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Bitar ZI, Maadarani O, Dashti H, Alenezi A, Almerri K. A prospective analysis of the correlation between ultrasonic B-lines, cardiac tissue doppler signals and left ventricular end-diastolic pressure in patients with severe aortic stenosis. Echo Res Pract 2024; 11:21. [PMID: 39129021 PMCID: PMC11318176 DOI: 10.1186/s44156-024-00055-y] [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: 07/05/2023] [Accepted: 07/02/2024] [Indexed: 08/13/2024] Open
Abstract
BACKGROUND The development of heart failure is a turning point in the natural course of aortic stenosis (AS). Pulmonary oedema and elevated left ventricular pressure (LVP) are cardinal features of heart failure. Evaluating pulmonary oedema by lung ultrasound involves taking the upper hand with a bedside noninvasive tool that may reflect LVP. AIM We sought to assess the correlation between sonographic pulmonary congestion, invasive LV pre-A pressure, and echocardiographic LV end-diastolic pressure (LVEDP) in symptomatic AS patients receiving transcatheter aortic valve replacement. METHODS Forty-eight consecutive patients with severe AS and planned transcatheter aortic valve implantation (TAVI) were enrolled. LVEDP was estimated to be normal or elevated using the ASE/EACVI algorithm and transmitral Doppler indices, the E/A ratio, the E/e', and the left atrial volume index. Invasive LV pre-A pressure was used as a reference, with > 12 mm Hg defined as elevated. RESULTS Forty-eight patients (25 women (52%), mean age 75 years, standard deviation (SD) ± 7.7 years) were enrolled in the study. We detected severe B-lines (≥ 30) in 13 (27%) patients and moderate B-lines (15-30) in 33 (68.6%) patients. The number of B-lines increased significantly with the severity of New York Heart Association (NYHA) functional classes (Fig. 1). The B-line count was 14 ± 13 in NYHA class I patients, 20 ± 20 in class II patients, and 44 ± 35 in class III patients (p < 0.05, rho = 0.384). The number of B-lines was correlated with the E/E' ratio (R = 0.664, p < 0.0001) and the proBNP level (R = 0. 882, p < 0.008). We found no significant correlation with the LVEDP or LVEF. The LVEDP correlated well with the E/E' ratio (R = 0.491, p < 0.001) but not at all with E/A, DT, or LAVI. All patients had an elevated LVEDP > 12, with a mean pressure of 26 mmHg, a minimum of 13 mmHg, and a maximum of 45 mmHg, with an SD of 7.85. CONCLUSION Assessing lung ultrasonic B-lines is a straightforward and practical approach to identifying pulmonary oedema in AS patients. The number of B-lines correlated with the E/E' ratio and the functional status of patients but did not correlate with invasive LVEDP or LVEF. All patients had elevated LVEDP that correlated with E/E'.
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Affiliation(s)
- Zouheir Ibrahim Bitar
- Consultant critical care medicine Internal medicine department Ahmadi hospital, Ahmadi, Kuwait.
- Critical care Unit, Ahmadi hospital, Fahahil, 64015, Kuwait.
| | - Ossama Maadarani
- Critical care Unit, Ahmadi hospital Kuwait oil company, Ahmadi, Kuwait
| | - Hussien Dashti
- Consultant internal medicine Internal medicine department, Ahmadi hospital, Ahmadi, Kuwait
| | - Abdullah Alenezi
- Consultant interventional cardiology Cardiology depart, Chest Hospital, Shuwaikh, Kuwait
| | - Khaled Almerri
- Department of Cardiology, Chest Disease Hospital, Shuwaikh, Kuwait
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Lee SH, Yoon SJ, Sun BJ, Kim HM, Kim HY, Lee S, Shim CY, Kim EK, Cho DH, Park JB, Seo JS, Son JW, Kim IC, Lee SH, Heo R, Lee HJ, Park JH, Song JM, Lee SC, Kim H, Kang DH, Ha JW, Kim KH. 2023 Korean Society of Echocardiography position paper for diagnosis and management of valvular heart disease, part I: aortic valve disease. J Cardiovasc Imaging 2024; 32:11. [PMID: 39061115 PMCID: PMC11282617 DOI: 10.1186/s44348-024-00019-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 11/24/2023] [Indexed: 07/28/2024] Open
Abstract
This manuscript represents the official position of the Korean Society of Echocardiography on valvular heart diseases. This position paper focuses on the clinical management of valvular heart diseases with reference to the guidelines recently published by the American College of Cardiology/American Heart Association and the European Society of Cardiology. The committee tried to reflect the recently published results on the topic of valvular heart diseases and Korean data by a systematic literature search based on validity and relevance. In part I of this article, we will review and discuss the current position of aortic valve disease in Korea.
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Affiliation(s)
- Sun Hwa Lee
- Division of Cardiology, Department of Internal Medicine, Jeonbuk National University Medical School, Jeonbuk National University Hospital, Jeonju, Republic of Korea
| | - Se-Jung Yoon
- Division of Cardiology, National Health Insurance Service Ilsan Hospital, Goyang, Republic of Korea
| | - Byung Joo Sun
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hyue Mee Kim
- Division of Cardiology, Department of Internal Medicine, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Republic of Korea
| | - Hyung Yoon Kim
- Department of Cardiovascular Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Sahmin Lee
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Chi Young Shim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Eun Kyoung Kim
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Heart Vascular Stroke Institute, Samsung Medical Center, Seoul, Republic of Korea
| | - Dong-Hyuk Cho
- Division of Cardiology, Department of Internal Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Jun-Bean Park
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jeong-Sook Seo
- Division of Cardiology, Department of Internal Medicine, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Jung-Woo Son
- Division of Cardiology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - In-Cheol Kim
- Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
| | - Sang-Hyun Lee
- Division of Cardiology, Pusan National Yangsan Hospital, Pusan National University School of Medicine, Busan, Republic of Korea
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National Yangsan Hospital, Busan, Republic of Korea
| | - Ran Heo
- Division of Cardiology, Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Hyun-Jung Lee
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jae-Hyeong Park
- Division of Cardiology, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Republic of Korea
- Regional Cardiocerebrovascular Center, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Jong-Min Song
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang-Chol Lee
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Heart Vascular Stroke Institute, Samsung Medical Center, Seoul, Republic of Korea
| | - Hyungseop Kim
- Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
| | - Duk-Hyun Kang
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jong-Won Ha
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kye Hun Kim
- Department of Cardiovascular Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea.
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Salem M, Gada H, Ramlawi B, Sotelo M, Nona P, Wagner L, Rogers C, Brigman L, Vora AN. Predictors of Disease Progression and Adverse Clinical Outcomes in Patients With Moderate Aortic Stenosis Using an Artificial Intelligence-Based Software Platform. Am J Cardiol 2024; 223:92-99. [PMID: 38710350 DOI: 10.1016/j.amjcard.2024.04.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 03/18/2024] [Accepted: 04/26/2024] [Indexed: 05/08/2024]
Abstract
Patients with moderate aortic stenosis (AS) have a greater risk of adverse clinical outcomes than that of the general population. How this risk compares with those with severe AS, along with factors associated with outcomes and disease progression, is less clear. We analyzed serial echoes (from 2017 to 2019) from a single healthcare system using Tempus Next (Chicago, Illinois) software. AS severity was defined according to American Heart Association/American College of Cardiology guidelines. Outcomes of interest included death or heart failure hospitalization. We used Cox proportional hazards models and logistic regression to identify predictors of clinical outcome and disease progression, respectively. From 82,805 echoes for 61,546 patients, 1,770; 914; 565; and 1,463 patients had no, mild, moderate, or severe AS, respectively. Both patients with moderate and those with severe AS experienced a similar prevalence of adverse clinical outcomes (p = 0.45) that was significantly greater than that of patients without AS (p <0.01). In patients with moderate AS, atrial fibrillation (hazard ratio 3.29, 95% confidence interval 1.79 to 6.02, p <0.001) and end-stage renal disease (hazard ratio 3.34, 95% confidence interval 1.87 to 5.95, p <0.001) were associated with adverse clinical outcomes. One-third of patients with moderate AS with a subsequent echo (139/434) progressed to severe AS within 1 year. In conclusion, patients with moderate AS can progress rapidly to severe AS and experience a similar risk of adverse clinical outcomes; predictors include atrial fibrillation and low left ventricular ejection fraction. Machine learning algorithms may help identify these patients. Whether these patients may warrant earlier intervention merits further study.
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Affiliation(s)
- Mahmoud Salem
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Harrisburg, Pennsylvania.
| | - Hemal Gada
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Harrisburg, Pennsylvania
| | - Basel Ramlawi
- Department of Cardiothoracic Surgery, Lankenau Heart Institute, Philadelphia, Pennsylvania
| | | | | | | | | | | | - Amit N Vora
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Harrisburg, Pennsylvania; Department of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
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Caprio MV, De Donno F, Bisaccia G, Mantini C, Di Baldassarre A, Gallina S, Khanji MY, Ricci F. Moderate aortic stenosis: Navigating the uncharted. Echocardiography 2024; 41:e15859. [PMID: 38853624 DOI: 10.1111/echo.15859] [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: 03/16/2024] [Revised: 05/18/2024] [Accepted: 05/25/2024] [Indexed: 06/11/2024] Open
Abstract
Aortic stenosis (AS) stands as the most common valvular heart disease in developed countries and is characterized by progressive narrowing of the aortic valve orifice resulting in elevated transvalvular flow resistance, left ventricular hypertrophy, and progressive increased risk of heart failure and sudden death. This narrative review explores clinical challenges and evolving perspectives in moderate AS, where discrepancies between aortic valve area and pressure gradient measurements may pose diagnostic and therapeutic quandaries. Transthoracic echocardiography is the first-line imaging modality for AS evaluation, yet cases of discordance may require the application of ancillary noninvasive diagnostic modalities. This review underscores the importance of accurate grading of AS severity, especially in low-gradient phenotypes, emphasizing the need for vigilant follow-up. Current clinical guidelines primarily recommend aortic valve replacement for severe AS, potentially overlooking latent risks in moderate disease stages. The noninvasive multimodality imaging approach-including echocardiography, cardiac magnetic resonance, computed tomography, and nuclear techniques-provides unique insights into adaptive and maladaptive cardiac remodeling in AS and offers a promising avenue to deliver precise indications and exact timing for intervention in moderate AS phenotypes and asymptomatic patients, potentially improving long-term outcomes. Nevertheless, what we may have gleaned from a large amount of observational data is still insufficient to build a robust framework for clinical decision-making in moderate AS. Future research will prioritize randomized clinical trials designed to weigh the benefits and risks of preemptive aortic valve replacement in the management of moderate AS, as directed by specific imaging and nonimaging biomarkers.
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Affiliation(s)
- Maria Vittoria Caprio
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University of Chieti-Pescara, Chieti, Italy
- SS Annunziata Polyclinic University Hospital, University Cardiology Division, Chieti, Italy
| | - Federica De Donno
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University of Chieti-Pescara, Chieti, Italy
- SS Annunziata Polyclinic University Hospital, University Cardiology Division, Chieti, Italy
| | - Giandomenico Bisaccia
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University of Chieti-Pescara, Chieti, Italy
| | - Cesare Mantini
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University of Chieti-Pescara, Chieti, Italy
| | - Angela Di Baldassarre
- Department of Medicine and Aging Sciences, and Reprogramming and Cell Differentiation Lab, Center for Advanced Studies and Technology (CAST), G. D'Annunzio University of Chieti-Pescara, Chieti, Italy
| | - Sabina Gallina
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University of Chieti-Pescara, Chieti, Italy
- SS Annunziata Polyclinic University Hospital, University Cardiology Division, Chieti, Italy
| | - Mohammed Y Khanji
- Newham University Hospital, Barts Health NHS Trust, Plaistow, London, UK
- Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, UK
- NIHR Barts Biomedical Research Centre, William Harvey Research Institute, Queen Mary University, London, UK
| | - Fabrizio Ricci
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University of Chieti-Pescara, Chieti, Italy
- SS Annunziata Polyclinic University Hospital, University Cardiology Division, Chieti, Italy
- Department of Clinical Sciences, Lund University, Malmö, Sweden
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Leitman M, Daoud M, Tyomkin V, Fuchs S. The Flow Rate in Patients With Low-Gradient Aortic Stenosis. Cureus 2024; 16:e60776. [PMID: 38903309 PMCID: PMC11188971 DOI: 10.7759/cureus.60776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/19/2024] [Indexed: 06/22/2024] Open
Abstract
PURPOSE The decision to assess the severity and determine the ideal timing of intervention for low-gradient aortic stenosis poses a greater challenge. Recently, a novel method for determining the flow status of patients with aortic stenosis has been introduced, utilizing flow rate measurements. In this study, we investigated whether the flow status of patients with low-gradient aortic stenosis is linked to mortality within a three-year timeframe. METHODS Twenty-nine patients diagnosed with low-gradient aortic stenosis and valve area ≤ 1 cm were identified during 2010-2015. Each patient's flow rate across the aortic valve was computed, and the study scrutinized echocardiographic parameters to ascertain their correlation with mortality over a three-year timeframe. RESULTS We observed that among patients with low-gradient aortic stenosis and a valve area of ≤1 cm, a decreased flow rate across the aortic valve emerged as an independent predictor of mortality. A flow rate < 210 ml/s was linked with a three-year mortality rate of 66.7%, whereas a low stroke volume index < 35 ml/m² did not show an association with three-year mortality. This observation might be attributed to the smaller body sizes prevalent among these older patients, particularly females, which could influence the calculation of the stroke volume index. CONCLUSION In older patients with low-gradient aortic stenosis, the flow rate can better reflect flow status than the stroke volume index, and it also suggests a prognostic significance in predicting mortality. Additional studies are warranted to validate these findings across broader patient populations and to assess the potential efficacy of early intervention strategies in this particular patient cohort.
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Affiliation(s)
- Marina Leitman
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, ISR
- Cardiology, Shamir Medical Center, Zerifin, ISR
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Moumneh MB, Damluji AA, Heslop AW, Sherwood MW. Structural heart disease review of TAVR in low-risk patients: importance of lifetime management. Front Cardiovasc Med 2024; 11:1362791. [PMID: 38495939 PMCID: PMC10941982 DOI: 10.3389/fcvm.2024.1362791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 02/19/2024] [Indexed: 03/19/2024] Open
Affiliation(s)
| | | | | | - Matthew W. Sherwood
- Inova Center of Outcomes Research, Inova Heart and Vascular Institute, Fairfax, VA, United States
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Weingarten N, Rekhtman D, Iyengar A, Song C, Patel M, Atluri P. Aortic valve replacement for moderate aortic stenosis during mitral surgery improves survival free from severe stenosis. Asian Cardiovasc Thorac Ann 2023; 31:475-482. [PMID: 37415529 DOI: 10.1177/02184923231186850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/08/2023]
Abstract
BACKGROUND Optimal management of moderate aortic stenosis during surgery for another indication is unclear. We assessed the effects of surgical aortic valve replacement for moderate aortic stenosis during mitral surgery. METHODS An institutional mitral surgery database was queried for patients with preoperative moderate aortic stenosis. Patients were stratified by whether they underwent concomitant surgical aortic valve replacement. Morbidity was analyzed using Student's t tests, Wilcoxon rank sum, chi-squared, and Fisher's exact tests. Survival was analyzed using Kaplan-Meier estimation and Cox regression. RESULTS Of 85 mitral surgery recipients with moderate aortic stenosis from 2012 to 2019, 62 (73%) underwent concomitant surgical aortic valve replacement. Surgical aortic valve replacement recipients were more likely to have bicuspid (11% vs. 0%, p = 0.019) or rheumatic (18% vs. 0%, p = 0.019) aortic valves, and to undergo mitral repair (32% vs. 9%, p = 0.028). Groups did not differ with respect to mitral etiology, New York Heart Association class, or cardiac intervention history (p > 0.05). Postoperatively, groups had similar stroke and gastrointestinal bleed rates (3% vs. 0% and 2% vs. 0% in the surgical aortic valve replacement vs. no surgical aortic valve replacement group respectively, both p > 0.99). Five-year survival free from severe aortic stenosis was higher in the surgical aortic valve replacement group (66% vs. 17%, p = 0.002). Surgical aortic valve replacement protected against the composite of death and progression to severe aortic stenosis at 5 years (hazard ratio: 0.32, p = 0.003). CONCLUSIONS Surgical aortic valve replacement for moderate aortic stenosis at time of mitral surgery is a well-tolerated strategy to reduce aortic disease progression.
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Affiliation(s)
- Noah Weingarten
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - David Rekhtman
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Amit Iyengar
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Cindy Song
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Mrinal Patel
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Pavan Atluri
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
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Strange G, Stewart S, Watts A, Playford D. Enhanced detection of severe aortic stenosis via artificial intelligence: a clinical cohort study. Open Heart 2023; 10:e002265. [PMID: 37491129 PMCID: PMC10373677 DOI: 10.1136/openhrt-2023-002265] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 06/30/2023] [Indexed: 07/27/2023] Open
Abstract
OBJECTIVE We developed an artificial intelligence decision support algorithm (AI-DSA) that uses routine echocardiographic measurements to identify severe aortic stenosis (AS) phenotypes associated with high mortality. METHODS 631 824 individuals with 1.08 million echocardiograms were randomly spilt into two groups. Data from 442 276 individuals (70%) entered a Mixture Density Network (MDN) model to train an AI-DSA to predict an aortic valve area <1 cm2, excluding all left ventricular outflow tract velocity or dimension measurements and then using the remainder of echocardiographic measurement data. The optimal probability threshold for severe AS detection was identified at the f1 score probability of 0.235. An automated feature also ensured detection of guideline-defined severe AS. The AI-DSA's performance was independently evaluated in 184 301 (30%) individuals. RESULTS The area under receiver operating characteristic curve for the AI-DSA to detect severe AS was 0.986 (95% CI 0.985 to 0.987) with 4622/88 199 (5.2%) individuals (79.0±11.9 years, 52.4% women) categorised as 'high-probability' severe AS. Of these, 3566 (77.2%) met guideline-defined severe AS. Compared with the AI-derived low-probability AS group (19.2% mortality), the age-adjusted and sex-adjusted OR for actual 5-year mortality was 2.41 (95% CI 2.13 to 2.73) in the high probability AS group (67.9% mortality)-5-year mortality being slightly higher in those with guideline-defined severe AS (69.1% vs 64.4%; age-adjusted and sex-adjusted OR 1.26 (95% CI 1.04 to 1.53), p=0.021). CONCLUSIONS An AI-DSA can identify the echocardiographic measurement characteristics of AS associated with poor survival (with not all cases guideline defined). Deployment of this tool in routine clinical practice could improve expedited identification of severe AS cases and more timely referral for therapy.
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Affiliation(s)
- Geoff Strange
- Cardiology, Heart Research Institute Ltd, Newtown, New South Wales, Australia
- The University of Notre Dame Australia, School of Medicine, Fremantle, Western Australia, Australia
| | - Simon Stewart
- Institute for Health Research, The University of Notre Dame Australia, Fremantle, Western Australia, Australia
- School of Medicine, Dentistry & Nursing, University of Glasgow, Glasgow, UK
| | - Andrew Watts
- Echo IQ Pty Ltd, Sydney, New South Wales, Australia
| | - David Playford
- School of Medicine, The University of Notre Dame Australia, Fremantle, Western Australia, Australia
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Stewart S, Afoakwah C, Chan YK, Strom JB, Playford D, Strange GA. Counting the cost of premature mortality with progressively worse aortic stenosis in Australia: a clinical cohort study. THE LANCET. HEALTHY LONGEVITY 2022; 3:e599-e606. [PMID: 36102774 PMCID: PMC9484033 DOI: 10.1016/s2666-7568(22)00168-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 06/26/2022] [Accepted: 06/28/2022] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Aortic stenosis is the most common cardiac valve disorder requiring clinical management. However, there is little evidence on the societal cost of progressive aortic stenosis. We sought to quantify the societal burden of premature mortality associated with progressively worse aortic stenosis. METHODS In this observational clinical cohort study, we examined echocardiograms on native aortic valves of 98 565 men and 99 357 women aged 65 years or older across 23 sites in Australia, from Jan 1, 2003, to Dec 31, 2017. Individuals were grouped according to their peak aortic valve velocity in 0·50 m/s increments up to 4·00 m/s or more (severe aortic stenosis), using 1·00-1·99 m/s (no aortic stenosis) as the reference group. Sex-specific premature mortality and years of life lost during a 5-year follow-up were calculated, along with willingness-to-pay to regain quality-adjusted life years (QALYs). FINDINGS Overall, 20 701 (21·0%) men and 18 576 (18·7%) women had evidence of mild-to-severe aortic stenosis. The actual 5-year mortality in men with normal aortic valves was 32·1% and in women was 26·1%, increasing to 40·9% (mild aortic stenosis) and 52·2% (severe aortic stenosis) in men and to 35·9% (mild aortic stenosis) and 55·3% (severe aortic stenosis) in women. Overall, the estimated societal cost of premature mortality associated with aortic stenosis was AU$629 million in men and $735 million in women. Per 1000 men and women investigated, aortic stenosis was associated with eight more premature deaths in men resulting in 32·5 more QALYs lost (societal cost of $1·40 million) and 12 more premature deaths in women resulting in 57·5 more QALYs lost (societal cost of $2·48 million) when compared with those without aortic stenosis. INTERPRETATION Any degree of aortic stenosis in older individuals is associated with premature mortality and QALYs. In this context, there is a crucial need for cost-effective strategies to promptly detect and optimally manage this common condition within our ageing populations. FUNDING Edwards LifeSciences, National Health and Medical Research Council of Australia, and the National Heart, Lung, and Blood Institute.
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Affiliation(s)
- Simon Stewart
- Institute for Health Research, University of Notre Dame Australia, Fremantle, WA, Australia; School of Medicine, Dentistry & Nursing, University of Glasgow, Glasgow, UK; Menzies Health Institute Queensland, Griffith University, Gold Coast, QLD, Australia
| | - Clifford Afoakwah
- Centre for Applied Health Economics, Griffith University, Brisbane, QLD, Australia; Menzies Health Institute Queensland, Griffith University, Gold Coast, QLD, Australia; Torrens University Australia, Adelaide, SA, Australia
| | - Yih-Kai Chan
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, VIC, Australia
| | - Jordan B Strom
- Richard A And Susan F Smith Centre for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Centre, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - David Playford
- Institute for Health Research, University of Notre Dame Australia, Fremantle, WA, Australia
| | - Geoffrey A Strange
- Institute for Health Research, University of Notre Dame Australia, Fremantle, WA, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
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Rizzi S, Ragazzini S, Pesce M. Engineering Efforts to Refine Compatibility and Duration of Aortic Valve Replacements: An Overview of Previous Expectations and New Promises. Front Cardiovasc Med 2022; 9:863136. [PMID: 35509271 PMCID: PMC9058060 DOI: 10.3389/fcvm.2022.863136] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 03/28/2022] [Indexed: 01/18/2023] Open
Abstract
The absence of pharmacological treatments to reduce or retard the progression of cardiac valve diseases makes replacement with artificial prostheses (mechanical or bio-prosthetic) essential. Given the increasing incidence of cardiac valve pathologies, there is always a more stringent need for valve replacements that offer enhanced performance and durability. Unfortunately, surgical valve replacement with mechanical or biological substitutes still leads to disadvantages over time. In fact, mechanical valves require a lifetime anticoagulation therapy that leads to a rise in thromboembolic complications, while biological valves are still manufactured with non-living tissue, consisting of aldehyde-treated xenograft material (e.g., bovine pericardium) whose integration into the host fails in the mid- to long-term due to unresolved issues regarding immune-compatibility. While various solutions to these shortcomings are currently under scrutiny, the possibility to implant fully biologically compatible valve replacements remains elusive, at least for large-scale deployment. In this regard, the failure in translation of most of the designed tissue engineered heart valves (TEHVs) to a viable clinical solution has played a major role. In this review, we present a comprehensive overview of the TEHVs developed until now, and critically analyze their strengths and limitations emerging from basic research and clinical trials. Starting from these aspects, we will also discuss strategies currently under investigation to produce valve replacements endowed with a true ability to self-repair, remodel and regenerate. We will discuss these new developments not only considering the scientific/technical framework inherent to the design of novel valve prostheses, but also economical and regulatory aspects, which may be crucial for the success of these novel designs.
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Affiliation(s)
- Stefano Rizzi
- Tissue Engineering Unit, Centro Cardiologico Monzino, Istituto di ricovero e cura a carattere scientifico (IRCCS), Milan, Italy
- Department of Chemistry, Materials and Chemical Engineering “Giulio Natta”, Politecnico di Milano, Milan, Italy
- Stefano Rizzi
| | - Sara Ragazzini
- Tissue Engineering Unit, Centro Cardiologico Monzino, Istituto di ricovero e cura a carattere scientifico (IRCCS), Milan, Italy
| | - Maurizio Pesce
- Tissue Engineering Unit, Centro Cardiologico Monzino, Istituto di ricovero e cura a carattere scientifico (IRCCS), Milan, Italy
- *Correspondence: Maurizio Pesce
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Bernava G, Fermi E, Gelpi G, Rizzi S, Benettin D, Barbuto M, Romagnoni C, Ventrella D, Palmieri MC, Agrifoglio M, Polvani G, Bacci ML, Pasquino E, Pesce M. Lithotripsy of Calcified Aortic Valve Leaflets by a Novel Ultrasound Transcatheter-Based Device. Front Cardiovasc Med 2022; 9:850393. [PMID: 35402526 PMCID: PMC8990875 DOI: 10.3389/fcvm.2022.850393] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 02/21/2022] [Indexed: 11/13/2022] Open
Abstract
The increasing incidence of calcific aortic valve disease necessitates the elaboration of new strategies to retard the progression of the pathology with an innovative solution. While the increasing diffusion of the transcatheter aortic valve replacements (TAVRs) allows a mini-invasive approach to aortic valve substitution as an alternative to conventional surgical replacement (SAVR) in an always larger patient population, TAVR implantation still has contraindications for young patients. In addition, it is liable to undergo calcification with the consequent necessity of re-intervention with conventional valve surgery or repeated implantation in the so-called TAVR-in-TAVR procedure. Inspired by applications for non-cardiac pathologies or for vascular decalcification before stenting (i.e., coronary lithotripsy), in the present study, we show the feasibility of human valve treatment with a mini-invasive device tailored to deliver shockwaves to the calcific leaflets. We provide evidence of efficient calcium deposit ruptures in human calcified leaflets treated ex vivo and the safety of the treatment in pigs. The use of this device could be helpful to perform shockwaves valvuloplasty as an option to retard TAVR/SAVR, or as a pretreatment to facilitate prosthesis implantation and minimize the occurrence of paravalvular leak.
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Affiliation(s)
- Giacomo Bernava
- Unità di Ingegneria Tissutale Cardiovascolare, Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Enrico Fermi
- AorticLab S.r.l., Bioindustry Park, Colleretto Giacosa, Italy
| | | | - Stefano Rizzi
- Unità di Ingegneria Tissutale Cardiovascolare, Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Davide Benettin
- AorticLab S.r.l., Bioindustry Park, Colleretto Giacosa, Italy
| | - Marianna Barbuto
- Unità di Ingegneria Tissutale Cardiovascolare, Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | | | | | | | | | | | | | - Enrico Pasquino
- AorticLab S.r.l., Bioindustry Park, Colleretto Giacosa, Italy
| | - Maurizio Pesce
- Unità di Ingegneria Tissutale Cardiovascolare, Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
- *Correspondence: Maurizio Pesce
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12
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Chew NWS, Zhang A, Ong J, Koh S, Kong G, Ho YJ, Lim O, Chin YH, Lin C, Djohan A, Kuntjoro I, Kong WKF, Hon J, Lee CH, Chan MY, Yeo TC, Tan HC, Poh KK, Loh PH. Long-Term Prognosis in Patients with Concomitant Acute Coronary Syndrome and Aortic Stenosis. Can J Cardiol 2022; 38:1220-1227. [DOI: 10.1016/j.cjca.2022.03.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 03/09/2022] [Accepted: 03/10/2022] [Indexed: 02/08/2023] Open
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13
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Katsanos S, Saranteas T, Mavrogenis AF. Orthopaedic cardiac considerations in emergency. SICOT J 2021; 7:E2. [PMID: 34738901 PMCID: PMC8570134 DOI: 10.1051/sicotj/2021051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Accepted: 10/07/2021] [Indexed: 01/09/2023] Open
Abstract
Orthopaedic patients undergoing emergency orthopaedic surgery should be referred for cardiac evaluation only when they are symptomatic or when a specific cardiac intervention is expected to reduce the surgical risk. A preoperative delay of 24-48 h of emergency orthopaedic operations has been associated with increased mortality and poor functional status of the patients. Research in the preoperative setting is almost exclusively retrospective because randomized studies are difficult to be performed and pose serious ethical concerns. Moreover, inevitably, guidelines have a low level of evidence and do not always provide a straightforward framework for the preoperative care of the patients. This editorial revisits the most common clinical cardiology dilemmas for emergency orthopaedic surgery to explore controversies of current recommendations and elaborate on the role of echocardiography in the perioperative period in emergency orthopaedic surgery.
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Affiliation(s)
- Spyridon Katsanos
- Department of Emergency Medicine and Cardiology, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Theodosis Saranteas
- Second Department of Anesthesiology, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Andreas F Mavrogenis
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, 11527 Athens, Greece
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14
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Pavithran A, Kennon S. Staging classification for cardiac damage associated with aortic stenosis. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2021; 7:524-525. [PMID: 34390239 DOI: 10.1093/ehjqcco/qcab055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Okuno et al's staging classification of cardiac damage associated with aortic stenosis predicts prognosis following TAVI. More research is required, not only to further improve risk stratification, particularly at the higher and lower end of the risk spectrum, but also to assess the value of aortic valve intervention in such patient groups.
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