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Sia CH, Poh KK. Refining the Role of Dobutamine Stress Echocardiography for Low-Gradient Aortic Stenosis in the Current Management Era. J Am Soc Echocardiogr 2024:S0894-7317(24)00401-2. [PMID: 39168273 DOI: 10.1016/j.echo.2024.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2024] [Accepted: 08/08/2024] [Indexed: 08/23/2024]
Affiliation(s)
- Ching-Hui Sia
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore; Department of Cardiology, National University Heart Centre Singapore, Singapore, Singapore
| | - Kian-Keong Poh
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore; Department of Cardiology, National University Heart Centre Singapore, Singapore, Singapore.
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2
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Abstract
Aortic stenosis is a heterogeneous disorder. Variations in the pathological and physiological responses to pressure overload are incompletely understood and generate a range of flow and pressure gradient patterns, which ultimately cause varying microvascular effects. The impact of cardiac-coronary coupling depends on these pressure and flow effects. In this article, we explore important concepts concerning cardiac physiology and the coronary microcirculation in aortic stenosis and their impact on myocardial remodeling, aortic valve flow patterns, and clinical progression.
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Affiliation(s)
- Hannah Z.R. McConkey
- Cardiovascular Division, King’s College London British Heart Foundation Centre of Excellence, The Rayne Institute, St. Thomas’ Hospital Campus, London, United Kingdom (H.Z.R.M., M.M., A.C., S.R.R., B.D.P.)
| | - Michael Marber
- Cardiovascular Division, King’s College London British Heart Foundation Centre of Excellence, The Rayne Institute, St. Thomas’ Hospital Campus, London, United Kingdom (H.Z.R.M., M.M., A.C., S.R.R., B.D.P.)
| | - Amedeo Chiribiri
- Cardiovascular Division, King’s College London British Heart Foundation Centre of Excellence, The Rayne Institute, St. Thomas’ Hospital Campus, London, United Kingdom (H.Z.R.M., M.M., A.C., S.R.R., B.D.P.)
| | - Philippe Pibarot
- Department of Medicine, Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, Québec, Canada (P.P.)
| | - Simon R. Redwood
- Cardiovascular Division, King’s College London British Heart Foundation Centre of Excellence, The Rayne Institute, St. Thomas’ Hospital Campus, London, United Kingdom (H.Z.R.M., M.M., A.C., S.R.R., B.D.P.)
| | - Bernard D. Prendergast
- Cardiovascular Division, King’s College London British Heart Foundation Centre of Excellence, The Rayne Institute, St. Thomas’ Hospital Campus, London, United Kingdom (H.Z.R.M., M.M., A.C., S.R.R., B.D.P.)
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3
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Gillis K, Bala G, Roosens B, Hernot S, Remory I, Scheirlynck E, Geers J, Droogmans S, Cosyns B. Clinical validation of an ultrasound quantification score for aortic valve calcifications. Int J Cardiol 2018; 252:68-71. [PMID: 29249440 DOI: 10.1016/j.ijcard.2017.07.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Revised: 07/01/2017] [Accepted: 07/10/2017] [Indexed: 01/17/2023]
Affiliation(s)
- Kris Gillis
- Centrum voor Hart- en Vaatziekten (CHVZ), UZ Brussel, Laarbeeklaan 101, 1090 Jette, Belgium; In vivo Cellular and Molecular Imaging laboratory (ICMI), Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel (VUB), Building K, Laarbeeklaan 103, 1090 Jette, Belgium.
| | - Gezim Bala
- Centrum voor Hart- en Vaatziekten (CHVZ), UZ Brussel, Laarbeeklaan 101, 1090 Jette, Belgium; In vivo Cellular and Molecular Imaging laboratory (ICMI), Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel (VUB), Building K, Laarbeeklaan 103, 1090 Jette, Belgium
| | - Bram Roosens
- Centrum voor Hart- en Vaatziekten (CHVZ), UZ Brussel, Laarbeeklaan 101, 1090 Jette, Belgium; In vivo Cellular and Molecular Imaging laboratory (ICMI), Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel (VUB), Building K, Laarbeeklaan 103, 1090 Jette, Belgium
| | - Sophie Hernot
- In vivo Cellular and Molecular Imaging laboratory (ICMI), Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel (VUB), Building K, Laarbeeklaan 103, 1090 Jette, Belgium
| | - Isabel Remory
- In vivo Cellular and Molecular Imaging laboratory (ICMI), Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel (VUB), Building K, Laarbeeklaan 103, 1090 Jette, Belgium
| | - Esther Scheirlynck
- Centrum voor Hart- en Vaatziekten (CHVZ), UZ Brussel, Laarbeeklaan 101, 1090 Jette, Belgium; In vivo Cellular and Molecular Imaging laboratory (ICMI), Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel (VUB), Building K, Laarbeeklaan 103, 1090 Jette, Belgium
| | - Jolien Geers
- Centrum voor Hart- en Vaatziekten (CHVZ), UZ Brussel, Laarbeeklaan 101, 1090 Jette, Belgium; In vivo Cellular and Molecular Imaging laboratory (ICMI), Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel (VUB), Building K, Laarbeeklaan 103, 1090 Jette, Belgium
| | - Steven Droogmans
- Centrum voor Hart- en Vaatziekten (CHVZ), UZ Brussel, Laarbeeklaan 101, 1090 Jette, Belgium; In vivo Cellular and Molecular Imaging laboratory (ICMI), Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel (VUB), Building K, Laarbeeklaan 103, 1090 Jette, Belgium
| | - Bernard Cosyns
- Centrum voor Hart- en Vaatziekten (CHVZ), UZ Brussel, Laarbeeklaan 101, 1090 Jette, Belgium; In vivo Cellular and Molecular Imaging laboratory (ICMI), Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel (VUB), Building K, Laarbeeklaan 103, 1090 Jette, Belgium
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Bleakley C, Monaghan MJ. Assessment of Normal-Flow Aortic Stenosis: Delving Too Deep? Circ Cardiovasc Imaging 2017; 10:CIRCIMAGING.117.007293. [PMID: 29222124 DOI: 10.1161/circimaging.117.007293] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Caroline Bleakley
- From the Department of Cardiology, King's College Hospital, London, United Kingdom
| | - Mark J Monaghan
- From the Department of Cardiology, King's College Hospital, London, United Kingdom.
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5
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Eberhard M, Mastalerz M, Frauenfelder T, Tanner F, Maisano F, Nietlispach F, Seifert B, Alkadhi H, Nguyen-Kim T. Quantification of aortic valve calcification on contrast-enhanced CT of patients prior to transcatheter aortic valve implantation. EUROINTERVENTION 2017. [DOI: 10.4244/eij-d-17-00060] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Abstract
Transcatheter aortic valve implantation (TAVI) has proven to be the standard of care for patients with prohibitive and high operative risk; today, it is considered a reasonable alternative to surgical aortic valve replacement in intermediate-risk patients. As indications for TAVI move toward patients at lower risk, safety aspects are becoming even more important. Furthermore, adequate patient selection is key for predictable procedural success with minimal complications, translating into an optimal clinical outcome. Decisions on valve type and size as well as on the access route are based on multimodality imaging including echocardiography, multislice computed tomography, and cardiac catheterization with peripheral angiography. This combination of multiple imaging modalities provides the best picture of a patient's anatomical and physiological suitability for the TAVI procedure. Yet, the reliability of preprocedural imaging is influenced by the quality of the images, which should be as high as possible, and both image acquisition and interpretation should be performed in a standardized manner. This article provides a concise overview of standardized multimodality imaging for the preprocedural planning and assessment of patients undergoing TAVI.
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Abstract
Many patients with severe aortic stenosis have a "low-flow, low-gradient" aortic stenosis. The management of these patients can be quite difficult, as these patients often show impairment of the left ventricle, which can lead to false measurements of the severity of stenosis and also leads to a higher risk during aortic valve replacement. More diagnostic tools than only standard echocardiography are needed to correctly differentiate true severe aortic stenosis from pseudo severe aortic stenosis.
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Mates M, Kopřiva K. Management of low-gradient aortic stenosis. COR ET VASA 2017. [DOI: 10.1016/j.crvasa.2017.01.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Schmermund A, Eckert J, Schelle SN, Eggebrecht H. [Imaging in structural heart disease : Impact on interventional therapy]. Herz 2016; 41:639-652. [PMID: 27646067 DOI: 10.1007/s00059-016-4481-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
For the treatment of structural heart disease, current options in the catheterization laboratory include MitraClip® implantation for treating severe mitral regurgitation, transcatheter aortic valve implantation (TAVI), closure of a patent foramen ovale (PFO) and occlusion of the left atrial appendage (LAA). These treatment options are based on a precise diagnosis provided by modern cardiac imaging, which is indispensable for treatment recommendations. Its importance for supporting the invasive procedures in the catheterization laboratory is less well known. Due to enhanced soft tissue characterization, it complements fluoroscopy and invasive angiography and thus enormously improves the safety of the procedures. In addition, it allows individualized follow-up care. The current article gives an overview of the clinically most frequently used procedures.
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Affiliation(s)
- A Schmermund
- Cardioangiologisches Centrum Bethanien, Im Prüfling 23, 60389, Frankfurt am Main, Deutschland.
| | - J Eckert
- Cardioangiologisches Centrum Bethanien, Im Prüfling 23, 60389, Frankfurt am Main, Deutschland
| | - S N Schelle
- Cardioangiologisches Centrum Bethanien, Im Prüfling 23, 60389, Frankfurt am Main, Deutschland
| | - H Eggebrecht
- Cardioangiologisches Centrum Bethanien, Im Prüfling 23, 60389, Frankfurt am Main, Deutschland
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10
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[Paradoxical low-flow low-gradient aortic stenosis]. Internist (Berl) 2016; 57:317-22. [PMID: 26886708 DOI: 10.1007/s00108-016-0027-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
In approximately one third of patients presenting with suspected severe aortic stenosis, there is a discrepancy between a severely reduced aortic valve opening area (< 1 cm(2)) and a non-severe increase of the mean transvalvular gradient (< 40 mmHg). In a substantial number of these cases there is evidence of a severe paradoxical low-flow low-gradient aortic stenosis, characterized by a reduced stroke volume index in the setting of a normal left ventricular ejection fraction. This finding should trigger an extensive diagnostic work-up, including echocardiography, stress echocardiography and computed tomography to rule out measurement errors and to identify the cause(s) of the hemodynamic discrepancy. If the diagnosis of a severe paradoxical low-flow low-gradient aortic stenosis is confirmed and, furthermore, the patient is normotensive and reports stenosis-associated symptoms, the feasibility of an aortic valve replacement should be considered.
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11
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Holmes AA, Taub CC, Garcia MJ, Shan J, Slovut DP. Paradoxical low-flow aortic stenosis is defined by increased ventricular hydraulic load and reduced longitudinal strain. J Cardiovasc Med (Hagerstown) 2015; 18:87-95. [PMID: 26556444 DOI: 10.2459/jcm.0000000000000324] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Patients with paradoxical low-flow severe aortic stenosis (PLF-AS) reportedly have higher left ventricular hydraulic load and more systolic strain dysfunction than patients with normal-flow aortic stenosis. This study investigates the relationship of systolic loading and strain to PLF-AS to further define its pathophysiology. METHODS One hundred and twenty patients (age 79 ± 12 years, 37% men) with an indexed aortic valve area (AVAi) of 0.6 cm/m or less and an ejection fraction of 50% or higher were divided into two groups based on indexed stroke volume (SVi): PLF-AS, SVi ≤ 35 ml/m, N = 46; normal-flow aortic stenosis, SVi > 35 ml/m, N = 74). Valvular and arterial load were assessed using multiple measurements, and strain was assessed using speckle-tracking echocardiography. RESULTS Patients with PLF-AS were found to have more valvular load (lower AVAi, P = 0.028; lower energy loss coefficient, P = 0.001), more arterial load [decreased arterial compliance and increased systemic vascular resistance (SVR), both P < 0.001] and more total hydraulic load [increased valvuloarterial impedance (Zva), P < 0.001]. Transvalvular gradients and arterial pressures were similar. Longitudinal strain was lower in PLF-AS (P < 0.001), but circumferential and rotation strains were similar. On adjusted regression, AVAi, SVR and longitudinal strain were associated with PLF-AS [odds ratio (OR) = 1.34, P = 0.043; OR = 1.31, P = 0.004; OR = 1.34, P = 0.011, respectively]. When SVR and AVAi were replaced with Zva, longitudinal strain and Zva (OR = 1.38, P = 0.015; OR = 1.33, P < 0.001 for both, respectively) were associated with PLF-AS. CONCLUSION Increased hydraulic load, from more severe valvular stenosis and increased vascular resistance, and longitudinal strain impairment are associated with PLF-AS and their interplay is likely fundamental to its pathophysiology.
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Affiliation(s)
- Anthony A Holmes
- aDepartment of Medicine bDivision of Cardiology cDepartment of Cardiovascular and Thoracic Surgery, Montefiore Medical Center, Bronx, New York, USA
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Siegel RJ, Luo H, Makar M, Beigel R. Optimal use of echocardiography in valvular heart disease evaluation. Heart 2015; 101:977-86. [DOI: 10.1136/heartjnl-2014-306293] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
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