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Qi W, Mathisen P, Kjekshus J, Simonsen S, Endresen K, Bjørnerheim R, Hall C. The effect of aortic valve replacement on N-terminal natriuretic propeptides in patients with aortic stenosis. Clin Cardiol 2006; 25:174-80. [PMID: 12000075 PMCID: PMC6654173 DOI: 10.1002/clc.4960250408] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Increased plasma concentrations of natriuretic peptides have been demonstrated to be associated with increased intracardiac pressure and left ventricular (LV) hypertrophy. After aortic valve replacement (AVR) in aortic stenosis patients, there is a relief of the left outflow obstruction with a substantial hemodynamic improvement. This is followed by a gradual regression of the LV hypertrophy. HYPOTHESIS After AVR, reduction in LV filling pressure is expected to occur rapidly, while regression of LV hypertrophy will take place over a longer time period. On this basis we hypothesized that the plasma levels of N-terminal proatrial natriuretic peptide (NT-proANP) would be reduced early in the postoperative period, while N-terminal probrain natriuretic peptide (NT-proBNP), through its closer reflection of LV hypertrophy, would be sustained for a longer period. METHODS Two groups of patients with aortic stenosis undergoing AVR were followed for 4 and 12 months, respectively. Plasma concentrations of NT-proANP and NT-proBNP were measured before and after AVR and related to preoperative findings and changes in the aortic valve area index. RESULTS Before AVR, the patients had significantly increased plasma levels of NT-proANP and NT-proBNP. After AVR, NT- proANP was decreased at 4 and 12 months but remained elevated compared with controls. N-terminal-proBNP tended to decrease, but did not change significantly. When the patients were followed for 12 months, only those with elevated preoperative pulmonary capillary wedge pressure had decreased peptide levels (NT-proANP: p = 0.017, NT-proBNP: p = 0.058). There was no regression of LV hypertrophy. The patients with the largest postoperative valve area index [1.27 (1.10-1.55) cm2/m2] had the largest reduction of NT-proBNP (47%). Those with the smallest valve area index [0.67 (0.54-0.73) cm2/m2] had no decrease in NT-proBNP. CONCLUSIONS Our study suggests that a reduction in left atrial pressure is the main factor causing the change of NT-proANP level after AVR. A small prosthetic valve orifice area with a high aortic valve gradient might prevent regression of LV hypertrophy, thus representing a stimulus for increased cardiac secretion of NT-proBNP.
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Abstract
In recent years, experience with transcatheter aortic valve implantation has led to improved outcomes in elderly patients with severe aortic stenosis (AS) who may not have previously been considered for intervention. These patients are often frail with significant comorbid conditions. As the prevalence of AS increases, there is a need for improved assessment parameters to determine the patients most likely to benefit from this novel procedure. This review discusses the diagnostic criteria for severe AS and the trials available to aid in the decision to refer for aortic valve procedures in the elderly.
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Masuda C, Dohi K, Sakurai Y, Bessho Y, Fukuda H, Fujii S, Sugimoto T, Tanabe M, Onishi K, Shiraki K, Ito M, Nobori T. Impact of chronic kidney disease on the presence and severity of aortic stenosis in patients at high risk for coronary artery disease. Cardiovasc Ultrasound 2011; 9:31. [PMID: 22087774 PMCID: PMC3228740 DOI: 10.1186/1476-7120-9-31] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2011] [Accepted: 11/16/2011] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE We evaluated the impact of chronic kidney disease (CKD) on the presence and severity of aortic stenosis (AS) in patients at high risk for coronary artery disease (CAD). METHODS One hundred and twenty consecutive patients who underwent invasive coronary angiography were enrolled. Aortic valve area (AVA) was calculated by the continuity equation using transthoracic echocardiography, and was normalized by body surface area (AVA index). RESULTS Among all 120 patients, 78% had CAD, 55% had CKD (stage 3: 81%; stage 4: 19%), and 34% had AS (AVA < 2.0 cm²). Patients with AS were older, more often female, and had a higher frequency of CKD than those without AS, but the prevalence of CAD and most other coexisting conventional risk factors was similar between patients with and without AS. Multivariate linear regression analysis indicated that only CKD and CAD were independent determinants of AVA index with standardized coefficients of -0.37 and -0.28, respectively. When patients were divided into 3 groups (group 1: absence of CKD and CAD, n = 16; group 2: presence of either CKD or CAD, n = 51; and group 3: presence of both CKD and CAD, n = 53), group 3 had the smallest AVA index (1.19 ± 0.30*# cm²/m², *p < 0.05 vs. group 1: 1.65 ± 0.32 cm²/m², and #p < 0.05 vs. group 2: 1.43 ± 0.29* cm²/m²) and the highest peak velocity across the aortic valve (1.53 ± 0.41*# m/sec; *p < 0.05 vs. group 1: 1.28 ± 0.29 m/sec, and #p < 0.05 vs. group 2: 1.35 ± 0.27 m/sec). CONCLUSION CKD, even pre-stage 5 CKD, has a more powerful impact on the presence and severity of AS than other conventional risk factors for atherosclerosis in patients at high risk for CAD.
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Kanamori N, Taniguchi T, Morimoto T, Watanabe H, Shiomi H, Ando K, Murata K, Kitai T, Kawase Y, Izumi C, Miyake M, Mitsuoka H, Kato M, Hirano Y, Matsuda S, Nagao K, Inada T, Mabuchi H, Takeuchi Y, Yamane K, Toyofuku M, Ishii M, Minamino-Muta E, Kato T, Inoko M, Ikeda T, Komasa A, Ishii K, Hotta K, Higashitani N, Kato Y, Inuzuka Y, Maeda C, Jinnai T, Morikami Y, Saito N, Minatoya K, Aoyama T, Kimura T. Prognostic Impact of Aortic Valve Area in Conservatively Managed Patients With Asymptomatic Severe Aortic Stenosis With Preserved Ejection Fraction. J Am Heart Assoc 2020; 8:e010198. [PMID: 30712486 PMCID: PMC6405588 DOI: 10.1161/jaha.118.010198] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background Data are scarce on the role of aortic valve area (AVA) to identify those patients with asymptomatic severe aortic stenosis (AS) who are at high risk of adverse events. We sought to explore the prognostic impact of AVA in asymptomatic patients with severe AS in a large observational database. Methods and Results Among 3815 consecutive patients with severe AS enrolled in the CURRENT AS (Contemporary Outcomes After Surgery and Medical Treatment in Patients With Severe Aortic Stenosis) registry, the present study included 1309 conservatively managed asymptomatic patients with left ventricular ejection fraction ≥50%. The study patients were subdivided into 3 groups based on AVA (group 1: AVA >0.80 cm2, N=645; group 2: 0.8 cm2 ≥AVA >0.6 cm2, N=465; and group 3: AVA ≤0.6 cm2, N=199). The prevalence of very severe AS patients (peak aortic jet velocity ≥5 m/s or mean aortic pressure gradient ≥60 mm Hg) was 2.0%, 5.8%, and 26.1% in groups 1, 2, and 3, respectively. The cumulative 5‐year incidence of AVR was not different across the 3 groups (39.7%, 43.7%, and 39.9%; P=0.43). The cumulative 5‐year incidence of the primary outcome measure (a composite of aortic valve–related death or heart failure hospitalization) was incrementally higher with decreasing AVA (24.1%, 29.1%, and 48.1%; P<0.001). After adjusting for confounders, the excess risk of group 3 and group 2 relative to group 1 for the primary outcome measure remained significant (hazard ratio, 2.21, 95% CI, 1.56–3.11, P<0.001; and hazard ratio, 1.34, 95% CI, 1.01–1.78, P=0.04, respectively). Conclusions AVA ≤0.6 cm2 would be a useful marker to identify those high‐risk patients with asymptomatic severe AS, who might benefit from early AVR. Clinical Trial Registration URL: www.umin.ac.jp. Unique identifier: UMIN000012140. See Editorial by Tribouilloy et al
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Research Support, Non-U.S. Gov't |
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Shen H, Stacey BR, Applegate RJ, Zhao D, Gandhi SK, Kon ND, Kincaid EH, Pu M. Assessment of the prognostic significance of low gradient severe aortic stenosis and preserved left ventricular function requires the integration of the consistency of stroke volume calculation and clinical data. Echocardiography 2020; 37:14-21. [PMID: 31990437 DOI: 10.1111/echo.14561] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Accepted: 11/19/2019] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND This study was to evaluate the prognostic significance of low gradient severe aortic stenosis (LG SAS) and preserved left ventricular ejection fraction (LVEF) with the integration of echocardiographic and clinical data. METHODS The study included 172 patients with LG SAS (AVAi ≤ 0.6 cm2 /m2 , mean aortic pressure gradient < 40 mm Hg) and LVEF (≥ 50%). LV outflow tract diameters were measured at both the aortic valve annulus and 5 mm below the annulus for the measurement consistency. Patients were divided into the low flow LG SAS (LF/LG SAS: SVi < 35mL/m2 and AVAi ≤ 0.6 cm2 /m2 ) and normal-flow LG SAS groups (NF/LG SAS: SVi ≥ 35mL/m2 and AVAi ≤ 0.6 cm2 /m2 ). Echocardiographic findings and clinical data were systematically analyzed with mean follow-up of 3.0 ± 1.6 years. RESULTS LF/LG SAS had significantly smaller AVAi, lower SVi, a higher prevalence of atrial fibrillation (28% vs 12% P = .01) and diabetes (47% vs 27% P = .007) and lower 3-year cumulative survival than NF/LG SAS. Multivariable analysis showed that dyspnea, renal dysfunction (CI 1.42-3.99, P < .01), left atrial diameter, and SVi were independently associated with an increased risk for all-cause mortality. Aortic valve intervention (AVI) improved survival in LF/LG SAS (68% vs 48%, P < .05) in comparison with medical management (HR: 4.20, CI: 1.12-15.76, P = .03), but only modestly in NF/LG SAS (75% vs 65% P > .05). CONCLUSION Outcome of LG SAS was independently associated with clinical characteristics. AVI likely improved outcome of LF/LG SAS who had high-risk clinical characteristics and unfavorable echocardiographic findings.
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Vranic II. Electrocardiographic appearance of aortic stenosis before and after aortic valve replacement. Ann Noninvasive Electrocardiol 2017; 22. [PMID: 28429500 DOI: 10.1111/anec.12457] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Accepted: 03/13/2017] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND So far, the specific appearance of QRS complex, ST-segment, and T wave was observed in aortic stenosis (AS). S-wave dynamic change in leads V1 -V3 was not reported in AS. METHODS In a single-center, prospective study, we included a total number of 1.175 patients who underwent surgical aortic valve replacement (AVR). We conducted 3-year gathering of patients with symptomatic and asymptomatic severe AS, and separated them by hemodynamic stability into groups A and B, through EFLV (of more or less than 50%), AVA (of more or less than 0.9 cm2 ), PG (between 55 and 75 mm Hg or over 75 mm Hg), and end-diastolic LV dimension (of more or less than 56 mm). We evaluated the impact of S-wave magnitude in right precordial leads before and after AVR in all patients. We followed S-wave changes in electrocardiogram altogether with hemodynamic measurements derived from echocardiography. RESULTS Analysis of echocardiographic parameters, measured in patients before surgery, did not show statistical significance between asymptomatic and symptomatic group. The statistical significance was observed in the change in S-wave magnitude in the right precordial leads in both subsets of patients before AVR. We found statistically significant predictive value of S-wave magnitude in leads V2 -V3 for dependent variables PG and end-diastolic LV dimension. CONCLUSIONS S-wave changes in right precordial leads can predict increase in PG and critical narrowing of AVA, suggestive of timely referral for AVR.
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Ozkan A. Low gradient "severe" aortic stenosis with preserved left ventricular ejection fraction. Cardiovasc Diagn Ther 2013; 2:19-27. [PMID: 24282693 DOI: 10.3978/j.issn.2223-3652.2012.01.01] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2011] [Accepted: 01/04/2012] [Indexed: 11/14/2022]
Abstract
In developed nations, aortic stenosis (AS) is the most common valvular heart disease presentation, and its prevalence is increasing due to aging populations. Accurate diagnosis of the disease process and determination of its severity are essential in clinical decision-making. Although current guidelines recommend measuring transvalvular gradients, maximal velocity, and aortic valve area in determining the disease severity, inconsistent grading of disease severity remains a common problem in clinical practice. Recent studies suggest that patients with paradoxical low-flow and/or low-gradient, severe AS are at a more advanced stage of the disease process and have a poorer prognosis. This mode of presentation may lead to an undervaluation of symptoms and inappropriate delay of AVR. Therefore, this challenging clinical situation should be carefully assessed in particular in symptomatic patients and clinical decisions should be tailored individually.
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Review |
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Norum IB, Edvardsen T, Ruddox V, Gunther A, Dahle G, Otterstad JE. Three-dimensional versus two-dimensional transthoracic echocardiography for left ventricular outflow tract measurements in severe aortic stenosis. A cross-sectional study using computer tomography and Haegar sizers as reference. SCAND CARDIOVASC J 2020; 54:220-226. [PMID: 32408833 DOI: 10.1080/14017431.2020.1761559] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Objectives. In grading of aortic stenosis, two-dimensional transthoracic echocardiography (2D TTE) routinely results in underestimation of the left ventricular outflow tract (LVOT) area, and hence the aortic valve area (AVA). We investigated whether three-dimensional (3D) TTE measurements of the LVOT would be more accurate. We evaluated the feasibility, agreement and inter-observer variability of 3D TTE LVOT measurements with computed tomography (CT) and Haegar sizers as reference. Design. Sixty-one patients with severe aortic stenosis were examined with 2D and 3D TTE. 41 had CT and 13 also had perioperative Haegar sizing. Pearson's correlation and Bland-Altman plots were used to compare methods. Inter-observer variability was tested for 2D and 3D TTE. Trial registration: Current research information system in Norway (CRISTIN). Id: 555249. Results. Feasibility was 67% with 3D TTE and 100% with 2D TTE and CT. Mean LVOT area for 2D, 3D, CT and Haegar sizers were 3.7 ± 0.6 cm2, 4.0 ± 0.9 cm2, 5.2 ± 0.8 cm2 and 4.4 ± 1.0 cm2 respectively. Bias and limits of agreements for 2D TTE was 1.5 ± 1.3 cm2, compared with CT and 0.4 ± 1.5 cm2 with Haegar sizers. Corresponding results for 3D TTE were 1.2 ± 1.6 cm2 and 0.2 ± 1.8 cm2. Intraclass correlation coefficients for LVOT area were 0.62 for 3D and 0.86 for 2D. Conclusions. 2D TTE showed better feasibility and inter-observer variability in measurements of LVOT than 3D TTE. Both echocardiographic methods underestimated LVOT area compared to CT and Haegar sizers. These observations suggest that 2D TTE is still preferable to 3D TTE in the assessment of aortic stenosis.
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Comparative Study |
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Zhong Z, Sun K, Dan G, Luo Q, Farzaneh-Far A, Karaman MM, Zhou XJ. Visualization of Human Aortic Valve Dynamics Using Magnetic Resonance Imaging with Sub-Millisecond Temporal Resolution. J Magn Reson Imaging 2021; 54:1246-1254. [PMID: 33761166 PMCID: PMC8440328 DOI: 10.1002/jmri.27603] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 03/03/2021] [Accepted: 03/05/2021] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Visualization of aortic valve dynamics is important in diagnosing valvular diseases but is challenging to perform with magnetic resonance imaging (MRI) due to the limited temporal resolution. PURPOSE To develop an MRI technique with sub-millisecond temporal resolution and demonstrate its application in visualizing rapid aortic valve opening and closing in human subjects in comparison with echocardiography and conventional MRI techniques. STUDY TYPE Prospective. POPULATION Twelve healthy subjects. FIELD STRENGTH/SEQUENCE 3 T; gradient-echo-train-based sub-millisecond periodic event encoded imaging (get-SPEEDI) and balanced steady-state free precession (bSSFP). ASSESSMENT Images were acquired using get-SPEEDI with a temporal resolution of 0.6 msec. get-SPEEDI was triggered by an electrocardiogram so that each echo in the gradient echo train corresponded to an image at a specific time point, providing a time-resolved characterization of aortic valve dynamics. For comparison, bSSFP was also employed with 12 msec and 24 msec temporal resolutions, respectively. The durations of the aortic valve rapid opening (Tro ), rapid closing (Trc ), and the maximal aortic valve area (AVA) normalized to height were measured with all three temporal resolutions. M-mode echocardiograms with a temporal resolution of 0.8 msec were obtained for further comparison. STATISTICAL TEST Parameters were compared between the three sequences, together with the echocardiography results, with a Mann-Whitney U test. RESULTS Significantly shorter Tro (mean ± SD: 27.5 ± 6.7 msec) and Trc (43.8 ± 11.6 msec) and larger maximal AVA/height (2.01 ± 0.29 cm2 /m) were measured with get-SPEEDI compared to either bSSFP sequence (Tro of 56.3 ± 18.8 and 63.8 ± 20.2 msec; Trc of 68.2 ± 16.6 and 72.8 ± 18.2 msec; maximal AVA/height of 1.63 ± 0.28 and 1.65 ± 0.32 cm2 /m for 12 msec and 24 msec temporal resolutions, respectively, P < 0.05). In addition, the get-SPEEDI results were more consistent with those measured using echocardiography, especially for Tro (29.0 ± 4.1 msec, P = 0.79) and Trc (41.6 ± 4.3 msec, P = 0.16). DATA CONCLUSION: get-SPEEDI allows for visualization of human aortic valve dynamics and provided values closer to those measured using echocardiography than the bSSFP sequences. LEVEL OF EVIDENCE 1 TECHNICAL EFFICACY STAGE: 1.
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Research Support, N.I.H., Extramural |
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Alskaf E, Gupta T, Kardos A. Aortic valve area using computed tomography-derived correction factor to improve the validity of left ventricular outflow tract measurements. Echocardiography 2020; 37:196-206. [PMID: 32003912 DOI: 10.1111/echo.14601] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 01/13/2020] [Accepted: 01/14/2020] [Indexed: 11/27/2022] Open
Abstract
AIMS Given the inherent inaccuracies stemming from the assumption that the left ventricular outflow tract (LVOT) is circular, this study aimed to improve the accuracy of transthoracic echocardiography (TTE)-based aortic valve area (AVA) calculation using continuity equation (CE) by introducing a correction factor (CF) derived from multidetector computed tomography angiography (MDCTA) images and validate it in aortic stenosis (AS) patients. METHODS AND RESULTS This retrospective study used MDCTA images of 400 patients for modeling and 403 TTE dataset for validation. Echocardiographic parasternal long-axis view was modeled using MDCTA, and LVOT diameter (D1) was measured. Direct planimetry of LVOT area was performed and subsequently converted into a theoretical circle. The assumed circle (D2) diameter was derived, and D2/D1 was calculated and termed as the CF. The CF was 1.13, and it improved the agreement between MDCTA- and TTE-derived LVOT areas and correlation between AVA and peak velocity, mean pressure gradient, and velocity ratio. In discordant subgroups of severe AS, the CF reclassified patients to moderate AS in 40% in the low flow (LF), low gradient (LG), and low ejection fraction (EF) group; 53% in the LF, LG, and normal EF group; and 68% in the LF, high gradient, and normal EF group. CONCLUSIONS CF of 1.13 derived from MDCTA improved the accuracy of TTE-derived LVOT area and AVA and improved correlation with hemodynamic variables in AS patients. Reclassification of AS patients using CF may have clinical applicability for patient selection for early intervention.
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Repanas TI, Papanastasiou CA, Efthimiadis GK, Fragkakis N, Sachpekidis V, Klein RM, Karvounis H, Karamitsos TD. Cardiovascular magnetic resonance as a complementary method to transthoracic echocardiography for aortic valve area estimation in patients with aortic stenosis: A systematic review and meta-analysis. Hellenic J Cardiol 2021; 62:107-111. [PMID: 32535246 DOI: 10.1016/j.hjc.2020.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Revised: 05/20/2020] [Accepted: 05/26/2020] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Aortic stenosis (AS) is the most common valvular heart disease. While two-dimensional transthoracic echocardiography (2D-TTE) is the standard imaging modality for AS assessment, cardiac magnetic resonance (CMR) offers a reliable and reproducible alternative. The aim of this study was to compare AVA measurements as determined by TTE and CMR in patients with AS. METHODS Electronic databases were searched to identify studies comparing TTE continuity equation to CMR planimetry for AVA assessment. A meta-analysis of mean difference was conducted by using the random effects model. Sensitivity analysis was performed after excluding studies reporting AVA indexed to body surface area (BSA). Heterogeneity was assessed with I2. RESULTS A total of 12 studies, encompassing 621 patients, were included in our systematic review. In the pooled analysis, measurements of AVA by CMR planimetry were found to be significantly higher than those calculated by the continuity equation in TTE (pooled mean difference: 0.09, 95% confidence intervals (CI): 0.01, 0.17, and I2: 93%). The results remained significant, albeit with moderate heterogeneity this time, after excluding the analysis measurements of AVA indexed to BSA (pooled mean difference: 0.08, 95% CI: 0.03 to 0.13, and I2 = 61%). CONCLUSIONS CMR planimetry slightly overestimates AVA compared to TTE continuity equation. Although, 2D-TTE should be the primary imaging modality for the estimation of AVA, CMR may be useful when there is discrepancy with the clinical assessment or when TTE results are discordant or difficult to obtain.
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Meta-Analysis |
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Haas ZA, Qian C, Dabski MA, Jafarisis S, Cousins J, Fernandez SF, Nader ND. The Use of Contrast May Improve Aortic Valve Assessment During Transesophageal Echocardiography. J Cardiothorac Vasc Anesth 2023; 37:904-910. [PMID: 36931908 DOI: 10.1053/j.jvca.2023.02.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 02/06/2023] [Accepted: 02/14/2023] [Indexed: 02/24/2023]
Abstract
OBJECTIVES The Doppler profile that quantifies the degree of aortic stenosis is essential, as an inaccurate measurement can alter the surgical plan. The authors aimed to examine the level of agreement between the contrast and noncontrast methods of aortic valve sizing during intraoperative transesophageal echocardiography (TEE). SETTING At a tertiary hospital. PARTICIPANTS A total of 30 patients undergoing surgical aortic valve replacement for a stenotic valve. INTERVENTIONS Perflutren lipid microsphere contrast injection. MEASUREMENTS AND MAIN RESULTS The authors reviewed Doppler studies of 30 consecutive patients undergoing aortic valve replacement in whom a contrast agent was given (perflutren lipid microsphere). They measured the peak and/or mean aortic valve gradients and velocity time integral readings through the left ventricular outflow tract (LVOT), and the aortic valve before and after administering the contrast agent. The aortic valve area was then calculated using both methods. Paired t tests and Bland-Altman analyses were used to examine the bias and the level of agreement between the 2 processes. By not using a contrast agent, the aortic valve area was overestimated by 0.26 cm2 compared to those measured by transthoracic echocardiography (TTE) (p < 0.001). Using a contrast agent, TEE measurements were comparable to those obtained by TTE. Moreover, the peak and mean aortic valve gradients were underestimated by 19 and 11 mmHg, respectively (p value <0.001). Adding contrast did not affect the pulse-wave Doppler readings of the V1 velocity of the LVOT. CONCLUSION This discrepancy is significant and could affect the decision to replace the aortic valve. When evaluating the aortic valve with TEE, the authors recommend using a contrast agent to improve the Doppler profile and to obtain a more accurate measurement of the aortic valve area.
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Comprehensive assessment of the aortic valve in critically ill patients for the non-cardiologist. Part I: Aortic stenosis of the native valve. Anaesthesiol Intensive Ther 2021; 53:37-54. [PMID: 33788503 DOI: 10.5114/ait.2021.104550] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Aortic stenosis (AS) causes left ventricular outflow obstruction. Severe AS has major haemodynamic implications in critically ill patients, in whom increased cardiac output and oxygen delivery are often required. Transthoracic echocardiography (TTE) plays a key role in the AS severity grading. In this review, we will give an overview of how to use the simplified Bernoulli equation to convert the echo Doppler measured velocities (cm s-1) to AS peak and mean gra-dient (mm Hg) and how to calculate the aortic valve area (AVA), using the continuity equation, based on the principle of preservation of flow. TTE allows quantification of compensatory left ventricular (LV) hypertrophy, assessment of LV systolic function, and determination of LV diastolic function and LV loading. Subsequently, the obtained results from the TTE study need to be integrated to establish the AS severity grading. The pitfalls of echocardiographic AS severity assessment are explained, and how to deal with inconsistency between AVA and mean gradient. The contribution of transoesophageal echocardiography, low-dose dobutamine stress echo (in case of low-flow low-gradient AS), echocardiography strain imaging, cardiac magnetic resonance imaging, cardiac multidetector computed tomography and the relatively new concept of Flow Pressure Gradient Classification to the work-up for aortic stenosis is discussed. Finally, the treatment of AS is overviewed. Elective aortic valve replacement is indicated in patients with severe symptomatic AS. In the ICU, afterload reduction by vasodilator therapy and treatment of pulmonary and venous congestion by diuretics could be considered.
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Review |
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Ahmed AA, Matyal R, Mahmood F, Feng R, Berry GB, Gilleland S, Khabbaz KR. Impact of left ventricular outflow tract flow acceleration on aortic valve area calculation in patients with aortic stenosis. Echo Res Pract 2019. [PMID: 31682093 PMCID: PMC6826166 DOI: 10.1530/erp-19-0017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Objective Due to its circular shape, the area of the proximal left ventricular tract (PLVOT) adjacent to aortic valve can be derived from a single linear diameter. This is also the location of flow acceleration (FA) during systole, and pulse wave Doppler (PWD) sample volume in the PLVOT can lead to overestimation of velocity (V1) and the aortic valve area (AVA). Therefore, it is recommended to derive V1 from a region of laminar flow in the elliptical shaped distal LVOT (away from the annulus). Besides being inconsistent with the assumptions of continuity equation (CE), spatial difference in the location of flow and area measurement can result in inaccurate AVA calculation. We evaluated the impact of FA in the PLVOT on the accuracy of AVA by continuity equation (CE) in patients with aortic stenosis (AS). Methods CE-based AVA calculations were performed in patients with AS once with PWD-derived velocity time integral (VTI) in the distal LVOT (VTILVOT) and then in the PLVOT to obtain a FA velocity profile (FA-VTILVOT) for each patient. A paired sample t-test (P < 0.05) was conducted to compare the impact of FA-VTILVOT and VTILVOT on the calculation of AVA. Result There were 46 patients in the study. There was a 30.3% increase in the peak FA-VTILVOT as compared to the peak VTILVOT and AVA obtained by FA-VTILVOT was 29.1% higher than obtained by VTILVOT. Conclusion Accuracy of AVA can be significantly impacted by FA in the PLVOT. LVOT area should be measured with 3D imaging in the distal LVOT.
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Ahmed AA, Matyal R, Mahmood F, Feng R, Berry GB, Gilleland S, Khabbaz KR. Impact of left ventricular outflow tract flow acceleration on aortic valve area calculation in patients with aortic stenosis. Echo Res Pract 2019; 6:97-103. [PMID: 31682093 PMCID: PMC6826166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 10/07/2019] [Indexed: 07/22/2024] Open
Abstract
Objective Due to its circular shape, the area of the proximal left ventricular tract (PLVOT) adjacent to aortic valve can be derived from a single linear diameter. This is also the location of flow acceleration (FA) during systole, and pulse wave Doppler (PWD) sample volume in the PLVOT can lead to overestimation of velocity (V1) and the aortic valve area (AVA). Therefore, it is recommended to derive V1 from a region of laminar flow in the elliptical shaped distal LVOT (away from the annulus). Besides being inconsistent with the assumptions of continuity equation (CE), spatial difference in the location of flow and area measurement can result in inaccurate AVA calculation. We evaluated the impact of FA in the PLVOT on the accuracy of AVA by continuity equation (CE) in patients with aortic stenosis (AS). Methods CE-based AVA calculations were performed in patients with AS once with PWD-derived velocity time integral (VTI) in the distal LVOT (VTILVOT) and then in the PLVOT to obtain a FA velocity profile (FA-VTILVOT) for each patient. A paired sample t-test (P < 0.05) was conducted to compare the impact of FA-VTILVOT and VTILVOT on the calculation of AVA. Result There were 46 patients in the study. There was a 30.3% increase in the peak FA-VTILVOT as compared to the peak VTILVOT and AVA obtained by FA-VTILVOT was 29.1% higher than obtained by VTILVOT. Conclusion Accuracy of AVA can be significantly impacted by FA in the PLVOT. LVOT area should be measured with 3D imaging in the distal LVOT.
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Dean LS, Kern MJ. Measuring Valve Gradients and Areas. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2022; 1:100433. [PMID: 39131451 PMCID: PMC11308807 DOI: 10.1016/j.jscai.2022.100433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 07/14/2022] [Accepted: 07/18/2022] [Indexed: 08/13/2024]
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Case Reports |
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Raghunathan D, Bhardwaj A. Moderate Aortic Stenosis Progression: When Do We Reassess? JACC. ADVANCES 2024; 3:100882. [PMID: 38939666 PMCID: PMC11198262 DOI: 10.1016/j.jacadv.2024.100882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/29/2024]
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Editorial |
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Maldonado Y, Singh S, Augoustides JG, MacKnight B, Zhou E, Gutsche JT, Ramakrishna H. Moderate Aortic Stenosis and Coronary Artery Bypass Grafting: Clinical Update for the Perioperative Echocardiographer. J Cardiothorac Vasc Anesth 2015; 29:1384-90. [PMID: 26275517 DOI: 10.1053/j.jvca.2015.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Indexed: 11/11/2022]
Abstract
Incidental aortic stenosis in the setting of coronary artery bypass surgery may be a perioperative challenge. The accurate assessment of the degree of aortic stenosis remains an important determinant. Although severe aortic stenosis is an indication for valve replacement, current guidelines advise a balanced approach to the management of moderate aortic stenosis in this setting. Multiple factors should be considered in a team discussion to balance risks versus benefits for the various management options in the given patient. The rapid progress in aortic valve technologies also offer alternatives for definitive management of moderate aortic stenosis in this setting that will likely become even safer in the near future.
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Review |
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Agahi S, Yaseri M, Eftekhari MR, Geraiely B, Sardari A, Sattarzadeh Badkoubeh R, Larti F. Revisiting the Normal Ranges of Aortic Valve Area in 2D Echocardiography and Its Association With Age, Sex, and Anthropometric Characteristics. Echocardiography 2024; 41:e70029. [PMID: 39512131 DOI: 10.1111/echo.70029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2024] [Revised: 10/15/2024] [Accepted: 10/24/2024] [Indexed: 11/15/2024] Open
Abstract
PURPOSE Defining normative aortic echocardiographic values in each geographical district is crucial as aortic valve area (AVA) may vary across races, genders, and ages. Notably, variations in normal values can have implications for clinical decision-making, and available data on the Middle East population is also scarce. We sought to establish normal ranges for aortic valve echocardiographic parameters in the Iranian population and assess the effect of age, gender, weight, height, BMI, BSA, and blood pressure on them. METHODS Our data were provided from the web-based echocardiographic data registry of Imam Khomeini Hospital Complex (IKHC). A total of 3251 healthy subjects older than 18 years old without any valvular stenosis were included in our study. RESULTS AVA's normal range was estimated at 1.92-4.52 and 1.67-3.80 cm2 in men and women, respectively. The annulus, AVA, AV VTI, and LVOT VTI were significantly larger in males, and this association remained significant after indexing AVA for weight, height, BMI, and BSA. Also, smaller AVA was associated with lower height, weight, BMI, and BSA in both men and women. Obese and hypertensive subjects had significantly larger AVA and annulus diameters. CONCLUSION Our study provided region-specific normal reference values for AV echocardiographic parameters and compared them across genders, ages, BMI, and blood pressure groups in the Iranian population.
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Schwartzenberg S, Vatury M, Wiessman M, Shechter A, Morelli O, Ofek H, Kazum S, Kornowski R, Sagie A, Shapira Y. Severe aortic stenosis echocardiographic thresholds revisited. Echocardiography 2021; 38:2016-2024. [PMID: 34854128 DOI: 10.1111/echo.15241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 09/11/2021] [Accepted: 10/21/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND In view of inconsistencies in threshold values of severe aortic stenosis (AS) hemodynamic indices, it is unclear what is the relative contribution of each variable in a binary classification of AS based on aortic valve replacement (AVR) indication. We aimed to assess relative discriminative value and optimal threshold of each constituent hemodynamic parameter for this classification and confirm additional prognostic value. METHODS Echocardiography studies of 168 patients with ≥ moderate AS were included. AS types were dichotomized into Group-A, comprising moderate and Normal-Flow Low-Gradient (NFLG), and Group-B, comprising High-Gradient(HG), Low Ejection Fraction Low-Flow Low-Gradient(Low EF-LFLG), and Paradoxical Low-Flow Low-Gradient(PLFLG) AS. Aortic valve area (AVA), Doppler velocity index (DVI), peak aortic velocity, mean gradient, stroke volume index and transaortic flow rate(TFR) were assessed for A/B Group discrimination value and optimal thresholds were determined. Dichotomized values were assessed for predictive value for AVR or death. RESULTS C-statistic values for binary AS classification was .74-.9 for the tested variables. AVA and DVI featured the highest score, and SVI the lowest one. AVA≤.81 cm2 and DVI≤.249 had 87.6% and 86% respective sensitivity for Group B patients, and a similar specificity of 80.9%. During a mean follow-up of 9.1±10.1 months, each of the tested dichotomized variables except for SVI predicted AVR or death on multivariate analysis. CONCLUSION An AVA value ≤.81 cm2 or a DVI ≤ .249 threshold carry the highest discriminative value for severe AS in patients with aortic stenosis, translating into an independent prognostic value, and can be helpful in making clinical decisions.
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Kim K, Lee SJ, Seo J, Suh YJ, Cho I, Hong GR, Ha JW, Kim YJ, Shim CY. Assessment of aortic valve area on cardiac computed tomography in symptomatic bicuspid aortic stenosis: Utility and differences from Doppler echocardiography. Front Cardiovasc Med 2022; 9:1035244. [PMID: 36601069 PMCID: PMC9807240 DOI: 10.3389/fcvm.2022.1035244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 11/18/2022] [Indexed: 12/23/2022] Open
Abstract
Background In this study, we investigate the utility of geometric orifice area (GOA) on cardiac computed tomography (CT) and differences from effective orifice area (EOA) on Doppler echocardiography in patients with bicuspid aortic stenosis (AS). Methods A total of 163 patients (age 64 ± 10 years, 56.4% men) with symptomatic bicuspid AS who were referred for surgery and underwent both cardiac CT and echocardiography within 3 months were studied. To calculate the aortic valve area, GOACT was measured by multiplanar CT planimetry, and EOAEcho was calculated by the continuity equation with Doppler echocardiography. The relationships between GOACT and EOAEcho and patient symptom scale, biomarkers, and left ventricular (LV) functional variables were analyzed. Results There was a significant but modest correlation between EOAEcho and GOACT (r = 0.604, p < 0.001). Both EOAEcho and GOACT revealed significant correlations with mean pressure gradient and peak transaortic velocity, and the coefficients were higher in EOAEcho than in GOACT. EOAEcho of 1.05 cm2 and GOACT of 1.25 cm2 corresponds to hemodynamic cutoff values for diagnosing severe AS. EOAEcho was well correlated with the patient symptom scale and log NT-pro BNP, but GOACT was not. In addition, EOAEcho had a higher correlation coefficient with estimated LV filling pressure and LV global longitudinal strain than GOACT. Conclusion GOACT can be used to evaluate the severity of bicuspid AS. The threshold for GOACT for diagnosing severe AS should be higher than that for EOAEcho. However, EOAEcho is still the method of choice because EOAEcho showed better correlations with clinical and functional variables than GOACT.
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Henning RJ. The current diagnosis and treatment of patients with aortic valve stenosis. Future Cardiol 2021; 17:1143-1160. [PMID: 33728942 DOI: 10.2217/fca-2020-0140] [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: 11/21/2022] Open
Abstract
Aortic valve stenosis (AS) is the third most frequent cardiovascular abnormality after coronary artery disease and hypertension. A bicuspid aortic valve is the most common cause for AS until seventh decade and calcific valve degeneration is responsible thereafter. In symptomatic patients, The risk of death increases from ≤1%/year to 2%/month. An echo valve area ≤1 cm2, peak transaortic velocity ≥4 m/s, mean valve gradient ≥40 mmHg and/or computerized tomography valve calcium score >2000 Agatston units (AU) for males or more than 1200 AU for females indicate severe AS. AS stages and management are discussed. Valve replacement is based on surgical risk, valve durability/hemodynamics, need for anticoagulation and patient preferences. EuroSCORE ≥20%, Society of Thoracic Surgeons Predicted Risk of Mortality ≥8% and co-morbidities indicate high surgical risk. Surgery is recommended for low-intermediate risk patients. Transcatheter aortic valve implantation is an alternative in older patients at low, intermediate, high or prohibitive risk. Transaortic valve implantation/replacement trials are summarized.
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Inoue N, Ohtani H, Morikawa S, Takayama Y, Ogane T, Hiramatsu T, Kumihashi H, Murohara T. Risk of supranormal left ventricular ejection fraction in patients with aortic stenosis. Clin Cardiol 2024; 47:e24255. [PMID: 38469926 PMCID: PMC10928761 DOI: 10.1002/clc.24255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 02/22/2024] [Accepted: 03/01/2024] [Indexed: 03/13/2024] Open
Abstract
BACKGROUND Cardiovascular events are increasing in patients with supranormal left ventricular ejection fraction (snLVEF). However, the effect of snLVEF in patients with aortic stenosis (AS) remains unclear, especially in patients with moderate AS. HYPOTHESIS This study aimed to evaluate the prognosis of mortality and heart failure (HF) in patients with LVEF ≥ 50% and moderate or severe AS. METHODS This retrospective study targeted patients with moderate or severe AS and LVEF > 50%. LVEF of 50%-65% was classified as normal LVEF (nLVEF, nEF group) and >65% as snLVEF (snEF group). AS severity was stratified based on the aortic valve area into moderate (1.0-1.5 cm²) and severe (<1.0 cm²). Primary outcomes included all-cause mortality and HF hospitalization. RESULTS A total of 226 participants were included in this study. There were 67 and 65 participants with moderate AS in snEF (m-snEF) and nEF groups (m-nEF), respectively, and 41 and 53 participants with severe AS in the snEF (s-snEF) and nEF groups (s-nEF), respectively. During the observation period (median: 554 days), the primary composite outcome occurred in 108 individuals. Cox hazard analysis revealed no significant differences among the four groups in primary composite outcomes. With respect to HF hospitalization, the adjusted hazard ratios (95% confidence intervals) with m-snEF as the reference were as follows: m-nEF, 0.41 (0.19-0.89); s-nEF, 1.43 (0.76-2.67); and s-snEF, 1.83 (1.00-3.35). CONCLUSIONS The risk of HF hospitalization for m-snLVEF was higher than m-nLVEF and not significantly different from s-nLVEF.
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