Sex Differences in the Progression and Long-Term Outcomes of Native Mild to Moderate Aortic Stenosis.

BACKGROUND: There are limited data on the sex differences in the hemodynamic progression and outcomes of early-stage aortic stenosis (AS). OBJECTIVES: The authors sought to determine sex differences in hemodynamic progression and outcomes of mild to moderate native AS. METHODS: This was a retrospective observational cohort study including patients with mild to moderate native tricuspid AS from the Cleveland Clinic echocardiographic database between 2008 and 2016 and followed until 2018. All-cause mortality, aortic valve replacement (AVR), and disease progression assessed by annualized changes in echocardiographic parameters were analyzed based on sex. RESULTS: The authors included 2,549 patients (mean age, 74 ± 7 years and 42.5% women) followed over a median duration of 5.7 years. There was no difference in all-cause mortality between sexes irrespective of age, baseline disease severity, progression to severe AS, and receipt of AVR. Relative to men, women had similar all-cause mortality but lower risk of AVR (adjusted HR: 0.81 [95% CI: 0.67-0.91]; P = 0.009) at 10 years. On 1:1 propensity-matched analysis, men had a significantly faster disease progression represented by greater increases in the median of annualized change in mean gradient (2.10 vs 1.15 mm Hg/y, respectively, P < 0.001), maximum transvalvular velocity (0.42 vs 0.28 m/s/y), left ventricular end-diastolic diameters (0.15 vs 0.048 mm/m2.7/y) (P = 0.014). Women have significantly higher left ventricular ejection fraction, filling pressures, and left ventricular septum thickness over time on follow-up echocardiograms compared with men. CONCLUSIONS: Women with mild to moderate AS had slower hemodynamic progression of AS, were more likely to have preserved left ventricular ejection fraction and concentric left ventricular hypertrophy in addition to lower incidence of AVR compared with men despite similar mortality. These findings provide further evidence that there are distinct sex-specific longitudinal echocardiographic and clinical profiles in patients with AS.

Evaluating troponin elevation in patients with chronic kidney disease and suspected acute coronary syndrome.

Many patients with chronic kidney disease have chronically elevated cardiac troponin levels, and if they present with symptoms suggesting an acute coronary syndrome, it is often difficult to determine if this is the correct diagnosis. This article briefly reviews the major challenges in diagnosing acute coronary syndrome in patients with chronic kidney disease, describes the mechanisms and prognostic significance of troponin elevation in chronic kidney disease, and provides a diagnostic algorithm to risk-stratify patients with chronic kidney disease who have troponin elevation and suspected acute coronary syndrome.

Postoperative Apical Ballooning Syndrome Following Orthotopic Liver Transplantation.

As the mainstay of therapy for end-stage liver disease (ESLD), orthotopic liver transplantation (OLT) has complex effects on multiple organ systems. We present a representative case of acute heart failure with apical ballooning syndrome following OLT and review its mechanisms. Recognition of this and other potential cardiovascular and hemodynamic complications of OLT are essential to periprocedural anesthesia management. Once an acute phase of the condition is stabilized, conservative treatment and resolution of physical or emotional stressors usually allow for rapid resolution of symptoms, typically recovering systolic ventricular function within one to three weeks.

Ross procedure after prosthetic valve thrombosis in a patient with antiphospholipid syndrome and recurrent bleeding.

The Ross procedure allows replacement of a diseased aortic valve with pulmonary root autograft, possibly avoiding the highly thrombotic mechanical valves and immunologic deterioration of tissue valves in antiphospholipid syndrome (APS). Here, we present the use of the Ross procedure in a 42-year-old woman with mild intellectual disability, APS, and a complex anticoagulation history after she presented with thrombosis of her mechanical On-X aortic valve previously implanted for non-bacterial thrombotic endocarditis.