medicine, General University Hospital in Prague, First Faculty of Medicine, Charles University, Czech Republic
| | - Roman Panovský
- International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czech Republic
- 1st Department of Internal, Brno, Czech Republic Medicine/Cardioangiology at St. Anne's University Hospital, Brno, Czech Republic
| | - Kryštof Slabý
- Department of Rehabilitation and Sports Medicine, Second Faculty of Medicine, Charles University in Prague, Czech Republic
| | - Elayne Kelen de Oliveira
- CardioPaTh PhD Program, Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
- Cardiovascular Center OLV Clinic Aalst, Belgium
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Ferrer-Sistach E, Teis A, Escabia C, Delgado V. Assessment of the Severity of Aortic Regurgitation by Noninvasive Imaging : Non-invasive MMI for AR. Curr Cardiol Rep 2024; 26:1-14. [PMID: 38091195 DOI: 10.1007/s11886-023-02011-4] [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] [Accepted: 12/04/2023] [Indexed: 01/27/2024]
Abstract
PURPOSE OF THE REVIEW The role of multimodality imaging in the evaluation of patients with aortic regurgitation is summarized in this review. RECENT FINDINGS The etiology (mechanism) of the aortic regurgitation and the severity of aortic regurgitation and hemodynamic consequences are key in the decision making of patients with severe aortic regurgitation. While echocardiography remains as the leading technique to assess all these parameters, other imaging techniques have become essential for the accurate assessment of aortic regurgitation severity and the timing of aortic intervention. The anatomic suitability of transcatheter aortic valve implantation in inoperable patients with severe aortic regurgitation is usually assessed with computed tomography. Aortic regurgitation is a prevalent disease with various pathophysiological mechanisms that need a personalized treatment. The evaluation of the mechanism and severity of aortic regurgitation can be initially performed with echocardiography. Three-dimensional techniques, including echocardiography, have become very relevant for accurate assessment of the regurgitation severity and its hemodynamic consequences. Assessment of myocardial tissue characteristics with cardiac magnetic resonance is key in the risk stratification of patients and in the timing of aortic intervention. Computed tomography is important in the assessment of aortic dimensions and selection of patients for transcatheter aortic valve implantation.
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Affiliation(s)
- Elena Ferrer-Sistach
- Heart Institute, University Hospital Germans Trias I Pujol, Carretera de Canyet S/N, 08916, Badalona, Spain
| | - Albert Teis
- Heart Institute, University Hospital Germans Trias I Pujol, Carretera de Canyet S/N, 08916, Badalona, Spain
| | - Claudia Escabia
- Heart Institute, University Hospital Germans Trias I Pujol, Carretera de Canyet S/N, 08916, Badalona, Spain
| | - Victoria Delgado
- Heart Institute, University Hospital Germans Trias I Pujol, Carretera de Canyet S/N, 08916, Badalona, Spain.
- Center for Comparative Medicine and Bioimaging (CMCIB), Germans Trias I Pujol Research Institute (IGTP), Badalona, Spain.
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Malahfji M, Saeed M, Zoghbi WA. Aortic Regurgitation: Review of the Diagnostic Criteria and the Management Guidelines. Curr Cardiol Rep 2023; 25:1373-1380. [PMID: 37715804 DOI: 10.1007/s11886-023-01955-x] [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] [Accepted: 08/28/2023] [Indexed: 09/18/2023]
Abstract
PURPOSE OF REVIEW The evaluation of aortic regurgitation (AR) has advanced from physical examination and angiography towards evidence based non-invasive quantitative methods, primarily with echocardiography and more recently with cardiac magnetic resonance (CMR). This review highlights the guidelines and recent evidence in the diagnosis and management of AR; and outlines future areas of research. RECENT FINDINGS Contemporary large cohorts of AR patients studied with echocardiography and CMR suggest that the left ventricular remodeling and systolic function triggers for intervention may be lower than previously recommended in the guidelines and emphasize the importance of LV volumes in risk stratification. Important gaps of knowledge in the quantitation of AR severity and patient risk stratification were fulfilled recently. Potential thresholds for intervention using ventricular volumes and CMR quantitative findings were recently described. The criteria for what constitutes hemodynamically significant AR and the optimal timing of intervention AR deserve further study.
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Affiliation(s)
- Maan Malahfji
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA.
| | - Mujtaba Saeed
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA
| | - William A Zoghbi
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA
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Lebehn M, Vahl T, Kampaktsis P, Hahn RT. Contemporary Evaluation and Clinical Treatment Options for Aortic Regurgitation. J Cardiovasc Dev Dis 2023; 10:364. [PMID: 37754793 PMCID: PMC10532324 DOI: 10.3390/jcdd10090364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 08/21/2023] [Accepted: 08/22/2023] [Indexed: 09/28/2023] Open
Abstract
Aortic regurgitation (AR) is the third most frequent form of valvular disease and has increasing prevalence with age. This will be of increasing clinical importance with the advancing age of populations around the globe. An understanding of the various etiologies and mechanisms leading to AR requires a detailed understanding of the structure of the aortic valve and aortic root. While acute and chronic AR may share a similar etiology, their hemodynamic impact on the left ventricle (LV) and management are very different. Recent studies suggest current guideline recommendations for chronic disease may result in late intervention and suboptimal outcomes. Accurate quantitation of ventricular size and function, as well as grading of the severity of regurgitation, requires a multiparametric and multimodality imaging approach with an understanding of the strengths and weaknesses of each metric. Echocardiography remains the primary imaging modality for diagnosis with supplemental information provided by computed tomography (CT) and cardiac magnetic resonance imaging (CMR). Emerging transcatheter therapies may allow the treatment of patients at high risk for surgery, although novel methods to assess AR severity and its impact on LV size and function may improve the timing and outcomes of surgical intervention.
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Affiliation(s)
- Mark Lebehn
- Department of Medicine, Columbia University Irving Medical Center, New York, NY 10032, USA
| | - Torsten Vahl
- Department of Medicine, Columbia University Irving Medical Center, New York, NY 10032, USA
- Cardiovascular Research Foundation, New York, NY 10019, USA
| | - Polydoros Kampaktsis
- Department of Medicine, Columbia University Irving Medical Center, New York, NY 10032, USA
| | - Rebecca T. Hahn
- Department of Medicine, Columbia University Irving Medical Center, New York, NY 10032, USA
- Cardiovascular Research Foundation, New York, NY 10019, USA
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7
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Malahfji M, Senapati A, Debs D, Saeed M, Tayal B, Nguyen DT, Graviss EA, Shah DJ. Sex differences in myocardial remodeling and extracellular volume in aortic regurgitation. Sci Rep 2023; 13:11334. [PMID: 37443191 PMCID: PMC10344872 DOI: 10.1038/s41598-023-37444-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 06/21/2023] [Indexed: 07/15/2023] Open
Abstract
Whether sex differences exist in the cardiac remodeling related to aortic regurgitation (AR) is unclear. Cardiac magnetic resonance (CMR) is the current non-invasive reference standard for cardiac remodeling assessment and can evaluate tissue characteristics. This prospective cohort included patients with AR undergoing CMR between 2011 and 2020. We excluded patients with confounding causes of remodeling. We quantified left ventricular (LV) volume, mass, AR severity, replacement fibrosis by late Gadolinium enhancement (LGE), and extracellular expansion by extracellular volume fraction (ECV). We studied 280 patients (109 women), median age 59.5 (47.2, 68.6) years (P for age = 0.25 between sexes). Women had smaller absolute LV volume and mass than men across the spectrum of regurgitation volume (RVol) (P ≤ 0.01). In patients with ≥ moderate AR and with adjustment for body surface area, indexed LV end-diastolic volume and mass were not significantly different between sexes (all P > 0.5) but men had larger indexed LV end systolic volume and lower LV ejection fraction (P ≥ 0.01). Women were more likely to have NYHA class II or greater symptoms than men but underwent surgery at a similar rate. Prevalence and extent of LGE was not significantly different between sexes or across RVol. Increasing RVol was independently associated with increasing ECV in women, but not in men (adjusted P for interaction = 0.03). In conclusion, women had lower LV volumes and mass than men across AR severity but their ECV increased with higher regurgitant volume, while ECV did not change in men. Indexing to body surface area did not fully correct for the cardiac remodeling differences between men and women. Women were more likely to have symptoms but underwent surgery at a similar rate to men. Further research is needed to determine if differences in ECV would translate to differences in the course of AR and outcomes.
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Affiliation(s)
- Maan Malahfji
- Cardiovascular MRI Laboratory, Division of Cardiovascular Imaging, Houston Methodist DeBakey Heart & Vascular Center, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA
| | - Alpana Senapati
- Cardiovascular MRI Laboratory, Division of Cardiovascular Imaging, Houston Methodist DeBakey Heart & Vascular Center, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA
| | - Dany Debs
- Cardiovascular MRI Laboratory, Division of Cardiovascular Imaging, Houston Methodist DeBakey Heart & Vascular Center, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA
| | - Mujtaba Saeed
- Cardiovascular MRI Laboratory, Division of Cardiovascular Imaging, Houston Methodist DeBakey Heart & Vascular Center, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA
| | - Bhupendar Tayal
- Cardiovascular MRI Laboratory, Division of Cardiovascular Imaging, Houston Methodist DeBakey Heart & Vascular Center, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA
| | - Duc T Nguyen
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital Research Institute, Houston, TX, USA
| | - Edward A Graviss
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital Research Institute, Houston, TX, USA
| | - Dipan J Shah
- Cardiovascular MRI Laboratory, Division of Cardiovascular Imaging, Houston Methodist DeBakey Heart & Vascular Center, 6550 Fannin Street, Smith Tower - Suite 1801, Houston, TX, 77030, USA.
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8
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Petersen J, Iqbal S, Gedeon N, Kloth B, Pecha S, Yildirim Y, Eschenhagen T, Reichenspurner H, Christ T, Girdauskas E. Valvular Cardiomyopathy in Aortic Valve Regurgitation Correlates with Myocardial Fibrosis. J Clin Med 2023; 12:jcm12082915. [PMID: 37109251 PMCID: PMC10145654 DOI: 10.3390/jcm12082915] [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: 02/05/2023] [Revised: 03/30/2023] [Accepted: 04/13/2023] [Indexed: 04/29/2023] Open
Abstract
Objective: At the tissue level, disruption of the extracellular matrix network leads to irreversible cardiac fibrosis, which contributes to myocardial dysfunction. At the myocyte level, downregulation of beta-adrenoceptors (beta-AR) reduces adaptation to increased workload. The aim of our study was to analyse the correlation between myocardial fibrosis and beta-AR sensitivity in patients with aortic valve (AV) disease. Methods: A total of 92 consecutive patients who underwent elective AV surgery between 2017-2019 were included in our study (51 with aortic regurgitation (AR-group); 41 with aortic stenosis (AS-group) and left ventricular (LV) biopsies were obtained intraoperatively. In vitro force contractility testing was performed by measuring beta-AR sensitivity (-log EC50[ISO]). In parallel, a quantitative analysis of myocardial fibrosis burden was performed. Results: Mean age at the time of AV surgery was not statistically different in both groups (AR: 53.3 ± 15.3 years vs. AS: 58.7 ± 17.0 years; p = 0.116). The LV end-diastolic diameter was significantly enlarged in the AR-group when compared to the AS-group (59.4 ± 15.6 vs. 39.7 ± 21.2; p < 0.001). Analysis of beta-AR sensitivity (AR: -6.769 vs. AS: -6.659; p = 0.316) and myocardial fibrosis (AR: 8.9% vs. AS: 11.3%; p = 0.284) showed no significant differences between patients with AS and AR. There was no correlation between myocardial fibrosis and beta-AR sensitivity in the whole study cohort (R = 0.1987; p = 0.100) or in the AS-subgroup (R = 0.009; p = 0.960). However, significant correlation of fibrosis and beta-AR sensitivity was seen in AR-patients (R = 0.363; p = 0.023). Conclusion: More severe myocardial fibrosis was associated with reduced beta-AR sensitivity in patients presenting with AR but not with AS. Therefore, our results suggest that in patients with AR, cellular myocardial dysfunction is present and correlates with the extent of myocardial fibrosis in the myocardium.
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Affiliation(s)
- Johannes Petersen
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Martinistraße 52, 20246 Hamburg, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, 20246 Hamburg, Germany
| | - Shahria Iqbal
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Martinistraße 52, 20246 Hamburg, Germany
- Institute of Experimental Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Naomi Gedeon
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Martinistraße 52, 20246 Hamburg, Germany
- Institute of Experimental Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Benjamin Kloth
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Martinistraße 52, 20246 Hamburg, Germany
- Department of Cardiothoracic Surgery, Augsburg University Hospital, 86156 Augsburg, Germany
| | - Simon Pecha
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Martinistraße 52, 20246 Hamburg, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, 20246 Hamburg, Germany
| | - Yalin Yildirim
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Martinistraße 52, 20246 Hamburg, Germany
| | - Thomas Eschenhagen
- DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, 20246 Hamburg, Germany
- Institute of Experimental Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Hermann Reichenspurner
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Martinistraße 52, 20246 Hamburg, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, 20246 Hamburg, Germany
| | - Torsten Christ
- DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, 20246 Hamburg, Germany
- Institute of Experimental Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Evaldas Girdauskas
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Martinistraße 52, 20246 Hamburg, Germany
- Department of Cardiothoracic Surgery, Augsburg University Hospital, 86156 Augsburg, Germany
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9
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Ajmone Marsan N, Delgado V, Shah DJ, Pellikka P, Bax JJ, Treibel T, Cavalcante JL. Valvular heart disease: shifting the focus to the myocardium. Eur Heart J 2023; 44:28-40. [PMID: 36167923 PMCID: PMC9805407 DOI: 10.1093/eurheartj/ehac504] [Citation(s) in RCA: 28] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 07/12/2022] [Accepted: 08/26/2022] [Indexed: 01/05/2023] Open
Abstract
Adverse cardiac remodelling is the main determinant of patient prognosis in degenerative valvular heart disease (VHD). However, to give an indication for valvular intervention, current guidelines include parameters of cardiac chamber dilatation or function which are subject to variability, do not directly reflect myocardial structural changes, and, more importantly, seem to be not sensitive enough in depicting early signs of myocardial dysfunction before irreversible myocardial damage has occurred. To avoid irreversible myocardial dysfunction, novel biomarkers are advocated to help refining indications for intervention and risk stratification. Advanced echocardiographic modalities, including strain analysis, and magnetic resonance imaging have shown to be promising in providing new tools to depict the important switch from adaptive to maladaptive myocardial changes in response to severe VHD. This review, therefore, summarizes the current available evidence on the role of these new imaging biomarkers in degenerative VHD, aiming at shifting the clinical perspective from a valve-centred to a myocardium-focused approach for patient management and therapeutic decision-making.
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Affiliation(s)
- Nina Ajmone Marsan
- Department of Cardiology, Leiden Univesity Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - Victoria Delgado
- Department of Cardiology, Leiden Univesity Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
- Department of Cardiology, Germans Trias i Pujol Hospital, Carretera de Canyet s/n. 08916 Badalona, Barcelona, Spain
| | - Dipan J Shah
- Division of Cardiovascular Imaging, Weill Cornell Medical College, Houston Methodist DeBakey Heart & Vascular Center, 6565 Fannin St, Houston, TX 77030, USA
| | - Patricia Pellikka
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA
| | - Jeroen J Bax
- Department of Cardiology, Leiden Univesity Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - Thomas Treibel
- Department of Cardiology, Barts Heart Centre and University College London, West Smithfield, London EC1A 7BE, UK
| | - João L Cavalcante
- Department of Cardiology, Minneapolis Heart Institute at Abbott Northwestern Hospital, 800 E 28th St, Minneapolis, MN 55407, USA
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10
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Kočková R, Línková H, Hlubocká Z, Mědílek K, Tuna M, Vojáček J, Skalský I, Černý Š, Malý J, Hlubocký J, Mizukami T, De Colle C, Pěnička M. Multiparametric Strategy to Predict Early Disease Decompensation in Asymptomatic Severe Aortic Regurgitation. Circ Cardiovasc Imaging 2022; 15:e014901. [PMID: 36538596 DOI: 10.1161/circimaging.122.014901] [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] [Indexed: 12/24/2022]
Abstract
BACKGROUND Use of the current echocardiography-based indications for aortic regurgitation (AR) surgery might result in late valve replacement at the stage of irreversible myocardial damage. Therefore, we aimed to identify simple models combining multiple echocardiography or magnetic resonance imaging (MRI)-derived indices and natriuretic peptides (BNP [brain natriuretic peptide] or NT-proBNP [N-terminnal pro-B type natriuretic peptide]) to predict early disease decompensation in asymptomatic severe AR. METHODS This prospective and multicenter study included asymptomatic patients with severe AR, preserved left ventricular ejection fraction (>50%), and sinus rhythm. The echocardiography and MRI images were analyzed centrally in the CoreLab. The study end point was the onset of indication for aortic valve surgery as per current guidelines. RESULTS The derivative cohort consisted of 127 asymptomatic patients (age 45±14 years, 84% males) with 41 (32%) end points during a median follow-up of 1375 (interquartile range, 1041-1783) days. In multivariable Cox regression analysis, age, BNP, 3-dimensional vena contracta area, MRI left ventricular end-diastolic volume index, regurgitant volume, and a fraction were identified as independent predictors of end point (all P<0.05). However, a combined model including one parameter of AR assessment (MRI regurgitant volume or regurgitant fraction or 3-dimensional vena contracta area), 1 parameter of left ventricular remodeling (MRI left ventricular end-diastolic volume index or echocardiography 2-dimensional global longitudinal strain or E wave), and BNP showed significantly higher predictive accuracy (area under the curve, 0.74-0.81) than any parameter alone (area under the curve, 0.61-0.72). These findings were confirmed in the validation cohort (n=100 patients, 38 end points). CONCLUSIONS In asymptomatic severe AR, multimodality and multiparametric model combining 2 imaging indices with natriuretic peptides, showed high accuracy to identify early disease decompensation. Further prospective studies are warranted to explore the clinical benefit of implementing these models to guide patient management. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT02910349.
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Affiliation(s)
- Radka Kočková
- Cardiothoracic Surgery Department, Na Homolce Hospital, Czech Republic (R.K., I.S., S.C.)
| | - Hana Línková
- Department of Cardiology, Royal Vinohrady University Hospital, Czech Republic (H.L.)
| | - Zuzana Hlubocká
- Department of Cardiology (Z.H.), General University Hospital, Prague, Czech Republic
| | - Karel Mědílek
- 1st Department Medicine - Cardioangiology, University Hospital Hradec Králové, Sokolská Czech Republic (K.M.)
| | - Martin Tuna
- Department of Cardiac Surgery, University Hospital Hradec Králové, Hradec Králové, Czech Republic (M.T., J.V.)
| | - Jan Vojáček
- Department of Cardiac Surgery, University Hospital Hradec Králové, Hradec Králové, Czech Republic (M.T., J.V.)
| | - Ivo Skalský
- Cardiothoracic Surgery Department, Na Homolce Hospital, Czech Republic (R.K., I.S., S.C.)
| | - Štěpán Černý
- Cardiothoracic Surgery Department, Na Homolce Hospital, Czech Republic (R.K., I.S., S.C.)
| | - Jiří Malý
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.M.)
| | - Jaroslav Hlubocký
- Department of Cardiovascular Surgery (J.H.), General University Hospital, Prague, Czech Republic
| | - Takuya Mizukami
- Cardiovascular Center Aalst, Belgium (T.M., C.D.C., M.P.).,Division of Clinical Pharmacology, Department of Pharmacology, Showa University, Tokyo, Japan (T.M.)
| | - Cristina De Colle
- Cardiovascular Center Aalst, Belgium (T.M., C.D.C., M.P.).,Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy (C.D.C.)
| | - Martin Pěnička
- Cardiovascular Center Aalst, Belgium (T.M., C.D.C., M.P.)
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11
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Siani A, Perone F, Costantini P, Rodolfi S, Muscogiuri G, Sironi S, Carriero S, Pavon AG, van der Bilt I, van Rosendael P, Broekhuizen L, Teske A, Cramer MJ, Guglielmo M. Aortic regurgitation: A multimodality approach. JOURNAL OF CLINICAL ULTRASOUND : JCU 2022; 50:1041-1050. [PMID: 36218214 PMCID: PMC9828136 DOI: 10.1002/jcu.23299] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 07/17/2022] [Accepted: 07/18/2022] [Indexed: 06/16/2023]
Abstract
Aortic regurgitation (AR) is a common valvular pathology. Multimodality noninvasive cardiovascular imaging is routinely used to assess the mechanism of AR, degree, and its hemodynamic impact on the cardiovascular system. Collecting this information is crucial in establishing the prognosis and in guiding patient management and follow-up. While echocardiography remains the primary test to assess AR, a comprehensive assessment of this valvulopathy can be obtained by combining the information from different techniques. This state-of-the-art review is intended to provide an update ed overview of the applications, strengths, and limits of transthoracic echocardiography, cardiac magnetic resonance, and cardiac computed tomography in patients with AR.
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Affiliation(s)
- Agnese Siani
- Radiology DepartmentOspedale Maggiore della Carità University HospitalNovaraItaly
| | - Francesco Perone
- Cardiac Rehabilitation Unit, Rehabilitation Clinic "Villa delle Magnolie", Castel MorroneCasertaItaly
| | - Pietro Costantini
- Radiology DepartmentOspedale Maggiore della Carità University HospitalNovaraItaly
| | - Sara Rodolfi
- Radiology DepartmentOspedale Maggiore della Carità University HospitalNovaraItaly
| | - Giuseppe Muscogiuri
- School of Medicine and Surgery, University of Milano‐BicoccaMilanItaly
- Department of RadiologyIRCCS Istituto Auxologico Italiano, San Luca HospitalMilanItaly
| | - Sandro Sironi
- School of Medicine and Surgery, University of Milano‐BicoccaMilanItaly
- Department of RadiologyASST Papa Giovanni XXIII HospitalBergamoItaly
| | - Serena Carriero
- Postgraduate School in Radiodiagnostics, Università degli Studi di MilanoMilanItaly
| | - Anna Giulia Pavon
- Cardiocentro Ticino Institute, Ente Ospedaliero CantonaleLuganoSwitzerland
| | - Ivo van der Bilt
- Department of CardiologyHaga Teaching HospitalThe HagueNetherlands
| | - Philippe van Rosendael
- Department of Cardiology, Division of Heart and LungsUtrecht University, Utrecht University Medical CenterUtrechtThe Netherlands
| | - Lysette Broekhuizen
- Department of Cardiology, Division of Heart and LungsUtrecht University, Utrecht University Medical CenterUtrechtThe Netherlands
| | - Arco Teske
- Department of Cardiology, Division of Heart and LungsUtrecht University, Utrecht University Medical CenterUtrechtThe Netherlands
| | - Maarten Jan Cramer
- Department of Cardiology, Division of Heart and LungsUtrecht University, Utrecht University Medical CenterUtrechtThe Netherlands
| | - Marco Guglielmo
- Department of Cardiology, Division of Heart and LungsUtrecht University, Utrecht University Medical CenterUtrechtThe Netherlands
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12
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Hashimoto G, Enriquez-Sarano M, Stanberry LI, Oh F, Wang M, Acosta K, Sato H, Lopes BBC, Fukui M, Garcia S, Goessl M, Sorajja P, Bapat VN, Lesser J, Cavalcante JL. Association of Left Ventricular Remodeling Assessment by Cardiac Magnetic Resonance With Outcomes in Patients With Chronic Aortic Regurgitation. JAMA Cardiol 2022; 7:924-933. [PMID: 35857306 DOI: 10.1001/jamacardio.2022.2108] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Importance Chronic aortic regurgitation (AR) causes left ventricular (LV) volume overload, which results in progressive LV remodeling negatively affecting outcomes. Whether cardiac magnetic resonance (CMR) volumetric quantification can provide incremental risk stratification over standard clinical and echocardiographic evaluation in patients with chronic moderate or severe AR is unknown. Objective To compare LV remodeling measurements by CMR and echocardiography between patients with and without heart failure symptoms and to verify the association of remodeling measurements of patients with chronic moderate or severe AR but no or minimal symptoms with clinical outcomes receiving medical management. Design, Setting, and Participants This multicenter retrospective cohort study included consecutive patients with at least moderate chronic native AR evaluated by 2-dimensional transthoracic echocardiography and CMR examination within 90 days from each other between January 2012 and February 2020 at Allina Health System. Data were analyzed from June 2021 to January 2022. Exposures Clinical evaluation and risk stratification by CMR. Main Outcomes and Measures The end point was a composite of death, heart failure hospitalization, or progression of New York Heart Association functional class while receiving medical management, censoring patients at the time of aortic valve replacement (when performed) or at the end of follow-up. Results Of the 178 included patients, 119 (66.9%) were male, 158 (88.8%) presented with no or minimal symptoms (New York Heart Association class I or II), and the median (IQR) age was 58 (44-69) years. Compared with patients with no or minimal symptoms, symptomatic patients had greater LV end-systolic volume index (LVESVi) by CMR (median [IQR], 66 [46-85] mL/m2 vs 42 [30-58] mL/m2; P < .001), while there were no significant differences by echocardiography (LVESVi: median [IQR], 38 [30-58] mL/m2 vs 27 [20-42] mL/m2; P = .07; LV end-systolic diameter index: median [IQR], 21 [17-25] mm/m2 vs 18 [15-22] mm/m2; P = .17). During the median (IQR) follow-up of 3.3 (1.6-5.8) years, 50 patients with no or minimal symptoms receiving medical management developed the composite end point, which, in multivariate analysis adjusted for age and EuroSCORE II, was independently associated with LVESVi of 45 mL/m2 or greater and aortic regurgitant fraction of 32% or greater, the latter adding incremental prognostic value to CMR volumetric assessment. Conclusions and Relevance In patients with chronic moderate or severe AR, patients presenting with heart failure symptoms have greater LVESVi by CMR than those with no or minimal symptoms. In patients with no or minimal symptoms, CMR quantification of LVESVi and AR severity may identify those at risk of death or incident heart failure and therefore should be considered in the clinical evaluation and decision-making of these patients.
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Affiliation(s)
- Go Hashimoto
- Cardiovascular Imaging Research Center and Core Lab, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Maurice Enriquez-Sarano
- Valve Science Center, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota.,Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Larissa I Stanberry
- Cardiovascular Imaging Research Center and Core Lab, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Felix Oh
- Cardiovascular Imaging Research Center and Core Lab, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Matthew Wang
- Cardiovascular Imaging Research Center and Core Lab, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Keith Acosta
- Cardiovascular Imaging Research Center and Core Lab, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Hirotomo Sato
- Cardiovascular Imaging Research Center and Core Lab, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Bernardo B C Lopes
- Cardiovascular Imaging Research Center and Core Lab, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Miho Fukui
- Cardiovascular Imaging Research Center and Core Lab, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Santiago Garcia
- Valve Science Center, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota.,Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Mario Goessl
- Valve Science Center, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota.,Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Paul Sorajja
- Valve Science Center, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota.,Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Vinayak N Bapat
- Valve Science Center, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota.,Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - John Lesser
- Valve Science Center, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota.,Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - João L Cavalcante
- Cardiovascular Imaging Research Center and Core Lab, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota.,Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
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13
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Vermes E, Iacuzio L, Levy F, Bohbot Y, Renard C, Gerber B, Maréchaux S, Tribouilloy C. Role of Cardiovascular Magnetic Resonance in Native Valvular Regurgitation: A Comprehensive Review of Protocols, Grading of Severity, and Prediction of Valve Surgery. Front Cardiovasc Med 2022; 9:881141. [PMID: 35872899 PMCID: PMC9300884 DOI: 10.3389/fcvm.2022.881141] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 06/07/2022] [Indexed: 11/15/2022] Open
Abstract
Valvular regurgitation is common in developed countries with an increasing prevalence due to the aging of the population and more accurate diagnostic imaging methods. Echocardiography is the gold standard method for the assessment of the severity of valvular heart regurgitation. Nonetheless, cardiovascular magnetic resonance (CMR) has emerged as an additional tool for assessing mainly the severity of aortic and mitral valve regurgitation in the setting of indeterminate findings by echocardiography. Moreover, CMR is a valuable imaging modality to assess ventricular volume and flow, which are useful in the calculation of regurgitant volume and regurgitant fraction of mitral valve regurgitation, aortic valve regurgitation, tricuspid valve regurgitation, and pulmonary valve regurgitation. Notwithstanding this, reference values and optimal thresholds to determine the severity and prognosis of valvular heart regurgitation have been studied lesser by CMR than by echocardiography. Hence, further larger studies are warranted to validate the potential prognostic relevance of the severity of valvular heart regurgitation determined by CMR. The present review describes, analyzes, and discusses the use of CMR to determine the severity of valvular heart regurgitation in clinical practice.
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Affiliation(s)
- Emmanuelle Vermes
- Department of Cardiology, Amiens University Hospital, Amiens, France
- *Correspondence: Emmanuelle Vermes,
| | - Laura Iacuzio
- Department of Cardiology, Center Cardio-Thoracique de Monaco, Monaco, Monaco
| | - Franck Levy
- Department of Cardiology, Center Cardio-Thoracique de Monaco, Monaco, Monaco
| | - Yohann Bohbot
- Department of Cardiology, Amiens University Hospital, Amiens, France
- UR UPJV 7517, Jules Verne University of Picardie, Amiens, France
| | - Cédric Renard
- Department of Radiology, Amiens University Hospital, Amiens, France
| | - Bernhard Gerber
- Division of Cardiology, Department of Cardiovascular Diseases, Cliniques Universitaires St. Luc, Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique (IREC), Université catholique de Louvain, Brussels, Belgium
| | - Sylvestre Maréchaux
- Department of Cardiology, Heart Valve Center, Lille Catholic University Hospital, Lille, France
| | - Christophe Tribouilloy
- Department of Cardiology, Amiens University Hospital, Amiens, France
- UR UPJV 7517, Jules Verne University of Picardie, Amiens, France
- Christophe Tribouilloy,
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14
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The Role of Cardiac Magnetic Resonance in Aortic Stenosis and Regurgitation. J Cardiovasc Dev Dis 2022; 9:jcdd9040108. [PMID: 35448084 PMCID: PMC9030119 DOI: 10.3390/jcdd9040108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 03/23/2022] [Accepted: 03/28/2022] [Indexed: 02/06/2023] Open
Abstract
Cardiac magnetic resonance (CMR) imaging is a well-set diagnostic technique for assessment of valvular heart diseases and is gaining ground in current clinical practice. It provides high-quality images without the administration of ionizing radiation and occasionally without the need of contrast agents. It offers the unique possibility of a comprehensive stand-alone assessment of the heart including biventricular function, left ventricle remodeling, myocardial fibrosis, and associated valvulopathies. CMR is the recognized reference for the quantification of ventricular volumes, mass, and function. A particular strength is the ability to quantify flow, especially with new techniques which allow accurate measurement of stenosis and regurgitation. Furthermore, tissue mapping enables the visualization and quantification of structural changes in the myocardium. In this way, CMR has the potential to yield important prognostic information predicting those patients who will progress to surgery and impact outcomes. In this review, the fundamentals of CMR in assessment of aortic valve diseases (AVD) are described, together with its strengths and weaknesses. This state-of-the-art review provides an updated overview of CMR potentials in all AVD issues, including valve anatomy, flow quantification, ventricular volumes and function, and tissue characterization.
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15
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Lancellotti P, Pibarot P, Chambers J, La Canna G, Pepi M, Dulgheru R, Dweck M, Delgado V, Garbi M, Vannan MA, Montaigne D, Badano L, Maurovich-Horvat P, Pontone G, Vahanian A, Donal E, Cosyns B. Multi-modality imaging assessment of native valvular regurgitation: an EACVI and ESC council of valvular heart disease position paper. Eur Heart J Cardiovasc Imaging 2022; 23:e171-e232. [PMID: 35292799 DOI: 10.1093/ehjci/jeab253] [Citation(s) in RCA: 111] [Impact Index Per Article: 55.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 11/10/2021] [Indexed: 01/10/2023] Open
Abstract
Valvular regurgitation represents an important cause of cardiovascular morbidity and mortality. Imaging is pivotal in the evaluation of native valve regurgitation and echocardiography is the primary imaging modality for this purpose. The imaging assessment of valvular regurgitation should integrate quantification of the regurgitation, assessment of the valve anatomy and function, and the consequences of valvular disease on cardiac chambers. In clinical practice, the management of patients with valvular regurgitation largely relies on the results of imaging. It is crucial to provide standards that aim at establishing a baseline list of measurements to be performed when assessing native valve regurgitation. The present document aims to present clinical guidance for the multi-modality imaging assessment of native valvular regurgitation.
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Affiliation(s)
- Patrizio Lancellotti
- Department of Cardiology, Valvular Disease Clinic, University of Liège Hospital, GIGA Cardiovascular Sciences, CHU Sart Tilman, 4000 Liège, Belgium.,Gruppo Villa Maria Care and Research, Maria Cecilia Hospital, Cotignola, Italy.,Anthea Hospital, Via Camillo Rosalba, 35, Bari, Italy
| | - Philippe Pibarot
- Department of Medicine, Québec Heart & Lung Institute, Laval University, 2725, chemin Sainte-Foy, Québec, Canada
| | - John Chambers
- Emeritus Professor of Clinical Cardiology, Guy's and St Thomas' Hospital, London SE1 7EH, UK
| | - Giovanni La Canna
- Cardiovascular Department, IRCCS Humanitas Clinical and Research Hospital, Applied Diagnostic Echocardiography, 20089 Rozzano, Milan, Italy
| | - Mauro Pepi
- Department of Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy
| | - Raluca Dulgheru
- Department of Cardiology, Valvular Disease Clinic, University of Liège Hospital, GIGA Cardiovascular Sciences, CHU Sart Tilman, 4000 Liège, Belgium
| | - Mark Dweck
- BHF Centre for Cardiovascular Science, University of Edinburgh, Little France Crescent, Edinburgh EH16 4SB, UK
| | - Victoria Delgado
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2 2300 RC Leiden, The Netherlands
| | - Madalina Garbi
- Royal Papworth Hospital, Cambridge University Health Partner, Cambridge Biomedical Campus, CB2 0AY Cambridge, UK
| | - Mani A Vannan
- Marcus Heart Valve Center, Piedmont Heart Institute, Atlanta, GA, USA
| | - David Montaigne
- University of Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1011-EGID, F-59000 Lille, France
| | - Luigi Badano
- Department of Medicine and Surgery, University of Milano-Bicocca, 20089 Milan, Italy.,Department of Cardiac, Metabolic and Neural Sciences, Istituto Auxologico Italiano, IRCCS, 20089 Milan, Italy
| | - Pal Maurovich-Horvat
- MTA-SE Cardiovascular Imaging Research Group, Medical Imaging Centre, Semmelweis University, 1083 Budapest, Hungary
| | | | - Alec Vahanian
- UFR Medecine, Université de Paris, Site Bichat, 16 rue Huchard, 75018 Paris, France.,LVTS INSERM U1148, GH Bichat, 46, rue Henri Huchard, 75018 Paris, France
| | - Erwan Donal
- University of Rennes, CHU Rennes, Inserm, LTSI-UMR 1099, Rennes, France
| | - Bernard Cosyns
- Department of Cardiology, CHVZ (Centrum voor Hart en Vaatziekten), ICMI (In Vivo Cellular and Molecular Imaging) Laboratory, Universitair Ziekenhuis Brussel, 101 Laarbeeklaan, 1090 Brussels, Belgium
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16
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Tower-Rader A, Mathias IS, Obuchowski NA, Kocyigit D, Kumar Y, Donnellan E, Bolen M, Phelan D, Flamm S, Griffin B, Cho L, Svensson LG, Pettersson G, Popovic Z, Kwon D. Sex-based differences in left ventricular remodeling in patients with chronic aortic regurgitation: a multi-modality study. J Cardiovasc Magn Reson 2022; 24:12. [PMID: 35193584 PMCID: PMC8862390 DOI: 10.1186/s12968-022-00845-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 01/16/2022] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Significant aortic regurgitation (AR) leads to left ventricular (LV) remodeling; however, little data exist regarding sex-based differences in LV remodeling in this setting. We sought to compare LV remodeling and AR severity, assessed by echocardiography and cardiovascular magnetic resonance (CMR), to discern sex-based differences. METHODS Patients with ≥ moderate chronic AR by echocardiography who underwent CMR within 90 days between December 2005 and October 2015 were included. Nonlinear regression models were built to assess the effect of AR regurgitant fraction (RF) on LV remodeling. A generalized linear model and Bland Altman analyses were constructed to evaluate differences between CMR and echocardiography. Referral for surgical intervention based on symptoms and LV remodeling was evaluated. RESULTS Of the 243 patients (48.3 ± 16.6 years, 58 (24%) female), 119 (49%) underwent surgical intervention with a primary indication of severe AR, 97 (82%) men, 22 (18%) women. Significant sex differences in LV remodeling emerged on CMR. Women demonstrated significantly smaller LV end-diastolic volume index (LVEDVI) (96.8 ml/m2 vs 125.6 ml/m2, p < 0.001), LV end-systolic volume index (LVESVI) (41.1 vs 54.5 ml/m2, p < 0.001), blunted LV dilation in the setting of increasing AR severity (LVEDVI p value < 0.001, LVESVI p value 0.011), and LV length indexed (8.32 vs 9.69 cm, p < 0.001). On Bland Altman analysis, a significant interaction with sex and LV diameters was evident, demonstrating a significant increase in the difference between CMR and echocardiography measurements as the LV enlarged in women: LVEDVI (p = 0.006), LVESVI (p < 0.001), such that echocardiographic measurements increasingly underestimated LV diameters in women as the LV enlarged. LV length was higher for males with a linear effect from RF (p < 0.001), with LV length increasing at a higher rate with increasing RF for males compared to females (two-way interaction with sex p = 0.005). Sphericity volume index was higher for men after adjusting for a relative wall thickness (p = 0.033). CONCLUSIONS CMR assessment of chronic AR revealed significant sex differences in LV remodeling and significant echocardiographic underestimation of LV dilation, particularly in women. Defining optimal sex-based CMR thresholds for surgical referral should be further developed. TRIAL REGISTRATION NA.
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Affiliation(s)
- Albree Tower-Rader
- Department of Cardiology, Harvard Medical School, Massachusetts General Hospital, 55 Fruit St, Yawkey 5B, Boston, MA, 02114, USA
| | - Isadora Sande Mathias
- Department of Cardiology, Houston Methodist Hospital, Weill Cornell Medical College, 6565 Fannin St., Houston, TX, 77030, USA
| | - Nancy A Obuchowski
- Quantitative Health Sciences, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
| | - Duygu Kocyigit
- Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
| | - Yash Kumar
- Case Western University, 10900 Euclid Ave, Cleveland, OH, 44106-7017, USA
| | - Eoin Donnellan
- Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
| | - Michael Bolen
- Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
| | - Dermot Phelan
- Sanger Heart & Vascular Institute, Atrium Health, 1237 Harding Place, MOB1 Suite 5000, Charlotte, NC, 28204, USA
| | - Scott Flamm
- Imaging Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
| | - Brian Griffin
- Imaging Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
| | - Leslie Cho
- Imaging Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
| | - Lars G Svensson
- Imaging Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
| | - Gosta Pettersson
- Imaging Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
| | - Zoran Popovic
- Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
- Imaging Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA
| | - Deborah Kwon
- Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Ave, J1-5, Cleveland, OH, 44195, USA.
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17
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Latifi AN, Ortiz J, Cunningham JW, McGregor PC, Aragam J. Early Identification of Decompensated Aortic Regurgitation With Stress Echocardiography. CASE (PHILADELPHIA, PA.) 2021; 5:403-407. [PMID: 34993372 PMCID: PMC8712953 DOI: 10.1016/j.case.2021.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
•Chronic severe AR progresses slowly with a long asymptomatic compensated phase.•Stress echocardiography (SE) has the ability to uncover subclinical LV dysfunction.•SE can identify patients with severe AR who may benefit from earlier intervention.
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Affiliation(s)
- Ahmad N. Latifi
- Cardiovascular Division, Boston Medical Center, Boston, Massachusetts
- Department of Cardiology, Boston Veterans Affairs Healthcare System, West Roxbury, Massachusetts
| | - Jake Ortiz
- Department of Cardiology, Boston Veterans Affairs Healthcare System, West Roxbury, Massachusetts
| | - Jonathan W. Cunningham
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Pei-Chun McGregor
- Department of Cardiology, Boston Veterans Affairs Healthcare System, West Roxbury, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Jayashri Aragam
- Department of Cardiology, Boston Veterans Affairs Healthcare System, West Roxbury, Massachusetts
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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18
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Kim K, Kim DY, Seo J, Cho I, Hong GR, Ha JW, Shim CY. Temporal Trends in Diagnosis, Treatments, and Outcomes in Patients With Bicuspid Aortic Valve. Front Cardiovasc Med 2021; 8:766430. [PMID: 34805321 PMCID: PMC8599961 DOI: 10.3389/fcvm.2021.766430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Accepted: 10/13/2021] [Indexed: 11/13/2022] Open
Abstract
Background: The population is aging and advances in multimodal imaging and transcatheter valve intervention have been prominent in the past two decades. This study investigated temporal trends in demographic characteristics, use of multimodal imaging, treatments, and outcomes in patients with bicuspid aortic valve (BAV). Methods and Results: A total of 1,497 patients (male 71.7%, 57 ± 14 years old) first diagnosed with BAV between January 2003 and December 2020, in a single tertiary center were divided into three groups according to year of diagnosis: group 1 (2003-2008, n = 269), group 2 (2009-2014, n = 594), and group 3 (2015-2020, n = 634). The patients' demographic characteristics, comorbidities, BAV morphology, BAV function, BAV-related disease, use of multimodal diagnostic imaging, treatment modality for BAV, and clinical outcomes were compared among the three groups. The ages at diagnosis and at the time of surgery/intervention increased considerably from group 1 to 3. The patients' comorbidity index also increased progressively. The proportion of non-dysfunctional BAV and significant AS increased, while that of significant AR decreased. The frequency of infective endocarditis as an initial presentation significantly decreased over time. Additionally, the use of multimodal imaging increased markedly in the most recent group. The results also indicated increasing trends in the use of bioprosthetic valves and transcatheter aortic valve replacement. Overall and cardiovascular survival rates improved from group 1 to 3 (log rank p < 0.001). Conclusions: For the past two decades, remarkable temporal changes have occurred in patient characteristics, use of multimodal diagnostic imaging, choice of treatment modality, and clinical outcomes in patients with BAV.
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Affiliation(s)
- Kyu Kim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Dae-Young Kim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Jiwon Seo
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Iksung Cho
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Geu-Ru Hong
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Jong-Won Ha
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Chi Young Shim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
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Malahfji M, Senapati A, Tayal B, Nguyen DT, Graviss EA, Nagueh SF, Reardon MJ, Quinones M, Zoghbi WA, Shah DJ. Myocardial Scar and Mortality in Chronic Aortic Regurgitation. J Am Heart Assoc 2020; 9:e018731. [PMID: 33241753 PMCID: PMC7763777 DOI: 10.1161/jaha.120.018731] [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] [Indexed: 12/26/2022]
Abstract
Background Chronic aortic regurgitation (AR) can be associated with myocardial scarring. It is unknown if scarring in AR is linked to poor outcomes and whether aortic valve replacement impacts this association. We investigated the relationship of myocardial scarring to mortality in chronic AR using cardiac magnetic resonance. Methods and Results We enrolled patients with moderate or greater AR between 2009 and 2019 and performed a blinded assessment of left ventricle remodeling, AR severity, and presence and extent of myocardial scarring by late gadolinium enhancement. The primary outcome was all‐cause mortality. We followed 392 patients (median age 62 [interquartile range, 51–71] years), and 78.1% were men, and 25.8% had bicuspid valves. Median aortic valve regurgitant volume was 39 mL (interquartile range, 30–60). Myocardial scar was present in 131 (33.4%) patients. Aortic valve replacement was performed in 165 (49.1%) patients. During follow‐up, up to 10.8 years (median 32.3 months [interquartile range, 9.8–69.5]), 51 patients (13%) died. Presence of myocardial scar (hazard ratio [HR], 3.62; 95% CI, 2.06–6.36; P<0.001), infarction scar (HR, 4.94; 95% CI, 2.58–9.48; P<0.001), and noninfarction scar (HR, 2.75; 95% CI, 1.39–5.44; P<0.004) were associated with mortality. In multivariable analysis, the presence of scar remained independently associated with death (HR, 2.53; 95% CI, 1.15–5.57; P=0.02). Among patients with myocardial scar, aortic valve replacement was independently associated with a lower risk of mortality (HR, 0.34; 95% CI, 0.12–0.97; P=0.03), even after adjustment for confounders. Conclusions In aortic regurgitation, myocardial scar is independently associated with a 2.5‐fold increase risk in mortality. Aortic valve replacement was associated with a reduction in risk of mortality in patients with scarring.
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Affiliation(s)
- Maan Malahfji
- Houston Methodist DeBakey Heart & Vascular Center Houston TX
| | - Alpana Senapati
- Houston Methodist DeBakey Heart & Vascular Center Houston TX
| | - Bhupendar Tayal
- Houston Methodist DeBakey Heart & Vascular Center Houston TX
| | - Duc T Nguyen
- Department of Pathology and Genomic Medicine Houston Methodist Hospital Research Institute Houston TX
| | - Edward A Graviss
- Department of Pathology and Genomic Medicine Houston Methodist Hospital Research Institute Houston TX
| | - Sherif F Nagueh
- Houston Methodist DeBakey Heart & Vascular Center Houston TX
| | | | - Miguel Quinones
- Houston Methodist DeBakey Heart & Vascular Center Houston TX
| | | | - Dipan J Shah
- Houston Methodist DeBakey Heart & Vascular Center Houston TX
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