Impact of concomitant aortic regurgitation on long-term outcome after surgical aortic valve replacement in patients with severe aortic stenosis.

BACKGROUND: Prognostic value of concomitant aprtic regurgitation (AR) in patients operated for severe aortic stenosis (AS) is not clarified. The aim of this study was to prospectively examine the impact of presence and severity of concomitant AR in patients operated for severe AS on long-term functional capacity, left ventricular (LV) function and mortality. METHODS: Study group consisted of 110 consecutive patients operated due to severe AS. The patients were divided into AS group (56 patients with AS without AR or with mild AR) and AS+AR group (54 patients with AS and moderate, severe or very severe AR). Follow-up included clinical examination, six minutes walk test (6MWT) and echocardiography 12 and 104 months after AVR. RESULTS: Patients in AS group had lower LV volume indices throughout the study than patients in AS+AR group. Patients in AS group did not have postoperative decrease in LV volume indices, whereas patients in AS+AR group experienced decrease in LV volume indices at 12 and 104 months. Unlike LV volume indices, LV mass index was significantly lower in both groups after 12 and 104 months as compared to preoperative values. Mean LVEF remained unchanged in both groups throughout the study. NYHA class was improved in both groups at 12 months, but at 104 months remained improved only in patients with AS. On the other hand, distance covered during 6MWT was longer at 104 months as compared to 12 months only in AS+AR group (p = 0,013), but patients in AS group walked longer at 12 months than patients in AS+AR group (p = 0,002). There were 30 deaths during study period, of which 13 (10 due to cardiovascular causes) in AS group and 17 (12 due to cardiovascular causes) in AS+AR group. Kaplan-Meier analysis showed that the survival probability was similar between the groups. Multivariate analysis identified diabetes mellitus (beta 1.78, p = 0.038) and LVEF < 45% (beta 1.92, p = 0.049) as the only independent predictor of long-term mortality. CONCLUSION: Our data indicate that the preoperative presence and severity of concomitant AR has no influence on long-term postoperative outcome, LV function and functional capacity in patients undergoing AVR for severe AS.

Frequency and significance of unrecognized chronic obstructive pulmonary disease in elderly patients with stable heart failure.

BACKGROUND AND AIMS: Due to prolonged life-spans and modern therapeutic approaches, there has been an increase in the number of patients aged ≥ 65 years with chronic heart failure (CHF). The duration and quality of life in elderly patients with CHF also depend on accompanying diseases. Although frequency of chronic obstructive pulmonary disease (COPD) in patients with CHF is about 30%, it is hard to find similar data in the elderly population. COPD is defined as a spirometrically assessed ratio of a post-dilatory forced expiratory volume in the first second, divided by forced vital capacity (FEV1/FVC) <70%. The aims of our study were to assess the prevalence of previously undiagnosed COPD in outpatients (≥ 65 yrs) with stable CHF and to determine the effect of the combination of COPD and CHF on patients' functional capacity as measured by a 6-minute walking test. METHODS AND RESULTS: Of the 174 study patients, 126 (72.4%) were men. In 48 patients (27.6%) we found previously unrecognized COPD. They were significantly older (75.6 ± 5.8 vs 73 ± 4.5 years, p<0.01) and more frequently had abdominal obesity and a greater waist circumference (98.8 ± 10.2 vs 94.9 ± 9.1 cm, p<0.05). Patients with COPD had significantly shorter 6-min walking distance (275.5 ± 112.9 vs 291.3 ± 96.7 m, p<0.05). Only patient's age had a positive prognostic association with unrecognized COPD (OR=1.16; 95% CI 1.01- 1.34, p<0.01). Patients with COPD showed a significant correlation between actual/predicted FEV1 and the 6-min walking distance (r=0.39, p<0.01). CONCLUSIONS: We found a high prevalence of unrecognized COPD in elderly patients with CHF and central obesity. Chronic obstructive pulmonary disease influenced functional capacity in CHF patients, as determined by the 6-minute walking test. Closer co-operation between pulmonologists and cardiologists is necessary to optimize management of this large proportion of CHF patients.

[Danon disease: a case report and literature overview].

Danon disease, a rare glycogen storage disease, is a dominant X-linked disorder. It is due to mutation in gene for lysosome-associated membrane protein 2 (LAMP 2). The LAMP 2 gene is located on Xq24, and its mutation causes primary deficiency of LAMP 2 and myocyte hypertrophy by accumulations of vacuoles containing glycogen. Danon disease is clinically characterized by the triad of hypertrophic cardiomyopathy (HCM), proximal myopathy and mental retardation. Myopathy and mental retardation can be absent, and cardiomyopathy is usually hypertrophic. This is a case report of the patient with genetically confirmed Danon disease and mixed cardiomyopathy, but without myopathy and mental retardation. ECG showed typical Wolff-Parkinson-White (WPW) pattern while echocardiography demonstrated hypertrophy and dilatation of all cardiac chambers with impaired systolic and diastolic function. Male sex, early onset of symptoms, massive hypertrophy of the myocardium and ventricular preexcitation indicate a genetic basis for HCM. Therapeutic measures, except heart transplantation, do not improve prognosis substantially. Only an accurate diagnosis in patients with unexplained HCM helps in establishing of the appropriate treatment strategies and adequate genetic consultation.

[Outcome and prognosis of surgical treatment in patients with severe aortic stenosis with respect to the duration and severity of associated aortic regurgitation]. / Ishod i prognoza hirurskog lecenja bolesnika sa teskom aortnom stenozom u odnosu na postojanje i tezinu pridruzene aortne regurgitacije.

INTRODUCTION: It is not clear whether associated aortic regurgitation (AR) should be regarded as a risk factor in patients undergoing surgery for severe aortic stenosis (AS). Some authors have suggested that morbidity and mortality are increased in these patients as compared to patients operated for pure AS, whereas others have found no difference of the outcome and prognosis between these groups. OBJECTIVE: This study made an attempt to compare the outcome and prognosis following the surgical intervention in patients with severe AS and associated AR and those operated for pure AS, as well as to determine predictive value of clinical, functional and echocardiographic data for the outcome of surgery. METHODS: Study population consisted of 122 consecutive patients operated at Dedinje Cardiovascular Institute during 1999 due to severe AS, defined as mean gradient over aortic valve >30 mmHg. The patients were divided into AS group (63 patients with AS without AR or with mild AR) and AS+AR group (59 patients with AS and moderate, severe or very severe AR). The patients were subjected to control clinical, functional and echocardiographic examinations 12 and 18 months following the surgery. RESULTS AND DISCUSSION: Preoperatively, the patients in AS group were older and had coronary artery disease more frequently, whereas patients in AS+AR group had higher left ventricular volumes and mass. Preoperative NYHA class, ejection fraction, mean gradient over aortic valve, type and size of the implanted mechanical prosthesis, and the incidence of associated coronary artery bypass surgery were similar between the groups. Similarly, the operative mortality was similar in AS and AS+AR groups (1.6% vs 8.5%, respectively, p=0.11). Twelve months postoperatively, there were no difference of average NYHA class and NYHA class III/IV between the groups. The patients in AS+AR group were unable to walk >300 meters on 6 minute walk test more frequently than those in AS group (64% vs. 36%, respectively; p=0.043). Eighteen months postoperatively, NYHA class III/IV was found more frequently in AS+AR than in AS group (26% vs. 8%, respectively; p=0.0343). In patients with associated AR, there was no difference of NYHA class with respect to the severity of AR (p=0.815). Multivariate analysis found the association of more than mild AR as an independent predictor of poor functional capacity, irrespective of its severity. CONCLUSION: Patients with severe AS and associated AR have poorer postoperative functional capacity as compared to patients operated for pure AS.