Patients with high left ventricular filling pressure may be missed applying 2016 echo guidelines: a pilot study.

2016 guidelines for the echographic evaluation of left ventricular filling pressure (LVFP) proposed a single algorithm with limited number of criteria (E/A ratio, tricuspid regurgitation velocity, left atrial volume index and average E/e') mainly related to left atrial pressure. Pulmonary venous flow analysis, evaluating more specifically left ventricular end diastolic pressure (LVEDP) has been withdrawn. We aim to evaluate the proportion of patients diagnosed with normal LVFP according to 2016 recommendations, despite an abnormal pulmonary venous flow profile suggesting high LVEDP. We prospectively studied patients with stable ischemic cardiomyopathy and aortic stenosis, before cardiac surgery. Extensive echocardiography was performed including pulmonary and mitral A wave durations. We included 76 patients (mean age 72 ± 10 years, 78% were men), 37 (49%) with aortic stenosis and 22 (29%) with ischemic cardiomyopathy. Mean left ventricular ejection fraction was 67 ± 11%. Applying recommendations, 58 patients had normal LVFP and 15 patients had high LVFP. Among the 58 patients with normal LVFP, 26 patients had Apd-Amd duration > 30 ms highly suggestive of high LVEDP. These patients had higher LV mass (112 ± 30 g/m2 vs. 86 ± 20 g/m2, p = 0.004) and shorter A wave duration (120 ± 13.6 ms vs. 132 ± 16.5 ms, p = 0.006) as compared to the remaining 15 patients with concordant evaluation (normal LVFP and normal Apd-Amd). In the present study, we found that 26/58 patients with low LVFP according to the 2016 recommendations had Apd-Amd suggestive of high LVEDP. Pulmonary venous flow should be added to the algorithm, particularly in patients with unexplained symptom, high LV mass or truncated mitral A wave.

Drug-induced aortic valve stenosis: An under recognized entity.

BACKGROUND: We have been intrigued by the observation that aortic stenosis (AS) may be associated with characteristic features of mitral drug-induced valvular heart disease (DI-VHD) in patients exposed to valvulopathic drugs, thus suggesting that beyond restrictive heart valve regurgitation, valvulopathic drugs may be involved in the pathogenesis of AS. METHODS: Herein are reported echocardiographic features, and pathological findings encountered in a series of patients suffering from both AS (mean gradient >15mmHg) and mitral DI-VHD after valvulopathic drugs exposure. History of rheumatic fever, chest radiation therapy, systemic disease or bicuspid aortic valve disease were exclusion criteria. RESULTS: Twenty-five (19 females, mean age 62years) patients having both AS and typical features of mitral DI-VHD were identified. Mean transaortic pressure gradient was 32+/-13mmHg. Aortic regurgitation was ≥ mild in 24 (96%) but trivial in one. Known history of aortic valve regurgitation following drug initiation prior the development of AS was previously diagnosed in 17 patients (68%). Six patients underwent aortic valve replacement and 3 both aortic and mitral valve replacement. In the 9 patients with pathology analysis, aortic valvular endocardium was markedly thickened by dense non-inflammatory fibrosis, a characteristic feature of DI-VHD. CONCLUSION: The association between AS and typical mitral DI-VHD after valvulopathic drug exposure may not be fortuitous. Aortic regurgitation was usually associated to AS and preceded AS in most cases but may be lacking. Pathology demonstrated the potential role of valvulopathic drugs in the development of AS.