[Vitamin D in aortic stenosis]. / Vitamin D a aortální stenóza.

Aortic stenosis is the third most common cardiovascular disease and the most commonly operataed valve disease in developed countries. Progressive valve calcification leading to significant flow obstruction is the main pathogenetic feature. Dysregulation of the systemic calcium-phosphate metabolism with low vitamin D level is a possible risk factor of aortic stenosis even in patients with preserved renal function. This hypothesis deserves further clinical and experimental study.

Sublingual isosorbide dinitrate for the detection of obstruction in hypertrophic cardiomyopathy.

AIMS: Hypertrophic cardiomyopathy (HCM) is predominantly associated with left ventricular outflow tract (LVOT) obstruction. The assessment of the obstruction with a provoking test should be a routine part of HCM evaluation. The aim of the study was to determine the utility of a sublingual spray application of isosorbide dinitrate (ISDN) for detection of an obstruction. METHODS AND RESULTS: We have prospectively analysed 77 consecutive HCM patients, measuring the LVOT gradient at rest, using the sublingual spray application of ISDN (2.5 mg; after 2, 5, and 10 min), and with exercise echocardiography. An obstruction was defined as a gradient ≥ 30 mmHg. An obstruction was present in 15 patients (19%) at rest, in 42 patients (55%) after ISDN, and in 55 patients (71%) after exercise. The ISDN test had a sensitivity of 76% and the specificity of 100% relative to exercise echocardiography, while at-rest measurements had a sensitivity of 27% and a specificity of 100%. The chronological difference in the prevalence of obstructions during the ISDN test was statistically significant (P < 0.05); at ISDN plus 2 min, obstructions were seen in only 29 patients (38%, gradient 28.8 ± 25.0 mmHg), however, at ISDN plus 5 and 10 min, obstructions were found in 42 patients (55%, gradient 44.5 ± 39.6 mmHg). CONCLUSION: The ISDN test is a reliable screening method for the detection of an HCM obstruction, however, the measurement should be delayed 5-10 min after the application of ISDN. Patients with negative ISDN tests should undergo exercise echocardiography.

Bisphosphonates in calcific aortic stenosis: association with slower progression in mild disease--a pilot retrospective study.

OBJECTIVES: An association between aortic valve calcification and osteoporosis has been observed. The aim of this study was to assess the association between bisphosphonate treatment for osteoporosis and the progression of calcific aortic stenosis (AS). METHODS: A retrospective study of patients with AS (mean gradient ≥10 mm Hg), preserved renal function and two echocardiographies >8 months apart was performed. The patients were divided into those treated with bisphosphonates for osteoporosis and those not treated and then subdivided into mild (mean gradient <30 mm Hg) and moderate-to-severe AS groups. We compared the annualized gradient change between the groups and identified predictors of AS progression. RESULTS: We analyzed the outcomes of 103 patients (51% females, age 68 ± 10 years, follow-up 29 ± 13 months), of whom 57 had mild and 46 moderate-to-severe AS. Bisphosphonates were taken by 28 patients, of whom 22 had mild and 6 moderate-to-severe AS. In the patients with mild AS, the annualized mean gradient change was lower in the bisphosphonate-treated than in the untreated patients (0.1 ± 3.3 vs. 2.8 ± 3.3 mm Hg/year; p = 0.002) and was negatively associated with bisphosphonate treatment (ß coefficient -2.36%, 95% confidence interval -4.47 to -0.26; p = 0.028) independent of age, gender and baseline gradient. CONCLUSION: Bisphosphonate treatment was independently associated with slower progression of mild AS in patients with preserved renal function.

Combined percutaneous treatment of atrial septal defect and pulmonic or aortic stenosis in adult patients.

Combined atrial septal defect and pulmonic or aortic stenosis are relatively uncommon conditions in adult patients, with few reported cases of percutaneous treatment. We present two patients with secundum type atrial septal defect and concomitant pulmonic or aortic stenosis and their treatment by transcatheter techniques.

Alcohol septal ablation for obstructive hypertrophic cardiomyopathy: ultra-low dose of alcohol (1 ml) is still effective.

Echo-guided alcohol septal ablation (ASA) is an alternative treatment for highly symptomatic patients with obstructive hypertrophic cardiomyopathy (HOCM). Previous reports suggest that a low dose of alcohol (1.5-2 ml) is as effective as the classic dose (2-4 ml) used in the past. Because a larger infarct might be associated with a potential long-term risk, in this pilot study we wanted to determine whether an ultra-low dose of alcohol (1 ml) would be effective in the mid-term follow-up. Seventy patients (55+/-13 years, range 24-81 years, septum thickness <31 mm) with a highly symptomatic HOCM receiving maximum medical therapy were enrolled. Thirty-five consecutive patients (group I) have been treated with an ultra-low alcohol dose (1.0+/-0.1 ml) and compared with a control group II of 35 patients treated by the same medical team using the classic alcohol dose (2.5+/-0.8 ml) in the past. At 6-month follow-up, both groups of patients improved in dyspnea (2.9+/-0.6 vs 1.5+/-0.5 New York Heart Association [NYHA] class for group I; P<0.01, and 2.5+/-0.7 vs 1.4+/-0.4 NYHA class for group II; P<0.01) and angina (2.1+/-1 vs 0.6+/-0.8 Canadian Cardiovascular Society [CCS] class for group I; P<0.01, and 2.1+/-0.9 vs 0.7+/-0.7 CCS class for group II; P<0.01). There was a significant decrease in left ventricular (LV) ejection fraction (P<0.05), septum thickness (P<0.01), and LV outflow gradient (P<0.01) in both groups of patients. However, there was no significant difference with regard to the extent of symptomatic or echocardiographic changes and complications between both groups. These results suggest that the ultra-low dose of alcohol (1 ml) is still effective in the treatment of the majority of HOCM patients without extreme septum hypertrophy (<31 mm).

Linking soluble vascular adhesion molecule-1 level to calcific aortic stenosis in patients with coronary artery disease.

BACKGROUND: Calcific aortic stenosis (AS) is an atherosclerosis-related process and the most common cause of valve disease requiring surgery. OBJECTIVE: To assess the association of inflammatory markers with AS in advanced atherosclerosis. METHODS: Consecutive patients with coronary artery disease (CAD) associated with AS were prospectively identified (mean transvalvular aortic gradient of 30 mmHg or greater). Subjects with aortic sclerosis (mean transvalvular aortic gradient of 10 mmHg or less) served as controls. All patients underwent clinical evaluation, echocardiography and coronary angiography. RESULTS: One hundred twenty-two patients with AS (85 men) and 101 with aortic sclerosis (76 men) of similar CAD severity were enrolled. The AS patients were older (mean [+/- SD] 71+/-7 years versus 66+/-7 years; P<0.001), had higher soluble vascular adhesion molecule-1 (s-VCAM-1) levels (1533+/-650 mug/L versus 1157+/-507 mug/L; P<0.001), but lower soluble intercellular adhesion molecule-1 (s-ICAM-1) (254+/-81 mug/L versus 293+/-84 mug/L; P<0.01) and soluble E-selectin (53+/-28 mug/L versus 62+/-29 mug/L; P<0.05) levels. The two groups did not differ with respect to C-reactive protein level (3+/-2.9 mg/L versus 3.4+/-2.6 mg/L; P not significant). Higher s-VCAM-1 (OR 1.09, 95% CI 1.04 to 1.14; P<0.001) and lower s-ICAM-1 (OR 0.82, 95% CI 0.72 to 0.94; P<0.001) levels were associated with AS after adjustment for age. CONCLUSION: Increased s-VCAM-1 levels were associated with calcific AS in patients with significant CAD.

Treatment of a large left main coronary artery thrombus by aspiration thrombectomy.

A left main coronary artery thrombosis is a life-threatening condition demanding immediate therapeutic management. Traditional treatment options include thrombolysis, percutaneous coronary intervention (PCI) with stenting or cardiac bypass surgery. The number of reported cases in which aspiration thrombectomy has been used is limited. Indications for this therapeutic approach are determined by coronary anatomy, clinical stability, and hemodynamic condition of the patient. We present the case of an acute left main coronary artery thrombosis leading to progressive deterioration of left ventricle function that was successfully treated with aspiration thrombectomy.

Parathyroid hormone and vitamin D levels are independently associated with calcific aortic stenosis.

BACKGROUND: In calcific aortic valve disease, the early lesion is similar to atherosclerotic plaque, but later calcification prevails. Parathyroid hormone (PTH) and vitamin D are the principal calcium pool regulators, so the present study was designed to assess their association with aortic stenosis (AS) in patients with significant coronary artery disease (CAD), and preserved renal function. METHODS AND RESULTS: The 122 consecutive patients with AS (mean gradient > or =30 mmHg) plus CAD, and 101 patients with nonobstructive aortic sclerosis (mean gradient < or =10 mmHg) plus CAD, as controls, were prospectively enrolled. The AS patients were older (71+/-7 vs 66+/-7 years; p<0.001), had higher serum intact (i)PTH (51.4 [39-70] vs 37.4 [27-50] pg/ml; p<0.001), and lower plasma vitamin D (32.0 [25-40] vs 35.8 [27-55] nmol/L; p=0.003) levels than those with aortic sclerosis. The groups did not differ significantly in creatinine level (93 [82-105] vs 96 [85-107] micromol/L, p=0.19), calcium - phosphate product, occurrence of hypertension, smoking, diabetes, dyslipidemia, or body mass index. The iPTH (odds ratio (OR) 1.04, 95% confidence interval (CI) 1.02-1.05; p<0.001) and vitamin D levels (OR 0.97, 95% CI 0.95-0.99; p=0.003) were independently associated with AS. CONCLUSION: Higher serum iPTH with lower vitamin D levels were independently associated with calcific AS in CAD patients.

Comparison of the aortic valve calcium content in the bicuspid and tricuspid stenotic aortic valve using non-enhanced 64-detector-row-computed tomography with prospective ECG-triggering.

PURPOSE: The aim of our study was to compare the calcium content measured by non-enhanced multidetector-row-computed tomography (MDCT) between patients with significant stenosis of bicuspid (BAV) and tricuspid aortic valve (TAV). Another aim of our study was to assess the accuracy of the non-enhanced MDCT to distinguish BAV and TAV based on the calcified plaque morphology, and to compare the results with the transesophageal echocardiography. SUBJECTS AND METHODS: A retrospective analysis of prospectively collected data was performed. Consecutive patients with symptomatic aortic stenosis (AS) admitted to hospital for evaluation before valve surgery underwent clinical evaluation, transthoracic and transesophageal echocardiography, and non-enhanced examination with the 64-detector-row CT using prospective ECG triggering with data acquisition in diastolic phase. The data acquisition started at 55% of the R-R interval. The patients were examined in the supine position in mild inspiration. Data were evaluated using dedicated software for calcium scoring, the volume of calcifications and calcium content were obtained. RESULTS: Thirty-seven patients (20 males, age 48-83 years) were enrolled. BAV was present in 13 patients, TAV in 24 patients. The calcium score in patients with severe AS (mean gradient >50 mmHg) was higher than in those with moderate AS (1123+/-616 mg versus 634+/-475, P=0.011). Significant correlation between the calcium scores and transaortic gradients was found (r=0.53, P=0.002). The patients with BAV did not differ significantly from those with TAV in the AS severity (58+/-13 versus 53+/-20 mmHg), nor in the valve calcium score (1168+/-717 versus 795+/-530 mg, P=0.093). The overall sensitivity to detect BAV in patients with calcified severe AS was 0.923 (12/13) and specificity 0.958 (23/24). The overall accuracy was 0.945 (35/37). CONCLUSION: We observed higher calcium score in patients with severe AS than with moderate AS. However, no difference in aortic valve calcium score between BAV and TAV was found. Thus, in our sample, the aortic valve calcium score correlated with AS severity, not with aortic valve morphology. Based on the calcified plaque space relationship, the aortic BAV and TAV could be distinguished in most cases.

Severe aortic stenosis and its association with hypertension: analysis of clinical and echocardiographic parameters.

BACKGROUND/AIMS: Aortic stenosis (AS) and hypertension are associated with cardiac hypertrophy and aortic dilatation. The effect of their coincidence on the ascending aortic dimensions has not yet been evaluated, and therefore was the aim of our study. METHODS: We performed cross-sectional analysis of history, clinical, angiographic and echocardiographic data of consecutive patients evaluated before surgery for non-rheumatic AS. RESULTS: The study sample included 225 patients (age 68+/-9 years, 60% males), with mean transaortic gradient of 55+/-17 mmHg. Hypertension was present in 153 (68%) patients. The hypertensives had more severe dyspnea (NYHA class 2.2+/-0.9 vs 1.9+/-0.9, p = 0.05) and higher prevalence of coronary artery disease (57% vs 33%, p = 0.001), but did not differ from the normotensives in the ascending aortic dimensions, the left ventricular mass, ejection fraction and remodeling patterns. Wider ascending aortic dimensions were independently associated with bicuspid aortic valve (p<0.001), and with maximal gradient in those with tricuspid aortic valve. Vasodilators were used in 84 (54%) hypertensives. CONCLUSION: We found hypertension in 68% of patients with severe AS. Bicuspid aortic valve and stenosis severity were independent predictors of ascending aortic dimensions, but not the history of hypertension and blood pressure.

Aortic stenosis severity is not a risk factor for poststenotic dilatation of the ascending aorta.

BACKGROUND: Dilatation of the ascending aorta in aortic stenosis may be partly explained by intrinsic wall structure changes, but the relative contribution of altered hemodynamics is unclear. The aim of this study was to assess the association between ascending aortic dimensions and valve stenosis severity. METHODS AND RESULTS: An analysis of echocardiographic examinations was conducted in 296 patients with aortic stenosis (179 males, mean age 71 years), 57 with bicuspid and 239 with tricuspid aortic valve, mean transaortic gradient 43+/-20 mmHg, and not more than moderate aortic regurgitation. Aortic dimensions at the level of annulus, sinuses of Valsalva, sinotubular junction and proximal ascending aorta were measured. Only height (p<0.001), degree of aortic regurgitation (p<0.01) and presence of bicuspid aortic valve (p<0.001) were independent predictors of ascending aortic dimensions. CONCLUSIONS: An independent association between aortic pressure gradients and proximal ascending aortic dimensions was not observed in patients with bicuspid or tricuspid aortic valve stenosis. Therefore, the poststenotic dilatation of the ascending aorta is not explained by aortic stenosis severity itself. Possible nonhemodynamic causes deserve detailed study at the time of diagnosis.

Impact of ethanol dosing on the long-term outcome of alcohol septal ablation for obstructive hypertrophic cardiomyopathy: a single-center prospective, and randomized study.

BACKGROUND: The impact of ethanol dose on the long-term outcome of alcohol septal ablation (ASA) for obstructive hypertrophic cardiomyopathy was investigated. METHODS AND RESULTS: Fifty-four patients (age 24-82 years; 65% women) undergoing ASA were randomized into 2 groups according to the dose of injected ethanol: Group A 1-2 ml, Group B >2 ml. Clinical and echocardiographic data were obtained at baseline and during follow-up. The volume of ethanol injected was 1.50+/-0.4 and 2.60+/-0.6 ml (p<0.001) with a subsequent peak of creatine kinase-MB of 2.25+/-1.00 and 2.62+/-1.57 microkat/L (p=0.02) in Groups A and B, respectively. The median follow-up was 39 (range 6-72) months after ASA, during which 1 patient died and 1 repeat procedure was necessary in both groups of patients. Both groups had a significant and similar improvement in outflow pressure gradient, dyspnea (New York Heart Association functional class) and angina pectoris (Canadian Cardiovascular Society class) (p<0.001). There was a significant decrease in the left ventricular ejection fraction (LVEF) in Group B (81+/-7 vs 75+/-7%; p=0.002), but not in Group A (80+/-7 vs 79+/-7%; p=0.67). Thinning of the basal septum was more pronounced in Group B than in Group A (9.3+/-5.7 vs 6.6+/-3.4 mm; p=0.04). CONCLUSIONS: A lower dose of ethanol injected into the target septal branch reduces both the size of necrosis and subsequent thinning of the basal septum, and preserves LVEF during long-term follow-up. Moreover, the low dose (1-2 ml) is as safe and as hemodynamically efficacious as higher doses.