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Frangogiannis NG. The fate and role of the pericytes in myocardial diseases. Eur J Clin Invest 2024:e14204. [PMID: 38586936 DOI: 10.1111/eci.14204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 03/24/2024] [Accepted: 03/25/2024] [Indexed: 04/09/2024]
Abstract
The adult mammalian heart contains a large population of pericytes that play important roles in homeostasis and disease. In the normal heart, pericytes regulate microvascular permeability and flow. Myocardial diseases are associated with marked alterations in pericyte phenotype and function. This review manuscript discusses the role of pericytes in cardiac homeostasis and disease. Following myocardial infarction (MI), cardiac pericytes participate in all phases of cardiac repair. During the inflammatory phase, pericytes may secrete cytokines and chemokines and may regulate leukocyte trafficking, through formation of intercellular gaps that serve as exit points for inflammatory cells. Moreover, pericyte contraction induces microvascular constriction, contributing to the pathogenesis of 'no-reflow' in ischemia and reperfusion. During the proliferative phase, pericytes are activated by growth factors, such as transforming growth factor (TGF)-β and contribute to fibrosis, predominantly through secretion of fibrogenic mediators. A fraction of pericytes acquires fibroblast identity but contributes only to a small percentage of infarct fibroblasts and myofibroblasts. As the scar matures, pericytes form a coat around infarct neovessels, promoting stabilization of the vasculature. Pericytes may also be involved in the pathogenesis of chronic heart failure, by regulating inflammation, fibrosis, angiogenesis and myocardial perfusion. Pericytes are also important targets of viral infections (such as SARS-CoV2) and may be implicated in the pathogenesis of cardiac complications of COVID19. Considering their role in myocardial inflammation, fibrosis and angiogenesis, pericytes may be promising therapeutic targets in myocardial disease.
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Affiliation(s)
- Nikolaos G Frangogiannis
- Department of Medicine (Cardiology), The Wilf Family Cardiovascular Research Institute, Albert Einstein College of Medicine, Bronx, New York, USA
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2
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Scarsini R, Portolan L, Della Mora F, Fabroni M, Andreaggi S, Mainardi A, Springhetti P, Dotto A, Del Sole PA, Fezzi S, Pazzi S, Tavella D, Mammone C, Lunardi M, Pesarini G, Benfari G, Ribichini FL. Coronary microvascular dysfunction in patients undergoing transcatheter aortic valve implantation. Heart 2024; 110:603-612. [PMID: 38040448 DOI: 10.1136/heartjnl-2023-323461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 11/09/2023] [Indexed: 12/03/2023] Open
Abstract
OBJECTIVES This study aimed to evaluate the prognostic value of coronary microvascular dysfunction (CMD) at long term after transcatheter aortic valve implantation (TAVI) and to explore its relationship with extravalvular cardiac damage (EVCD). Moreover, we sought to test the correlation between angiography-derived index of microcirculatory resistance (IMRangio) and invasive IMR in patients with aortic stenosis (AS). METHODS This was a retrospective analysis of the Verona Valvular Heart Disease Registry (Italy) including 250 patients (83 (80-86) years, 53% female) with severe AS who underwent TAVI between 2019 and 2021. IMRangio was calculated offline using a computational flow model applied to coronary angiography obtained during the TAVI workup. CMD was defined as IMRangio ≥30 units.The primary endpoint was the composite of cardiovascular death and rehospitalisation for heart failure (HF). Advanced EVCD was defined as pulmonary circulation impairment, severe tricuspid regurgitation or right ventricular dysfunction.The correlation between IMR and IMRangio was prospectively assessed in 31 patients undergoing TAVI. RESULTS The primary endpoint occurred in 28 (11.2%) patients at a median follow-up of 22 (IQR 12-30) months. Patients with CMD met the primary endpoint more frequently than those without CMD (22.9% vs 2.8%, p<0.0001). Patients with CMD were more frequently characterised by advanced EVCD (33 (31.4%) vs 27 (18.6%), p=0.024). CMD was an independent predictor of adverse outcomes (adjusted HR 6.672 (2.251 to 19.778), p=0.001) and provided incremental prognostic value compared with conventional clinical and imaging variables. IMRangio demonstrated fair correlation with IMR. CONCLUSIONS CMD is an independent predictor of cardiovascular mortality and HF after TAVI.
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Affiliation(s)
- Roberto Scarsini
- Department of Medicine, Division of Cardiology, University of Verona, Verona, Italy
- Interventional Cardiology Unit, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Leonardo Portolan
- Department of Medicine, Division of Cardiology, University of Verona, Verona, Italy
| | - Francesco Della Mora
- Department of Medicine, Division of Cardiology, University of Verona, Verona, Italy
| | - Margherita Fabroni
- Department of Medicine, Division of Cardiology, University of Verona, Verona, Italy
| | - Stefano Andreaggi
- Department of Medicine, Division of Cardiology, University of Verona, Verona, Italy
| | - Andrea Mainardi
- Department of Medicine, Division of Cardiology, University of Verona, Verona, Italy
| | - Paolo Springhetti
- Department of Medicine, Division of Cardiology, University of Verona, Verona, Italy
| | - Alberto Dotto
- Department of Medicine, Division of Cardiology, University of Verona, Verona, Italy
| | | | - Simone Fezzi
- Department of Medicine, Division of Cardiology, University of Verona, Verona, Italy
| | - Sara Pazzi
- Department of Medicine, Division of Cardiology, University of Verona, Verona, Italy
| | - Domenico Tavella
- Department of Medicine, Division of Cardiology, University of Verona, Verona, Italy
- Interventional Cardiology Unit, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Concetta Mammone
- Department of Medicine, Division of Cardiology, University of Verona, Verona, Italy
- Interventional Cardiology Unit, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Mattia Lunardi
- Department of Medicine, Division of Cardiology, University of Verona, Verona, Italy
- Interventional Cardiology Unit, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Gabriele Pesarini
- Department of Medicine, Division of Cardiology, University of Verona, Verona, Italy
- Interventional Cardiology Unit, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Giovanni Benfari
- Department of Medicine, Division of Cardiology, University of Verona, Verona, Italy
| | - Flavio Luciano Ribichini
- Department of Medicine, Division of Cardiology, University of Verona, Verona, Italy
- Interventional Cardiology Unit, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
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3
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Scarsini R, Gallinoro E, Ancona MB, Portolan L, Paolisso P, Springhetti P, Della Mora F, Mainardi A, Belmonte M, Moroni F, Ferri LA, Bellini B, Russo F, Vella C, Bertolone DT, Pesarini G, Benfari G, Vanderheyden M, Montorfano M, De Bruyne B, Barbato E, Ribichini F. Characterisation of coronary microvascular dysfunction in patients with severe aortic stenosis undergoing TAVI. EUROINTERVENTION 2024; 20:e289-e300. [PMID: 37982178 PMCID: PMC10905195 DOI: 10.4244/eij-d-23-00735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 10/27/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND Microvascular resistance reserve (MRR) is a validated measure of coronary microvascular function independent of epicardial resistances. AIMS We sought to assess whether MRR is associated with adverse cardiac remodelling, a low-flow phenotype and extravalvular cardiac damage (EVCD) in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI). METHODS Invasive thermodilution-based assessment of the coronary microvascular function of the left anterior descending artery was performed in a prospective, multicentre cohort of patients undergoing TAVI. Coronary microvascular dysfunction (CMD) was defined as the lowest MRR tertile of the study cohort. Haemodynamic measurements were performed at baseline and then repeated immediately after TAVI. EVCD and markers of a low-flow phenotype were assessed with echocardiography. RESULTS A total of 134 patients were included in this study. Patients with low MRR were more frequently females, had a lower estimated glomerular filtration rate and a higher rate of atrial fibrillation. MRR was significantly lower in patients with advanced EVCD (median 1.80 [1.26-3.30] vs 2.50 [1.87-3.41]; p=0.038) and in low-flow, low-gradient AS (LF LG-AS) (median 1.85 [1.20-3.04] vs 2.50 [1.87-3.40]; p=0.008). Overall, coronary microvascular function tended to improve after TAVI and, in particular, MRR increased significantly after TAVI in the subgroup with low MRR at baseline. However, MRR was significantly impaired in 38 (28.4%) patients immediately after TAVI. Advanced EVCD (adjusted odds ratio 3.08 [1.22-7.76]; p=0.017) and a low-flow phenotype (adjusted odds ratio 3.36 [1.08-10.47]; p=0.036) were significant predictors of CMD. CONCLUSIONS In this observational, hypothesis-generating study, CMD was associated with extravalvular cardiac damage and a low-flow phenotype in patients with severe AS undergoing TAVI.
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Affiliation(s)
- Roberto Scarsini
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Emanuele Gallinoro
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
- Division of University Cardiology, IRCCS Galeazzi - Sant'Ambrogio Hospital, Milan, Italy
| | - Marco B Ancona
- Interventional Cardiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Leonardo Portolan
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Pasquale Paolisso
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
- Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy
| | - Paolo Springhetti
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Francesco Della Mora
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Andrea Mainardi
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Marta Belmonte
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
- Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy
| | - Francesco Moroni
- Interventional Cardiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Luca A Ferri
- Interventional Cardiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Barbara Bellini
- Interventional Cardiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Filippo Russo
- Interventional Cardiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Ciro Vella
- Interventional Cardiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Dario Tino Bertolone
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
- Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy
| | - Gabriele Pesarini
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Giovanni Benfari
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | | | - Matteo Montorfano
- Interventional Cardiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | | | - Emanuele Barbato
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
| | - Flavio Ribichini
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
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Suzuki W, Fujimoto M, Ando H, Amano T. A case with assessment of cardiac-coronary interactions with transthoracic echocardiography before and after transcatheter aortic valve replacement. Eur Heart J Case Rep 2024; 8:ytae037. [PMID: 38313327 PMCID: PMC10834111 DOI: 10.1093/ehjcr/ytae037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 01/08/2024] [Accepted: 01/19/2024] [Indexed: 02/06/2024]
Affiliation(s)
- Wataru Suzuki
- Department of Cardiology, Aichi Medical University, 1-1, Yazakokarimata, Nagakute, Aichi 480-1195, Japan
| | - Masanobu Fujimoto
- Department of Cardiology, Aichi Medical University, 1-1, Yazakokarimata, Nagakute, Aichi 480-1195, Japan
| | - Hirohiko Ando
- Department of Cardiology, Aichi Medical University, 1-1, Yazakokarimata, Nagakute, Aichi 480-1195, Japan
| | - Tetsuya Amano
- Department of Cardiology, Aichi Medical University, 1-1, Yazakokarimata, Nagakute, Aichi 480-1195, Japan
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Tabrizi NS, Ramadan R, Musuku SR, Shapeton AD. Diastolic Left Main Coronary Artery Flow Reversal. J Cardiothorac Vasc Anesth 2023; 37:2674-2677. [PMID: 37349188 DOI: 10.1053/j.jvca.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 05/19/2023] [Accepted: 06/02/2023] [Indexed: 06/24/2023]
Abstract
In patients undergoing percutaneous cardiac interventions, perioperative transesophageal echocardiography is used routinely, often revealing an unusual pathology that was not previously detected with transthoracic echocardiography. In this e-challenge, the authors present a patient undergoing percutaneous transcatheter aortic valve replacement, with preprocedural transesophageal echocardiography revealing an abnormal color Doppler signal near the left main coronary artery during diastole.
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Affiliation(s)
| | - Ronnie Ramadan
- Georgia Heart Institute, Northeast Georgia Health System, Gainesville, GA
| | | | - Alexander D Shapeton
- Veterans Affairs Boston Healthcare System, Department of Anesthesia, Critical Care and Pain Medicine, and Tufts University School of Medicine, Boston, MA
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Khodaei S, Abdelkhalek M, Maftoon N, Emadi A, Keshavarz-Motamed Z. Early Detection of Risk of Neo-Sinus Blood Stasis Post-Transcatheter Aortic Valve Replacement Using Personalized Hemodynamic Analysis. Struct Heart 2023; 7:100180. [PMID: 37745677 PMCID: PMC10512011 DOI: 10.1016/j.shj.2023.100180] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 02/27/2023] [Accepted: 03/01/2023] [Indexed: 09/26/2023]
Abstract
Background Despite the demonstrated benefits of transcatheter aortic valve replacement (TAVR), subclinical leaflet thrombosis and hypoattenuated leaflet thickening are commonly seen as initial indications of decreased valve durability and augmented risk of transient ischemic attack. Methods We developed a multiscale patient-specific computational framework to quantify metrics of global circulatory function, metrics of global cardiac function, and local cardiac fluid dynamics of the aortic root and coronary arteries. Results Based on our findings, TAVR might be associated with a high risk of blood stagnation in the neo-sinus region due to the lack of sufficient blood flow washout during the diastole phase (e.g., maximum blood stasis volume increased by 13, 8, and 2.7 fold in the left coronary cusp, right coronary cusp, and noncoronary cusp, respectively [N = 26]). Moreover, in some patients, TAVR might not be associated with left ventricle load relief (e.g., left ventricle load reduced only by 1.2 % [N = 26]) and diastolic coronary flow improvement (e.g., maximum coronary flow reduced by 4.94%, 15.05%, and 23.59% in the left anterior descending, left circumflex coronary artery, and right coronary artery, respectively, [N = 26]). Conclusions The transvalvular pressure gradient amelioration after TAVR might not translate into adequate sinus blood washout, optimal coronary flow, and reduced cardiac stress. Noninvasive personalized computational modeling can facilitate the determination of the most effective revascularization strategy pre-TAVR and monitor leaflet thrombosis and coronary plaque progression post-TAVR.
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Affiliation(s)
- Seyedvahid Khodaei
- Department of Mechanical Engineering, McMaster University, Hamilton, Ontario, Canada
| | - Mohamed Abdelkhalek
- School of Biomedical Engineering, McMaster University, Hamilton, Ontario, Canada
| | - Nima Maftoon
- Department of Systems Design Engineering, University of Waterloo, Waterloo, Ontario, Canada
- Centre for Bioengineering and Biotechnology, University of Waterloo, Waterloo, Ontario, Canada
| | - Ali Emadi
- Department of Mechanical Engineering, McMaster University, Hamilton, Ontario, Canada
- Department of Electrical and Computer Engineering, McMaster University, Hamilton, Ontario, Canada
| | - Zahra Keshavarz-Motamed
- Department of Mechanical Engineering, McMaster University, Hamilton, Ontario, Canada
- School of Biomedical Engineering, McMaster University, Hamilton, Ontario, Canada
- School of Computational Science and Engineering, McMaster University, Hamilton, Ontario, Canada
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7
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Lu DY, Yalcin H, Yalcin F, Sivalokanathan S, Greenland GV, Ventoulis I, Vakrou S, Pampaloni MH, Zimmerman SL, Valenta I, Schindler TH, Abraham TP, Abraham MR. Systolic blood pressure ≤110 mm Hg is associated with severe coronary microvascular ischemia and higher risk for ventricular arrhythmias in hypertrophic cardiomyopathy. Heart Rhythm O2 2023; 4:538-548. [PMID: 37744936 PMCID: PMC10513918 DOI: 10.1016/j.hroo.2023.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/26/2023] Open
Abstract
Background Coronary microvascular dysfunction (CMD) and hypertension (HTN) occur frequently in hypertrophic cardiomyopathy (HCM), but whether blood pressure (BP) influences CMD and outcomes is unknown. Objective The purpose of this study was to test the hypothesis that HTN is associated with worse CMD and outcomes. Methods This retrospective study included 690 HCM patients. All patients underwent cardiac magnetic resonance imaging, echocardiography, and rhythm monitoring; 127 patients also underwent rest/vasodilator stress 13NH3 positron emission tomography myocardial perfusion imaging. Patients were divided into 3 groups based on their rest systolic blood pressure (SBP) (group 1 ≤110 mm Hg; group 2 111-140; group 3 >140 mm Hg) and were followed for development of ventricular tachycardia (VT)/ventricular fibrillation (VF), heart failure (HF), death, and composite outcome. Results Group 1 patients had the lowest age and left ventricular (LV) mass but the highest prevalence of nonobstructive hemodynamics and restrictive diastolic filling. LV scar was similar in the 3 groups. Group 1 had the lowest rest and stress myocardial blood flow (MBF) and highest SDS (summed difference score). Rest SBP was positively correlated with stress MBF and negatively correlated with SDS. Group 1 had the highest incidence of VT/VF, whereas the incidences of HF, death, and composite outcome were similar among the 3 groups. In multivariate analysis, rest SBP ≤110 mm Hg was independently associated with VT/VF (hazard ratio 2.6; 95% confidence interval 1.0-6.7; P = .04). Conclusion SBP ≤110 mm Hg is associated with greater severity of CMD and coronary microvascular ischemia and higher incidence of ventricular arrhythmias in HCM.
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Affiliation(s)
- Dai-Yin Lu
- Hypertrophic Cardiomyopathy Center of Excellence, Johns Hopkins University, Baltimore, Maryland
- Institute of Public Health, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Division of Cardiology, University of California San Francisco, San Francisco, California
| | - Hulya Yalcin
- Hypertrophic Cardiomyopathy Center of Excellence, Johns Hopkins University, Baltimore, Maryland
- Division of Cardiology, University of California San Francisco, San Francisco, California
| | - Fatih Yalcin
- Hypertrophic Cardiomyopathy Center of Excellence, Johns Hopkins University, Baltimore, Maryland
- Division of Cardiology, University of California San Francisco, San Francisco, California
| | - Sanjay Sivalokanathan
- Hypertrophic Cardiomyopathy Center of Excellence, Johns Hopkins University, Baltimore, Maryland
- Division of Cardiology, University of California San Francisco, San Francisco, California
| | - Gabriela V. Greenland
- Hypertrophic Cardiomyopathy Center of Excellence, Johns Hopkins University, Baltimore, Maryland
- Division of Cardiology, University of California San Francisco, San Francisco, California
| | - Ioannis Ventoulis
- Hypertrophic Cardiomyopathy Center of Excellence, Johns Hopkins University, Baltimore, Maryland
- Department of Occupational Therapy, University of Western Macedonia, Ptolemaida, Greece
| | - Styliani Vakrou
- Hypertrophic Cardiomyopathy Center of Excellence, Johns Hopkins University, Baltimore, Maryland
| | - Miguel Hernandez Pampaloni
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California
| | - Stefan L. Zimmerman
- Department of Radiology and Radiological Science, Johns Hopkins University, Baltimore, Maryland
| | - Ines Valenta
- Department of Radiology and Radiological Science, Johns Hopkins University, Baltimore, Maryland
| | - Thomas H. Schindler
- Department of Radiology and Radiological Science, Johns Hopkins University, Baltimore, Maryland
| | - Theodore P. Abraham
- Hypertrophic Cardiomyopathy Center of Excellence, Johns Hopkins University, Baltimore, Maryland
- Division of Cardiology, University of California San Francisco, San Francisco, California
| | - M. Roselle Abraham
- Hypertrophic Cardiomyopathy Center of Excellence, Johns Hopkins University, Baltimore, Maryland
- Division of Cardiology, University of California San Francisco, San Francisco, California
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Belur AD, Solankhi N, Sharma R. Management of coronary artery disease in patients with aortic stenosis in the era of transcatheter aortic valve replacement. Front Cardiovasc Med 2023; 10:1139360. [PMID: 37408653 PMCID: PMC10318168 DOI: 10.3389/fcvm.2023.1139360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 05/30/2023] [Indexed: 07/07/2023] Open
Abstract
Aortic stenosis (AS) is a common valve disorder among the elderly, and these patients frequently have concomitant coronary artery disease (CAD). Risk factors for calcific AS are similar to those for CAD. Historically, the treatment of these conditions involved simultaneous surgical replacement of the aortic valve (AV) with coronary artery bypass grafting. Since the advancement of transcatheter AV therapies, there have been tremendous advancements in the safety, efficacy, and feasibility of this procedure with expanding indications. This has led to a paradigm shift in our approach to the patient with AS and concomitant CAD. Data regarding the management of CAD in patients with AS are largely limited to single-center studies or retrospective analyses. This article aims to review available literature around the management of CAD in patients with AS and assist in the current understanding in approaches toward management.
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Affiliation(s)
- Agastya D. Belur
- Cardiovascular Disease Fellowship Program, University of Louisville School of Medicine, Louisville, KY, United States
| | - Naresh Solankhi
- Jewish Hospital Cardiology, University of Louisville Jewish Hospital, Louisville, KY, United States
| | - Ravi Sharma
- Jewish Hospital Cardiology, University of Louisville Jewish Hospital, Louisville, KY, United States
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9
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Garber L, Khodaei S, Maftoon N, Keshavarz-Motamed Z. Impact of TAVR on coronary artery hemodynamics using clinical measurements and image-based patient-specific in silico modeling. Sci Rep 2023; 13:8948. [PMID: 37268642 DOI: 10.1038/s41598-023-31987-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 03/21/2023] [Indexed: 06/04/2023] Open
Abstract
In recent years, transcatheter aortic valve replacement (TAVR) has become the leading method for treating aortic stenosis. While the procedure has improved dramatically in the past decade, there are still uncertainties about the impact of TAVR on coronary blood flow. Recent research has indicated that negative coronary events after TAVR may be partially driven by impaired coronary blood flow dynamics. Furthermore, the current technologies to rapidly obtain non-invasive coronary blood flow data are relatively limited. Herein, we present a lumped parameter computational model to simulate coronary blood flow in the main arteries as well as a series of cardiovascular hemodynamic metrics. The model was designed to only use a few inputs parameters from echocardiography, computed tomography and a sphygmomanometer. The novel computational model was then validated and applied to 19 patients undergoing TAVR to examine the impact of the procedure on coronary blood flow in the left anterior descending (LAD) artery, left circumflex (LCX) artery and right coronary artery (RCA) and various global hemodynamics metrics. Based on our findings, the changes in coronary blood flow after TAVR varied and were subject specific (37% had increased flow in all three coronary arteries, 32% had decreased flow in all coronary arteries, and 31% had both increased and decreased flow in different coronary arteries). Additionally, valvular pressure gradient, left ventricle (LV) workload and maximum LV pressure decreased by 61.5%, 4.5% and 13.0% respectively, while mean arterial pressure and cardiac output increased by 6.9% and 9.9% after TAVR. By applying this proof-of-concept computational model, a series of hemodynamic metrics were generated non-invasively which can help to better understand the individual relationships between TAVR and mean and peak coronary flow rates. In the future, tools such as these may play a vital role by providing clinicians with rapid insight into various cardiac and coronary metrics, rendering the planning for TAVR and other cardiovascular procedures more personalized.
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Affiliation(s)
- Louis Garber
- School of Biomedical Engineering, McMaster University, Hamilton, ON, Canada
| | - Seyedvahid Khodaei
- Department of Mechanical Engineering (Mail to JHE-310), McMaster University, Hamilton, ON, L8S 4L7, Canada
| | - Nima Maftoon
- Department of Systems Design Engineering, University of Waterloo, Waterloo, ON, Canada
- Centre for Bioengineering and Biotechnology, University of Waterloo, Waterloo, ON, Canada
| | - Zahra Keshavarz-Motamed
- School of Biomedical Engineering, McMaster University, Hamilton, ON, Canada.
- Department of Mechanical Engineering (Mail to JHE-310), McMaster University, Hamilton, ON, L8S 4L7, Canada.
- School of Computational Science and Engineering, McMaster University, Hamilton, ON, Canada.
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10
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Ciampi Q, Cortigiani L, Rivadeneira Ruiz M, Barbieri A, Manganelli F, Mori F, D’Alfonso MG, Bursi F, Villari B. ABCDEG Stress Echocardiography in Aortic Stenosis. Diagnostics (Basel) 2023; 13:1727. [PMID: 37238211 PMCID: PMC10217228 DOI: 10.3390/diagnostics13101727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 05/06/2023] [Accepted: 05/10/2023] [Indexed: 05/28/2023] Open
Abstract
Rest and stress echocardiography (SE) plays a pivotal role in the evaluation of valvular heart disease. The use of SE is recommended in valvular heart disease when there is a mismatch between resting transthoracic echocardiography findings and symptoms. In aortic stenosis (AS), rest echocardiographic analysis is a stepwise approach that begins with the evaluation of aortic valve morphology and proceeds to the measurement of the transvalvular aortic gradient and aortic valve area (AVA) using continuity equations or planimetry. The presence of the following three criteria suggests severe AS: AVA < 1.0 cm2, a peak velocity > 4.0 m/s, or a mean gradient > 40 mmHg. However, in approximately one in three cases, we can observe a discordant AVA < 1 cm2 with a peak velocity < 4.0 m/s or a mean gradient <40 mmHg. This is due to reduced transvalvular flow associated with LV systolic dysfunction (LVEF < 50%) defined as "classical" low-flow low-gradient (LFLG) AS or normal LVEF "paradoxical" LFLG AS. SE has an established role in evaluating LV contractile reserve (CR) patients with reduced LVEF. In classical LFLG AS, LV CR distinguished pseudo-severe AS from truly severe AS. Some observational data suggest that long-term prognosis in asymptomatic severe AS may not be as favorable as previously thought, offering a window of opportunity for intervention prior to the onset of symptoms. Therefore, guidelines recommend evaluating asymptomatic AS with exercise stress in physically active patients, particularly those younger than 70 years, and symptomatic classical LFLG severe AS with low-dose dobutamine SE. A comprehensive SE assessment includes evaluating valve function (gradients), the global systolic function of the LV, and pulmonary congestion. This assessment integrates considerations of blood pressure response, chronotropic reserve, and symptoms. StressEcho 2030 is a prospective, large-scale study that employs a comprehensive protocol (ABCDEG) to analyze the clinical and echocardiographic phenotypes of AS, capturing various vulnerability sources which support stress echo-driven treatment strategies.
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Affiliation(s)
- Quirino Ciampi
- Cardiology Division, Fatebenefratelli Hospital, 82100 Benevento, Italy;
| | | | | | - Andrea Barbieri
- Department of Biomedical, Cardiology Division, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, 41121 Modena, Italy;
| | - Fiore Manganelli
- Cardiology Division, San Giuseppe Moscati Hospital, 83100 Avellino, Italy;
| | - Fabio Mori
- Cardiology Division, Careggi Hospital, 50134 Florence, Italy; (F.M.); (M.G.D.)
| | | | - Francesca Bursi
- Department of Health Science, University of Milan, Cardiology Division, San Paolo Hospital, ASST Santi Paolo e Carlo, 20142 Milano, Italy;
| | - Bruno Villari
- Cardiology Division, Fatebenefratelli Hospital, 82100 Benevento, Italy;
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11
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Aziminia N, Nitsche C, Mravljak R, Bennett J, Thornton GD, Treibel TA. Heart failure and excess mortality after aortic valve replacement in aortic stenosis. Expert Rev Cardiovasc Ther 2023; 21:193-210. [PMID: 36877090 PMCID: PMC10069375 DOI: 10.1080/14779072.2023.2186853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 02/28/2023] [Indexed: 03/07/2023]
Abstract
INTRODUCTION In aortic stenosis (AS), the heart transitions from adaptive compensation to an AS cardiomyopathy and eventually leads to decompensation with heart failure. Better understanding of the underpinning pathophysiological mechanisms is required in order to inform strategies to prevent decompensation. AREAS COVERED In this review, we therefore aim to appraise the current pathophysiological understanding of adaptive and maladaptive processes in AS, appraise potential avenues of adjunctive therapy before or after AVR and highlight areas of further research in the management of heart failure post AVR. EXPERT OPINION Tailored strategies for the timing of intervention accounting for individual patient's response to the afterload insult are underway, and promise to guide better management in the future. Further clinical trials of adjunctive pharmacological and device therapy to either cardioprotect prior to intervention or promote reverse remodeling and recovery after intervention are needed to mitigate the risk of heart failure and excess mortality.
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Affiliation(s)
- Nikoo Aziminia
- Institute of Cardiovascular Science, University College London, London, England
- Barts Heart Centre, London, England
| | - Christian Nitsche
- Institute of Cardiovascular Science, University College London, London, England
- Barts Heart Centre, London, England
| | | | - Jonathan Bennett
- Institute of Cardiovascular Science, University College London, London, England
- Barts Heart Centre, London, England
| | - George D Thornton
- Institute of Cardiovascular Science, University College London, London, England
- Barts Heart Centre, London, England
| | - Thomas A Treibel
- Institute of Cardiovascular Science, University College London, London, England
- Barts Heart Centre, London, England
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12
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Chen JS, Huang JH, Chiu KM, Chiang CY. Extent of Left Ventricular Mass Regression and Impact of Global Left Ventricular Afterload on Cardiac Events and Mortality after Aortic Valve Replacement. J Clin Med 2022; 11:jcm11247482. [PMID: 36556098 PMCID: PMC9783780 DOI: 10.3390/jcm11247482] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/09/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022] Open
Abstract
Patient-prosthesis mismatch (PPM) causes a high transvalvular pressure gradient and residual left ventricular (LV) hypertrophy, consequently influencing long-term results. This study aimed to find the relationships between hemodynamic parameters and LV mass regression and determine the risk predictors of major adverse cardiovascular and cerebral events (MACCE) after aortic valve replacement (AVR) for aortic stenosis. Methods and Results: Preoperative and postoperative Doppler echocardiography data were evaluated for 120 patients after AVR. The patients' mean age was 67.7 years; 55% of the patients were male. Forty-four (37%) patients suffered from MACCE during a mean follow-up period of 3.6 ± 2 years. The following hemodynamic parameters at follow-up were associated with lower relative indexed LV mass (LVMI) regression: lower postoperative indexed effective orifice area, greater mean transvalvular pressure gradient (MPG), greater stroke work loss (SWL), and concentric or eccentric LV remodeling mode. The following hemodynamic parameters at follow-up were associated with a higher risk of MACCE: higher valvuloarterial impedance (ZVA), greater SWL, greater MPG, greater relative wall thickness, greater LVMI, and hypertrophic LV remodeling mode. Lower relative LVMI regression was associated with a higher risk of MACCE (hazard ratio, 1.01: 95% confidence interval, 1.003-1.03). The corresponding cutoff of relative LVMI regression was -14%. Conclusions: Changes in hemodynamic parameters were independently associated with relative LVMI regression. Impaired reverse remodeling and persistent residual LV hypertrophy were independent risk predictors of MACCE. An LVMI regression lower than 14% indicated higher MACCE. A postoperative ZVA greater than 3.5 mmHg/mL/m2 was an independent risk predictor of cardiac events and mortality after AVR. Preventive strategies should be used at the time of the operation to avoid PPM.
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Affiliation(s)
- Jer-Shen Chen
- Department of Cardiovascular Surgery, Cardiovascular Center, Far Eastern Memorial Hospital, New Taipei City 220216, Taiwan
- Department of Healthcare Administration, Asian Eastern University of Science and Technology, New Taipei City 220303, Taiwan
| | - Jih-Hsin Huang
- Department of Cardiovascular Surgery, Cardiovascular Center, Far Eastern Memorial Hospital, New Taipei City 220216, Taiwan
- Department of Applied Cosmetology, LeeMing Institute of Technology, New Taipei City 243083, Taiwan
| | - Kuan-Ming Chiu
- Department of Cardiovascular Surgery, Cardiovascular Center, Far Eastern Memorial Hospital, New Taipei City 220216, Taiwan
- Department of Electrical Engineering, Yuan Ze University, Taoyuan 320315, Taiwan
| | - Chih-Yao Chiang
- Department of Cardiovascular Surgery, Cardiovascular Center, Far Eastern Memorial Hospital, New Taipei City 220216, Taiwan
- Division of Cardiovascular Surgery, Department of Surgery, School of Medicine, National Defense Medical Center, Taipei 114201, Taiwan
- Correspondence: ; Tel.: +886-2-7728-1618; Fax: +886-2-7738-6057
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13
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Scarsini R, Pighi M, Mainardi A, Portolan L, Springhetti P, Mammone C, Della Mora F, Fanti D, Tavella D, Gottin L, Bergamini C, Benfari G, Pesarini G, Ribichini FL. Proof of concept study on coronary microvascular function in low flow low gradient aortic stenosis. Heart 2022; 109:785-793. [PMID: 36598066 DOI: 10.1136/heartjnl-2022-321907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 11/30/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVES We hypothesised that low flow low gradient aortic stenosis (LFLGAS) is associated with more severe coronary microvascular dysfunction (CMD) compared with normal-flow high-gradient aortic stenosis (NFHGAS) and that CMD is related to reduced cardiac performance. METHODS Invasive CMD assessment was performed in 41 consecutive patients with isolated severe aortic stenosis with unobstructed coronary arteries undergoing transcatheter aortic valve implantation (TAVI). The index of microcirculatory resistance (IMR), resistive reserve ratio (RRR) and coronary flow reserve (CFR) were measured in the left anterior descending artery before and after TAVI. Speckle tracking echocardiography was performed to assess cardiac function at baseline and repeated at 6 months. RESULTS IMR was significantly higher in patients with LFLGAS compared with patients with NFHGAS (24.1 (14.6 to 39.1) vs 12.8 (8.6 to 19.2), p=0.002), while RRR was significantly lower (1.4 (1.1 to 2.1) vs 2.6 (1.5 to 3.3), p=0.020). No significant differences were observed in CFR between the two groups. High IMR was associated with low stroke volume index, low cardiac output and reduced peak atrial longitudinal strain (PALS). TAVI determined no significant variation in microvascular function (IMR: 16.0 (10.4 to 26.1) vs 16.6 (10.2 to 25.6), p=0.403) and in PALS (15.9 (9.9 to 26.5) vs 20.1 (12.3 to 26.7), p=0.222). Conversely, left ventricular (LV) global longitudinal strain increased after TAVI (-13.2 (8.4 to 16.6) vs -15.1 (9.4 to 17.8), p=0.047). In LFLGAS, LV systolic function recovered after TAVI in patients with preserved microvascular function but not in patients with CMD. CONCLUSIONS CMD is more severe in patients with LFLGAS compared with NFHGAS and is associated with low-flow state, left atrial dysfunction and reduced cardiac performance.
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Affiliation(s)
- Roberto Scarsini
- Department of Medicine, Division of Cardiology, University of Verona, Verona, Italy .,Department of Medicine, Division of Cardiology, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Veneto, Italy
| | - Michele Pighi
- Department of Medicine, Division of Cardiology, University of Verona, Verona, Italy
| | - Andrea Mainardi
- Department of Medicine, Division of Cardiology, University of Verona, Verona, Italy
| | - Leonardo Portolan
- Department of Medicine, Division of Cardiology, University of Verona, Verona, Italy
| | - Paolo Springhetti
- Department of Medicine, Division of Cardiology, University of Verona, Verona, Italy
| | - Concetta Mammone
- Department of Medicine, Division of Cardiology, University of Verona, Verona, Italy
| | - Francesco Della Mora
- Department of Medicine, Division of Cardiology, University of Verona, Verona, Italy
| | - Diego Fanti
- Department of Medicine, Division of Cardiology, University of Verona, Verona, Italy
| | - Domenico Tavella
- Department of Medicine, Division of Cardiology, University of Verona, Verona, Italy
| | - Leonardo Gottin
- Department of Intensive Care and Anesthesiology, University of Verona, Verona, Italy
| | - Corinna Bergamini
- Department of Medicine, Division of Cardiology, University of Verona, Verona, Italy
| | - Giovanni Benfari
- Department of Medicine, Division of Cardiology, University of Verona, Verona, Italy
| | - Gabriele Pesarini
- Department of Medicine, Division of Cardiology, University of Verona, Verona, Italy
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14
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Khodaei S, Garber L, Bauer J, Emadi A, Keshavarz-Motamed Z. Long-term prognostic impact of paravalvular leakage on coronary artery disease requires patient-specific quantification of hemodynamics. Sci Rep 2022; 12:21357. [PMID: 36494362 DOI: 10.1038/s41598-022-21104-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 09/22/2022] [Indexed: 12/13/2022] Open
Abstract
Transcatheter aortic valve replacement (TAVR) is a frequently used minimally invasive intervention for patient with aortic stenosis across a broad risk spectrum. While coronary artery disease (CAD) is present in approximately half of TAVR candidates, correlation of post-TAVR complications such as paravalvular leakage (PVL) or misalignment with CAD are not fully understood. For this purpose, we developed a multiscale computational framework based on a patient-specific lumped-parameter algorithm and a 3-D strongly-coupled fluid-structure interaction model to quantify metrics of global circulatory function, metrics of global cardiac function and local cardiac fluid dynamics in 6 patients. Based on our findings, PVL limits the benefits of TAVR and restricts coronary perfusion due to the lack of sufficient coronary blood flow during diastole phase (e.g., maximum coronary flow rate reduced by 21.73%, 21.43% and 21.43% in the left anterior descending (LAD), left circumflex (LCX) and right coronary artery (RCA) respectively (N = 6)). Moreover, PVL may increase the LV load (e.g., LV load increased by 17.57% (N = 6)) and decrease the coronary wall shear stress (e.g., maximum wall shear stress reduced by 20.62%, 21.92%, 22.28% and 25.66% in the left main coronary artery (LMCA), left anterior descending (LAD), left circumflex (LCX) and right coronary artery (RCA) respectively (N = 6)), which could promote atherosclerosis development through loss of the physiological flow-oriented alignment of endothelial cells. This study demonstrated that a rigorously developed personalized image-based computational framework can provide vital insights into underlying mechanics of TAVR and CAD interactions and assist in treatment planning and patient risk stratification in patients.
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15
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Gupta K, Dixit P, Ananthasubramaniam K. Cardiac PET in aortic stenosis: Potential role in risk refinement? J Nucl Cardiol 2022; 29:3474-3479. [PMID: 34228335 DOI: 10.1007/s12350-021-02714-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 06/17/2021] [Indexed: 01/18/2023]
Affiliation(s)
- Kartik Gupta
- Department of Internal Medicine, Henry Ford Hospital, Detroit, MI, USA
| | | | - Karthik Ananthasubramaniam
- Department of Internal Medicine, Heart and Vascular Institute, Henry Ford West Bloomfield Hospital, West Bloomfield, MI, USA.
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16
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Kawase Y, Matsuo H. The Complexity of Physiology in the Evaluation of the Effect of Medication for Cardiovascular Disease. JACC Asia 2022; 2:704-705. [PMID: 36444325 PMCID: PMC9700002 DOI: 10.1016/j.jacasi.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Affiliation(s)
- Yoshiaki Kawase
- Address for correspondence: Dr Yoshiaki Kawase, Gifu Heart Center, 4-14-4, Yabutaminami, Gifu City, Gifu 500-8384, Japan.
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Tayal R, Kalra S, Seth A, Chandra P, Sohal S, Punamiya K, Rao R, Rastogi V, Kapardhi PLN, Sharma S, Kumar P, Arneja J, Mathew R, Kumar D, Mahesh NK, Trehan V. Clinical expert consensus document on the use of percutaneous left ventricular assist devices during complex high-risk PCI in India using a standardised algorithm. AsiaIntervention 2022; 8:75-85. [PMID: 36483283 PMCID: PMC9706744 DOI: 10.4244/aij-d-22-00021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 04/12/2022] [Indexed: 06/17/2023]
Abstract
Over the past decade, percutaneous left ventricular assist devices (pLVAD), such as the Impella microaxial flow pump (Abiomed), have been increasingly used to provide haemodynamic support during complex and high-risk revascularisation procedures to reduce the risk of intraprocedural haemodynamic compromise and to facilitate complete and optimal revascularisation. A global consensus on patient selection for the use of pLVADs, however, is currently lacking. Access to these devices is different across the world, thus, individual health care environments need to create and refine patient selection paradigms to optimise the use of these devices. The Impella pLVAD has recently been introduced in India and is being used in several centres in the management of high-risk percutaneous coronary intervention (PCI) and cardiogenic shock. With this increasing utilisation, there is a need for a standardised evaluation protocol to guide Impella use that factors in the unique economic and infrastructural characteristics of India's health care system to ensure that the needs of patients are optimally managed. In this consensus document, we present an algorithm to guide Impella use in Indian patients: to establish a standardised patient selection and usage paradigm that will allow both optimal patient outcomes and ongoing data collection.
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Affiliation(s)
- Rajiv Tayal
- Interventional Cardiology Unit, The Valley Hospital, Ridgewood, NJ, USA
| | - Sanjog Kalra
- Interventional Cardiology Unit, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Canada
| | - Ashok Seth
- Interventional Cardiology Unit, Fortis Escorts Heart Institute, New Delhi, India
| | - Praveen Chandra
- Interventional Cardiology Unit, Medanta Heart Institute, Gurgaon, India
| | - Sumit Sohal
- Interventional Cardiology Unit, Newark Beth Israel Medical Center, Newark, NJ, USA
| | - Kirti Punamiya
- Interventional Cardiology Unit, Breach Candy Hospital, Mumbai, India
| | - Ravinder Rao
- Interventional Cardiology Unit, Rajasthan Hospital, Jaipur, India
| | - Vishal Rastogi
- Interventional Cardiology Unit, Fortis Escorts Heart Institute, New Delhi, India
| | - P L N Kapardhi
- Interventional Cardiology Unit, CARE Hospitals, Hyderabad, India
| | - Sanjeev Sharma
- Interventional Cardiology Unit, Eternal Hospital, Jaipur, India
| | - Prathap Kumar
- Interventional Cardiology Unit, Meditrina Group of Hospitals, Kollam, India
| | - Jaspal Arneja
- Interventional Cardiology Unit, Arneja Heart and Multispeciality Hospital, Nagpur, India
| | - Rony Mathew
- Interventional Cardiology Unit, Lisie Hospital, Ernakulam, India
| | - Dilip Kumar
- Interventional Cardiology Unit, Medica Superspecialty Hospital, Kolkata, India
| | - N K Mahesh
- Interventional Cardiology Unit, Apollo Adlux Hospital, Kochi, India
| | - Vijay Trehan
- Interventional Cardiology Unit, Govind Ballabh Pant Hospital, New Delhi, India
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18
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Wienemann H, Ameskamp C, Mejía-Rentería H, Mauri V, Hohmann C, Baldus S, Adam M, Escaned J, Halbach M. Diagnostic performance of quantitative flow ratio versus fractional flow reserve and resting full-cycle ratio in intermediate coronary lesions. Int J Cardiol 2022; 362:59-67. [PMID: 35662563 DOI: 10.1016/j.ijcard.2022.05.066] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 05/23/2022] [Accepted: 05/29/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Quantitative flow ratio (QFR) is a novel angiography-derived index aimed to assess the functional relevance of coronary stenoses without pressure wires and adenosine. Good diagnostic yield with the hyperemic fractional flow reserve (FFR) have been reported, while data on the comparison of QFR to non-hyperemic pressure ratios (NHPR) are scarce. METHODS In this retrospective, observational and single-center study with a large population representative of the real practice, we assessed and compared the diagnostic performance of contrast flow (cQFR) and fixed flow (fQFR) QFR against the NHPR resting full-cyle ratio (RFR) using FFR as reference standard. RESULTS A total of 626 lesions from 544 patients were investigated. Mean diameter stenosis, FFR, cQFR, fQFR and RFR were 44.8%, 0.842, 0.847, 0.857 and 0.912, respectively. The correlation between cQFR and FFR was stronger (r = 0.830, P < 0.001) compared to that between FFR and RFR (r = 0.777, P < 0.001) and between cQFR and RFR (r = 0.687, P < 0.001). Using FFR ≤0.80 as reference, the sensitivity, specificity, positive predictive value, negative predictive value, and overall diagnostic accuracy for cQFR were 82%, 95%, 87%, 92%, and 91%, respectively. cQFR displayed a higher area under the curve (AUC) than fQFR and RFR (0.938 vs. 0.891 vs. 0.869, P < 0.01). The good diagnostic yield of cQFR appeared to be maintained in different clinical subsets including female gender, aortic valve stenosis and atrial fibrillation, and in different anatomical subsets including focal and non-focal lesions. CONCLUSION cQFR has a high and better diagnostic performance than the NHPR RFR in predicting FFR-based functional significance of coronary stenoses.
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Affiliation(s)
- Hendrik Wienemann
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, Kerpener Str. 61, 50937 Cologne, Germany
| | - Christopher Ameskamp
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, Kerpener Str. 61, 50937 Cologne, Germany
| | - Hernán Mejía-Rentería
- Department of Cardiology, Hospital Clínico San Carlos IDISSC and Universidad Complutense de Madrid, Madrid, Spain
| | - Victor Mauri
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, Kerpener Str. 61, 50937 Cologne, Germany
| | - Christopher Hohmann
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, Kerpener Str. 61, 50937 Cologne, Germany
| | - Stephan Baldus
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, Kerpener Str. 61, 50937 Cologne, Germany
| | - Matti Adam
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, Kerpener Str. 61, 50937 Cologne, Germany
| | - Javier Escaned
- Department of Cardiology, Hospital Clínico San Carlos IDISSC and Universidad Complutense de Madrid, Madrid, Spain
| | - Marcel Halbach
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, Kerpener Str. 61, 50937 Cologne, Germany.
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Abstract
Purpose of Review
Stress echocardiography is recommended in valvular heart disease when there is a mismatch between resting transthoracic echocardiography findings and symptoms during activities of daily living. We describe the current methodology and the evidence supporting these applications. Recent Findings The comprehensive stress echo assessment includes valve function (gradients and regurgitation), left ventricular global systolic and diastolic function, left atrial volume, pulmonary congestion, pulmonary arterial pressure, and right ventricular function, integrated with blood pressure response with cuff sphygmomanometer, chronotropic reserve with heart rate, and symptoms. Summary Recent guidelines recommend the evaluation of asymptomatic severe or symptomatic non-severe mitral regurgitation or stenosis with exercise stress and suspected low-flow, low-gradient severe aortic stenosis with reduced ejection fraction with low dose (up to 20 mcg, without atropine) dobutamine stress. Prospective, large-scale studies based on a comprehensive protocol (ABCDE +) capturing the multiplicity of clinical phenotypes are needed to support stress echo-driven treatment strategies.
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Affiliation(s)
- Rodolfo Citro
- Division of Cardiology, Cardiovascular and Thoracic Department, San Giovanni Di Dio E Ruggi d, Aragona University Hospital, Salerno, Italy
- Vascular Pathophysiology Unit, IRCCS Neuromed, Pozzilli, Isernia, Italy
| | - Francesca Bursi
- Dipartimento Di Scienze Della Salute, ASST Santi Paolo E Carlo Milano, Università Degli Studi Statale Di Milano, Ospedale San Paolo, Milan, Italy
| | - Michele Bellino
- Department of Medicine, Surgery, and Dentistry, University of Salerno, Salerno, Italy
| | - Eugenio Picano
- Institute of Clinical Physiology, National Research Council, CNR Research Campus, Via Moruzzi, 1, Building C, First floor, Room 130, 56124, Pisa, Italy.
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20
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Shan Y, Li J, Wu B, Barker AJ, Markl M, Lin J, Shu X, Wang Y. Aortic Viscous Energy Loss for Assessment of Valve-related
Hemodynamics in Asymptomatic Severe Aortic Stenosis. Radiol Cardiothorac Imaging 2022; 4:e220010. [PMCID: PMC9434981 DOI: 10.1148/ryct.220010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 06/26/2022] [Accepted: 07/15/2022] [Indexed: 08/29/2023]
Abstract
Purpose To investigate whether functional assessment of aberrant flow patterns by viscous energy loss (E′L ) using four-dimensional (4D) flow MRI could determine aortic stenosis (AS) severity in accordance with transvalvular energy loss and aid in surgical decision-making in asymptomatic patients with severe AS. Materials and Methods In this prospective, single-center study, E′L was measured in the thoracic aorta of 74 consecutive asymptomatic patients with severe AS and preserved left ventricular ejection fraction who presented between January 2015 and December 2017, and 23 healthy volunteers using 4D flow MRI. Transvalvular energy loss was assessed based on the energy loss index (ELI) measured using Doppler echocardiography. The association between E′L and AS-related events including aortic valve replacement was evaluated by receiver operating characteristic curve analysis, Kaplan-Meier analysis, and multivariable Cox regression analysis. Results Among 74 asymptomatic patients with severe AS (mean age, 60 years ± 9 [SD]; 43 men; 56 with bicuspid aortic valve), 33 experienced AS-related events during a median follow-up of 42 months (IQR, 30–53 months). Altered flow patterns in severe AS resulted in a sevenfold increase in peak systolic E′L in the ascending aorta compared with controls (13.9 mW ± 3.4 vs 1.80 mW ± 0.44; P < .001). Peak systolic E′L in the ascending aorta was independently associated with the ELI (standardized β, −0.52; P < .001) and showed better discrimination for AS-related events (area under the curve, 0.83; 95% CI: 0.74, 0.93; P < .001) than conventional echocardiographic parameters. After adjustment for confounding variables, peak systolic E′L in the ascending aorta was associated with a significant increase in AS-related events (P < .001 for adjusted hazard ratio). Conclusion Changes in AS-mediated poststenotic three-dimensional outflow patterns can be quantified by 4D flow MRI-derived energetic markers to aid in the risk stratification and clinical management of asymptomatic patients with severe AS. Keywords: Aortic Stenosis, 4D Flow MRI, Flow Energetics, Vascular, Aorta, Aortic Valve, MR Angiography Supplemental material is available for this article. © RSNA, 2022
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Affiliation(s)
| | | | - Boting Wu
- From the Shanghai Institute of Medical Imaging (Y.S., J. Lin, X.S.,
Y.W.), Shanghai Institute of Cardiovascular Diseases (J. Li, X.S., Y.W.),
Department of Cardiovascular Surgery (J. Li), and Department of Transfusion
(B.W.), Zhongshan Hospital Fudan University, 180 Fenglin Road, Shanghai 200032,
China; Department of Radiology, Children’s Hospital Colorado, University
of Colorado Denver, Anschutz Medical Campus, Aurora, Colo (A.J.B.); and
Department of Radiology, Feinberg School of Medicine, Northwestern University,
Chicago, Ill (M.M.)
| | - Alex J. Barker
- From the Shanghai Institute of Medical Imaging (Y.S., J. Lin, X.S.,
Y.W.), Shanghai Institute of Cardiovascular Diseases (J. Li, X.S., Y.W.),
Department of Cardiovascular Surgery (J. Li), and Department of Transfusion
(B.W.), Zhongshan Hospital Fudan University, 180 Fenglin Road, Shanghai 200032,
China; Department of Radiology, Children’s Hospital Colorado, University
of Colorado Denver, Anschutz Medical Campus, Aurora, Colo (A.J.B.); and
Department of Radiology, Feinberg School of Medicine, Northwestern University,
Chicago, Ill (M.M.)
| | - Michael Markl
- From the Shanghai Institute of Medical Imaging (Y.S., J. Lin, X.S.,
Y.W.), Shanghai Institute of Cardiovascular Diseases (J. Li, X.S., Y.W.),
Department of Cardiovascular Surgery (J. Li), and Department of Transfusion
(B.W.), Zhongshan Hospital Fudan University, 180 Fenglin Road, Shanghai 200032,
China; Department of Radiology, Children’s Hospital Colorado, University
of Colorado Denver, Anschutz Medical Campus, Aurora, Colo (A.J.B.); and
Department of Radiology, Feinberg School of Medicine, Northwestern University,
Chicago, Ill (M.M.)
| | - Jiang Lin
- From the Shanghai Institute of Medical Imaging (Y.S., J. Lin, X.S.,
Y.W.), Shanghai Institute of Cardiovascular Diseases (J. Li, X.S., Y.W.),
Department of Cardiovascular Surgery (J. Li), and Department of Transfusion
(B.W.), Zhongshan Hospital Fudan University, 180 Fenglin Road, Shanghai 200032,
China; Department of Radiology, Children’s Hospital Colorado, University
of Colorado Denver, Anschutz Medical Campus, Aurora, Colo (A.J.B.); and
Department of Radiology, Feinberg School of Medicine, Northwestern University,
Chicago, Ill (M.M.)
| | - Xianhong Shu
- From the Shanghai Institute of Medical Imaging (Y.S., J. Lin, X.S.,
Y.W.), Shanghai Institute of Cardiovascular Diseases (J. Li, X.S., Y.W.),
Department of Cardiovascular Surgery (J. Li), and Department of Transfusion
(B.W.), Zhongshan Hospital Fudan University, 180 Fenglin Road, Shanghai 200032,
China; Department of Radiology, Children’s Hospital Colorado, University
of Colorado Denver, Anschutz Medical Campus, Aurora, Colo (A.J.B.); and
Department of Radiology, Feinberg School of Medicine, Northwestern University,
Chicago, Ill (M.M.)
| | - Yongshi Wang
- From the Shanghai Institute of Medical Imaging (Y.S., J. Lin, X.S.,
Y.W.), Shanghai Institute of Cardiovascular Diseases (J. Li, X.S., Y.W.),
Department of Cardiovascular Surgery (J. Li), and Department of Transfusion
(B.W.), Zhongshan Hospital Fudan University, 180 Fenglin Road, Shanghai 200032,
China; Department of Radiology, Children’s Hospital Colorado, University
of Colorado Denver, Anschutz Medical Campus, Aurora, Colo (A.J.B.); and
Department of Radiology, Feinberg School of Medicine, Northwestern University,
Chicago, Ill (M.M.)
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21
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Pujitha V, Pandey NN, Deepti S, Kumar S. Incidentally detected Vieussens' arterial ring-to-pulmonary trunk fistula in a patient with aortic stenosis. J Card Surg 2022; 37:3882-3883. [PMID: 35924997 DOI: 10.1111/jocs.16828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 07/14/2022] [Accepted: 07/18/2022] [Indexed: 11/28/2022]
Abstract
We report a case of a 45-year-old man with severe aortic stenosis where computed tomography angiography incidentally revealed a fistulous communication between the conal branches of the right coronary artery and anterior interventricular artery and the left anterolateral aspect of the pulmonary trunk with a conglomerate of nondilated tortuous vessels along the anterior surface of right ventricular outflow tract.
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Affiliation(s)
- Vidiyala Pujitha
- Department of Cardiovascular Radiology & Endovascular Interventions, All India Institute of Medical Sciences, New Delhi, India
| | - Niraj Nirmal Pandey
- Department of Cardiovascular Radiology & Endovascular Interventions, All India Institute of Medical Sciences, New Delhi, India
| | - Siddharthan Deepti
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India
| | - Sanjeev Kumar
- Department of Cardiovascular Radiology & Endovascular Interventions, All India Institute of Medical Sciences, New Delhi, India
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22
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Zhou J, Onuma Y, Garg S, Kotoku N, Kageyama S, Masuda S, Ninomiya K, Huo Y, Reiber JHC, Tu S, Piek JJ, Escaned J, Perera D, Bourantas C, Yan H, Serruys PW. Angiography derived assessment of the coronary microcirculation: is it ready for prime time? Expert Rev Cardiovasc Ther 2022; 20:549-566. [PMID: 35899781 DOI: 10.1080/14779072.2022.2098117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Non-obstructive coronary arteries (NOCA) are present in 39.7% to 62.4% of patients who undergo elective angiography. Coronary microcirculation (<400 µm) is not visible on angiography therefore functional assessment, invasive or non-invasive plays a prior role to help provide a more personalized diagnosis of angina. AREA COVERED In this review, we revise the pathophysiology, clinical importance and invasive assessment of the coronary microcirculation, and discuss angiography-derived indices of microvascular resistance. A comprehensive literature review over four decades is also undertaken. EXPERT OPINION The coronary microvasculature plays an important role in flow autoregulation and metabolic regulation. Invasive assessment of microvascular resistance is a validated modality with independent prognostic value, nevertheless, its routine application is hampered by the requirement of intravascular instrumentation and hyperaemic agents. The angiography-derived index of microvascular resistance has emerged as a promising surrogate in pilot studies, however, more data are needed to validate and compare the diagnostic and prognostic accuracy of different equations as well as to illustrate the relationship between angiography-derived parameters for epicardial coronary arteries and those for the microvasculature.
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Affiliation(s)
- Jinying Zhou
- National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China.,Department of Cardiology, National University of Ireland Galway (NUIG), Galway, Ireland
| | - Yoshinobu Onuma
- Department of Cardiology, National University of Ireland Galway (NUIG), Galway, Ireland
| | - Scot Garg
- Department of CardiologyRoyal Blackburn Hospital, Blackburn, United Kingdom
| | - Nozomi Kotoku
- Department of Cardiology, National University of Ireland Galway (NUIG), Galway, Ireland
| | - Shigetaka Kageyama
- Department of Cardiology, National University of Ireland Galway (NUIG), Galway, Ireland
| | - Shinichiro Masuda
- Department of Cardiology, National University of Ireland Galway (NUIG), Galway, Ireland
| | - Kai Ninomiya
- Department of Cardiology, National University of Ireland Galway (NUIG), Galway, Ireland
| | - Yunlong Huo
- PKU-HKUST Shenzhen-Hong Kong Institution, Shenzhen, China; Department of Cardiology, Peking University First Hospital, Beijing, China; Institute of Mechanobiology & Medical Engineering, School of Life Sciences & Biotechnology, Shanghai Jiao Tong University, Shanghai, China
| | - Johan H C Reiber
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Shengxian Tu
- School of Biomedical Engineering,Biomedical Instrument Institute Shanghai Jiao Tong University, Shanghai, China
| | - Jan J Piek
- Department of Cardiology, Academic Medical Center of Amsterdam, Amsterdam, The Netherlands
| | - Javier Escaned
- Complutense University of Madrid Hospital Clinico San Carlos IDISCC, Madrid, Spain
| | - Divaka Perera
- Cardiovascular Division, King's College London, London, UK
| | - Christos Bourantas
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, UK; Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, UK; Institute of Cardiovascular Sciences, University College London, London, UK
| | - Hongbing Yan
- Chinese Academy of Medical Sciences, Shenzhen, China; Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital,, Beijing, China
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23
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Długosz D, Surdacki A, Zawiślak B, Bartuś S, Chyrchel B. Impaired Left Ventricular Circumferential Midwall Systolic Performance Appears Linked to Depressed Preload, but Not Intrinsic Contractile Dysfunction or Excessive Afterload, in Paradoxical Low-Flow/Low-Gradient Severe Aortic Stenosis. J Clin Med 2022; 11:2873. [PMID: 35628998 PMCID: PMC9144151 DOI: 10.3390/jcm11102873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 04/30/2022] [Accepted: 05/09/2022] [Indexed: 11/16/2022] Open
Abstract
Paradoxical low-flow/low-gradient aortic stenosis (P-LFLG-AS) occurs in about one-third of patients with severe AS and preserved left ventricular (LV) ejection fraction (EF). Our aim was to differentiate between altered LV loading conditions and contractility as determinants of subtle LV systolic dysfunction in P-LFLG-AS. We retrospectively analyzed medical records of patients with isolated severe degenerative AS and preserved EF (30 subjects with P-LFLG-AS and 30 patients with normal-flow/high-gradient severe AS (NFHG-AS)), without relevant coexistent diseases (e.g., diabetes, coronary artery disease and chronic kidney disease) or any abnormalities which could account for a low-flow state. Patients with P-LFLG-AS and NFHG-AS did not differ in aortic valve area index and most clinical characteristics. Compared to NFHG-AS, subjects with P-LFLG-AS exhibited smaller LV end-diastolic diameter (LVd) (44 ± 5 vs. 54 ± 5 mm, p < 0.001) (consistent with lower LV preload) with pronounced concentric remodeling, higher valvulo-arterial impedance (3.8 ± 1.1 vs. 2.2 ± 0.5 mmHg per mL/m2, p < 0.001) and diminished systemic arterial compliance (0.45 ± 0.11 vs. 0.76 ± 0.23 mL/m2 per mmHg, p < 0.001), while circumferential end-systolic LV midwall stress (cESS), an estimate of afterload at the LV level, was similar in P-LFLG-AS and NFHG-AS (175 ± 83 vs. 198 ± 69 hPa, p = 0.3). LV midwall fractional shortening (mwFS) was depressed in P-LFLG-AS vs. NFHG-AS (12.3 ± 3.5 vs. 14.7 ± 2.9%, p = 0.006) despite similar EF (61 ± 6 vs. 59 ± 8%, p = 0.4). By multiple regression, the presence of P-LFLG-AS remained a significant predictor of lower mwFS compared to NFHG-AS upon adjustment for cESS (β ± SEM: −2.35 ± 0.67, p < 0.001); however, the significance was lost after further correction for LVd (β = −1.10 ± 0.85, p = 0.21). In conclusion, the association of P-LFLG-AS with a lower cESS-adjusted mwFS, an index of afterload-corrected LV circumferential systolic function at the midwall level, appears secondary to a smaller LV end-diastolic cavity size according to the Frank−Starling law. Thus, low LV preload, not intrinsic contractile dysfunction or excessive afterload, may account for impaired LV circumferential midwall systolic performance in P-LFLG-AS.
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Affiliation(s)
- Dorota Długosz
- Department of Cardiology and Cardiovascular Interventions, University Hospital, 2 Jakubowskiego Street, 30-688 Cracow, Poland; (D.D.); (A.S.); (S.B.)
| | - Andrzej Surdacki
- Department of Cardiology and Cardiovascular Interventions, University Hospital, 2 Jakubowskiego Street, 30-688 Cracow, Poland; (D.D.); (A.S.); (S.B.)
- Second Department of Cardiology, Institute of Cardiology, Jagiellonian University, 2 Jakubowskiego Street, 30-688 Cracow, Poland
| | - Barbara Zawiślak
- Intensive Care Unit, Department of Cardiology and Cardiovascular Interventions, University Hospital, 2 Jakubowskiego Street, 30-688 Cracow, Poland;
| | - Stanisław Bartuś
- Department of Cardiology and Cardiovascular Interventions, University Hospital, 2 Jakubowskiego Street, 30-688 Cracow, Poland; (D.D.); (A.S.); (S.B.)
- Second Department of Cardiology, Institute of Cardiology, Jagiellonian University, 2 Jakubowskiego Street, 30-688 Cracow, Poland
| | - Bernadeta Chyrchel
- Department of Cardiology and Cardiovascular Interventions, University Hospital, 2 Jakubowskiego Street, 30-688 Cracow, Poland; (D.D.); (A.S.); (S.B.)
- Second Department of Cardiology, Institute of Cardiology, Jagiellonian University, 2 Jakubowskiego Street, 30-688 Cracow, Poland
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24
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Abstract
Ischemic heart disease (IHD) is commonly recognized as the consequence of coronary atherosclerosis and obstructive coronary artery disease (CAD). However, a significant number of patients may present angina or myocardial infarction even in the absence of any significant coronary artery stenosis and impairment of the coronary microcirculation has been increasingly implicated as a relevant cause of IHD. The term "coronary microvascular dysfunction" (CMD) encompasses several pathogenic mechanisms resulting in functional and/or structural changes in the coronary microcirculation and determining angina and myocardial ischemia in patients with angina without obstructive CAD ("primary" microvascular angina), as well as in several other conditions, including obstructive CAD, cardiomyopathies, Takotsubo syndrome and heart failure, especially the phenotype with preserved ejection fraction. The pathogenesis of CMD is complex and involves the combination of functional and structural alterations leading to impaired coronary blood flow and resulting in myocardial ischemia. In the absence of therapies specifically targeting CMD, attention has been focused on the role of modifiable risk factors. Here, we provide updated evidence regarding the pathophysiological mechanisms underlying CMD, with a particular focus on the role of cardiovascular risk factors and comorbidities. Moreover, we discuss the specific pathogenic mechanisms of CMD across the different cardiovascular diseases, aiming to pave the way for further research and the development of novel strategies for a precision medicine approach.
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Affiliation(s)
- Filippo Crea
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS.,Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart
| | - Rocco A Montone
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS
| | - Riccardo Rinaldi
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart
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25
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Del Buono MG, Montone RA, Camilli M, Carbone S, Narula J, Lavie CJ, Niccoli G, Crea F. Coronary Microvascular Dysfunction Across the Spectrum of Cardiovascular Diseases: JACC State-of-the-Art Review. J Am Coll Cardiol 2021; 78:1352-1371. [PMID: 34556322 PMCID: PMC8528638 DOI: 10.1016/j.jacc.2021.07.042] [Citation(s) in RCA: 165] [Impact Index Per Article: 55.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 07/08/2021] [Accepted: 07/19/2021] [Indexed: 12/12/2022]
Abstract
Coronary microvascular dysfunction (CMD) encompasses several pathogenetic mechanisms involving coronary microcirculation and plays a major role in determining myocardial ischemia in patients with angina without obstructive coronary artery disease, as well as in several other conditions, including obstructive coronary artery disease, nonischemic cardiomyopathies, takotsubo syndrome, and heart failure, especially the phenotype associated with preserved ejection fraction. Unfortunately, despite the identified pathophysiological and prognostic role of CMD in several conditions, to date, there is no specific treatment for CMD. Due to the emerging role of CMD as common denominator in different clinical phenotypes, additional research in this area is warranted to provide personalized treatments in this "garden variety" of patients. The purpose of this review is to describe the pathophysiological mechanisms of CMD and its mechanistic and prognostic role across different cardiovascular diseases. We will also discuss diagnostic modalities and the potential therapeutic strategies resulting from recent clinical studies.
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Affiliation(s)
- Marco Giuseppe Del Buono
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy. https://twitter.com/marcodelbuono3
| | - Rocco A Montone
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
| | - Massimiliano Camilli
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Salvatore Carbone
- Department of Kinesiology and Health Sciences, College of Humanities and Sciences, Virginia Commonwealth University, Richmond, Virginia, USA; VCU Pauley Heart Center, Division of Cardiology, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Jagat Narula
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Carl J Lavie
- Department of Cardiovascular Diseases, Ochsner Clinical School, New Orleans, Louisiana, USA
| | | | - Filippo Crea
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy; Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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26
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Di Gioia G, Bartunek J, Tesorio T, Vukcevic V, Aleksandric S, Dobric M, Franco D, Barbato E, Banovic M. Pathophysiology, Diagnosis, and Treatment of Patients with Concomitant Severe Aortic Stenosis and Coronary Artery Disease: A Closer Look to the Unresolved Perplexity. J Clin Med 2021; 10:1617. [PMID: 33920349 DOI: 10.3390/jcm10081617] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 04/01/2021] [Accepted: 04/08/2021] [Indexed: 01/09/2023] Open
Abstract
Degenerative aortic stenosis (AS) and coronary artery disease (CAD) are the most prevalent cardiovascular diseases in developed countries, and they coexist in up to 50% of patients. The pathophysiological rationale behind concomitant AS and CAD is discussed in detail in this review, together with prognostic implications. Detecting CAD in patients with AS may be challenging, as AS may mask the existence and symptoms of CAD. The safety and reliability of invasive and non-invasive physiological assessment for epicardial coronary disease are also a matter of debate. Finally, the selection and timing of optimal treatment of CAD in patients with severe AS are still unclear. Given the aging of the population, the increase in the prevalence of AS, and the ongoing paradigm shift in its treatment, controversies in the diagnosis and treatment of CAD in the setting of AS are deemed to grow in importance. In this paper, we present contemporary issues in the diagnosis and management of CAD in patients with severe AS who are transcatheter aortic valve implantation (TAVI) candidates and provide perspective on the treatment approach.
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27
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Onishi K, Watanabe H, Kakehi K, Ikeda T, Takase T, Yamaji K, Ueno M, Kobuke K, Nakazawa G, Miyazaki S, Iwanaga Y. Determinants and prognostic implications of instantaneous wave-free ratio in patients with mild to intermediate coronary stenosis: Comparison with those of fractional flow reserve. PLoS One 2020; 15:e0237275. [PMID: 32760123 PMCID: PMC7410195 DOI: 10.1371/journal.pone.0237275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 07/22/2020] [Indexed: 01/10/2023] Open
Abstract
The instantaneous wave-free ratio (iFR) is used for assessing the hemodynamic severity of a lesion, as an alternative to the fractional flow reserve (FFR). We evaluated the relationship between iFR and FFR in detail and the clinical significance of iFR in patients with mild to intermediate coronary artery stenosis. We recruited consecutive 323 patients (421 lesions) with lesions exhibiting 30% to 80% diameter stenosis on angiography in whom FFR and iFR were measured. In the total lesions, mean diameter stenosis was 48.6% ± 9.0%, and physiological significance, defined by FFR of 0.80 or less or by iFR of 0.92 or less, was observed in 32.5% or 33.5%, respectively. Mismatch between iFR and FFR was observed in 18.1% of the lesions. Clinical factors did not predict FFR value; however, gender, diabetes mellitus, aortic stenosis, anemia, high-sensitivity CRP value, and renal function predicted iFR value. In multivariate logistic analysis after adjustment for FFR value, gender (p < 0.001), diabetes mellitus (p = 0.005), aortic stenosis (p = 0.016), high-sensitivity CRP (p < 0.001), and renal function (p = 0.003) were all independent predictors of iFR value. In Kaplan-Meier analysis, the baseline iFR predicted the subsequent major cardiovascular events (MACE) (hazard ratio, 2.40; 95% CI, 1.16–4.93; p = 0.018) and the results of the iFR-guided strategy for predicting rates of MACE and myocardial infarction/revascularization were superior to those of the FFR-guided strategy. In conclusion, significant clinical factors predicted iFR value, which affected the prognostic capacity. The iFR-guided strategy may be superior in patients with mild to intermediate stenosis.
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Affiliation(s)
- Kyohei Onishi
- Division of Cardiology, Department of Internal Medicine, Kindai University Faculty of Medicine, Osakasayama, Japan
| | - Heitaro Watanabe
- Division of Cardiology, Department of Internal Medicine, Kindai University Faculty of Medicine, Osakasayama, Japan
| | - Kazuyoshi Kakehi
- Division of Cardiology, Department of Internal Medicine, Kindai University Faculty of Medicine, Osakasayama, Japan
| | - Tomoyuki Ikeda
- Division of Cardiology, Department of Internal Medicine, Kindai University Faculty of Medicine, Osakasayama, Japan
| | - Toru Takase
- Division of Cardiology, Department of Internal Medicine, Kindai University Faculty of Medicine, Osakasayama, Japan
| | - Kenji Yamaji
- Division of Cardiology, Department of Internal Medicine, Kindai University Faculty of Medicine, Osakasayama, Japan
| | - Masafumi Ueno
- Division of Cardiology, Department of Internal Medicine, Kindai University Faculty of Medicine, Osakasayama, Japan
| | - Kazuhiro Kobuke
- Division of Cardiology, Department of Internal Medicine, Kindai University Faculty of Medicine, Osakasayama, Japan
| | - Gaku Nakazawa
- Division of Cardiology, Department of Internal Medicine, Kindai University Faculty of Medicine, Osakasayama, Japan
| | | | - Yoshitaka Iwanaga
- Division of Cardiology, Department of Internal Medicine, Kindai University Faculty of Medicine, Osakasayama, Japan
- * E-mail:
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28
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Lentz S, Grossman A, Koyfman A, Long B. High-Risk Airway Management in the Emergency Department: Diseases and Approaches, Part II. J Emerg Med 2020; 59:573-585. [PMID: 32591298 DOI: 10.1016/j.jemermed.2020.05.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 04/30/2020] [Accepted: 05/04/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Successful airway management is critical to the practice of emergency medicine. Thus, emergency physicians must be ready to optimize and prepare for airway management in critically ill patients with a wide range of physiologic challenges. Challenges in airway management commonly encountered in the emergency department are discussed using a pearl and pitfall discussion in this second part of a 2-part series. OBJECTIVE This narrative review presents an evidence-based approach to airway and patient management during endotracheal intubation in challenging cases commonly encountered in the emergency department. DISCUSSION Adverse events during emergent airway management are common with postintubation cardiac arrest, reported in as many as 1 in 25 intubations. Many of these adverse events can be avoided by proper identification and understanding the underlying physiology, preparation, and postintubation management. Those with high-risk features including trauma, elevated intracranial pressure, upper gastrointestinal bleed, cardiac tamponade, aortic stenosis, morbid obesity, and pregnancy must be managed with airway expertise. CONCLUSIONS This narrative review discusses the pearls and pitfalls of commonly encountered physiologic high-risk intubations with a focus on the emergency clinician.
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Affiliation(s)
- Skyler Lentz
- Division of Emergency Medicine, Department of Surgery, Larner College of Medicine, University of Vermont, Burlington, Vermont
| | - Alexandra Grossman
- Department of Emergency Medicine, Harbor-University of California, Los Angeles Medical Center, Torrance, California
| | - Alex Koyfman
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
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