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1.
Eur Heart J ; 43(29): 2770-2780, 2022 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-35695691

RESUMO

AIM: Fatality of infective endocarditis (IE) is high worldwide, and its diagnosis remains a challenge. The objective of the present study was to compare the clinical characteristics and outcomes of patients with culture-positive (CPIE) vs. culture-negative IE (CNIE). METHODS AND RESULTS: This was an ancillary analysis of the ESC-EORP EURO-ENDO registry. Overall, 3113 patients who were diagnosed with IE during the study period were included in the present study. Of these, 2590 (83.2%) had CPIE, whereas 523 (16.8%) had CNIE. As many as 1488 (48.1%) patients underwent cardiac surgery during the index hospitalization, 1259 (48.8%) with CPIE and 229 (44.5%) with CNIE. The CNIE was a predictor of 1-year mortality [hazard ratio (HR) 1.28, 95% confidence interval (CI) 1.04-1.56], whereas surgery was significantly associated with survival (HR 0.49, 95% CI 0.41-0.58). The 1-year mortality was significantly higher in CNIE than CPIE patients in the medical subgroup, but it was not significantly different in CNIE vs. CPIE patients who underwent surgery. CONCLUSION: The present analysis of the EURO-ENDO registry confirms a higher long-term mortality in patients with CNIE compared with patients with CPIE. This difference was present in patients receiving medical therapy alone and not in those who underwent surgery, with surgery being associated with reduced mortality. Additional efforts are required both to improve the aetiological diagnosis of IE and identify CNIE cases early before progressive disease potentially contraindicates surgery.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Endocardite Bacteriana , Endocardite , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Endocardite/diagnóstico , Endocardite/epidemiologia , Endocardite Bacteriana/diagnóstico , Endocardite Bacteriana/epidemiologia , Endocardite Bacteriana/terapia , Humanos , Modelos de Riscos Proporcionais , Sistema de Registros , Estudos Retrospectivos
2.
Heart Lung Circ ; 32(10): 1230-1239, 2023 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-37743221

RESUMO

BACKGROUND: Some observational studies and randomised controlled trials (RCTs) have reported an association between calcium supplementation and increased risk of cardiovascular disease. Previous meta-analyses on the topic, based on data from RCTs and observational studies, have contradictory findings. This meta-analysis was conducted to determine the difference in associated risks of calcium supplementation with cardiovascular disease and stroke in RCTs. METHODS: Relevant studies published from database inception to 6 August 2021 were sourced from PubMed, Embase, Scopus, and the Cochrane Central Register of Controlled Trials. Any RCTs focusing on the relationship between calcium supplementation and incidence of cardiovascular disease or stroke were included. Articles were screened independently by two authors, according to the PICO criteria, with disagreements resolved by a third author. RESULTS: Twelve RCTs were included in the meta-analysis. Calcium supplementation was not associated with myocardial infarction, total stroke, heart failure admission, and all-cause/cardiovascular mortality. Subgroup analysis focusing on calcium monotherapy/calcium co-therapy with vitamin D, female sex, follow-up duration, and geographical region did not affect the findings. CONCLUSION: Calcium supplementation was not associated with myocardial infarction, total stroke, heart failure admission, and cardiovascular/all-cause mortality. Further studies are required to examine and understand these associations.


Assuntos
Doenças Cardiovasculares , Insuficiência Cardíaca , Infarto do Miocárdio , Acidente Vascular Cerebral , Feminino , Humanos , Doenças Cardiovasculares/epidemiologia , Cálcio , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle , Suplementos Nutricionais
3.
Eur J Clin Pharmacol ; 78(10): 1589-1600, 2022 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-35941300

RESUMO

PURPOSE: Transcatheter aortic valve replacement (TAVR) is increasingly carried out in patients with aortic valvular conditions. Atrial fibrillation (AF) is a common comorbidity among patients undergoing TAVR. Despite this, there remains a paucity of data and established guidelines regarding anticoagulation use post-TAVR in patients with AF. METHODS: Four databases were searched from inception until 12 October 2021. A title and abstract sieve, full-text review and data extraction were conducted by independent authors, and articles including patients without AF were excluded. The Review Manager (Version 5.4) was utilised in data analysis. RESULTS: A total of 25,199 post-TAVR patients with AF were included from seven articles, with 9764 patients on non-vitamin K antagonist oral anticoagulants (NOAC) and 15,435 patients on vitamin K antagonists (VKA). In this analysis, there was a significantly lower risk of all-cause mortality at 1 year (RR: 0.75, CI: 0.58-0.97, p = 0.04, I2 = 56%), and bleeding at 1 year (RR: 0.73, CI: 0.68-0.79, p = < 0.00001, I2 = 0%), between patients on NOAC and VKA. There were no detectable differences between patients on NOAC and VKA for all-cause mortality at 2 years, stroke within 30 days, stroke within 1 year, ischaemic stroke at 1 year and life-threatening bleeding at 30 days. CONCLUSION: While the results of this analysis reveal NOAC as a potential alternate treatment modality to VKA in post-TAVR patients with AF, further research is needed to determine the full safety and efficacy profile of NOAC (PROSPERO: CRD42021283548).


Assuntos
Fibrilação Atrial , Isquemia Encefálica , Acidente Vascular Cerebral , Substituição da Valva Aórtica Transcateter , Administração Oral , Anticoagulantes/uso terapêutico , Fibrilação Atrial/complicações , Isquemia Encefálica/tratamento farmacológico , Fibrinolíticos/uso terapêutico , Hemorragia/induzido quimicamente , Humanos , Acidente Vascular Cerebral/tratamento farmacológico , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/prevenção & controle , Substituição da Valva Aórtica Transcateter/efeitos adversos , Resultado do Tratamento
4.
J Thromb Thrombolysis ; 53(2): 335-345, 2022 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-34448103

RESUMO

The pandemic has led to adverse short-term outcomes for patients with ST-segment elevation myocardial infarction (STEMI). It is unknown if this translates to poorer long-term outcomes. In Singapore, the escalation of the outbreak response on February 7, 2020 demanded adaptation of STEMI care to stringent infection control measures. A total of 321 patients presenting with STEMI and undergoing primary percutaneous coronary intervention at a tertiary hospital were enrolled and followed up over 1-year. They were allocated into three groups based on admission date-(1) Before outbreak response (BOR): December 1, 2019-February 6, 2020, (2) During outbreak response (DOR): February 7-March 31, 2020, and (3) control group: November 1-December 31, 2018. The incidence of cardiac-related mortality, cardiac-related readmissions, and recurrent coronary events were examined. Although in-hospital outcomes were worse in BOR and DOR groups compared to the control group, there were no differences in the 1-year cardiac-related mortality (BOR 8.7%, DOR 7.1%, control 4.8%, p = 0.563), cardiac-related readmissions (BOR 15.1%, DOR 11.6%, control 12.0%, p = 0.693), and recurrent coronary events (BOR 3.2%, DOR 1.8%, control 1.2%, p = 0.596). There were higher rates of additional PCI during the index admission in DOR, compared to BOR and control groups (p = 0.027). While patients admitted for STEMI during the pandemic may have poorer in-hospital outcomes, their long-term outcomes remain comparable to the pre-pandemic era.


Assuntos
COVID-19 , Intervenção Coronária Percutânea , Infarto do Miocárdio com Supradesnível do Segmento ST , Humanos , Pandemias , Readmissão do Paciente/estatística & dados numéricos , Recidiva , Infarto do Miocárdio com Supradesnível do Segmento ST/epidemiologia , Infarto do Miocárdio com Supradesnível do Segmento ST/cirurgia , Singapura/epidemiologia , Centros de Atenção Terciária , Resultado do Tratamento
5.
Heart Lung Circ ; 31(1): 128-135, 2022 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-34116941

RESUMO

BACKGROUND: Paradoxical low-flow (LF) severe aortic stenosis (AS) despite preserved left ventricular (LV) ejection fraction (LVEF) has been shown to be distinct from normal-flow (NF) AS, with a poorer prognosis. Relative valve load (RVL) is a novel echocardiographic haemodynamic index based on the ratio of transaortic mean pressure gradient to the global valvulo-arterial impedance (Zva) in order to estimate the contribution of the valvular afterload to the global LV load. We aimed to determine the usefulness of RVL in LF AS versus NF AS. METHOD: A total of 450 consecutive patients with medically managed severe AS (aortic valve area <1.0 cm2) with preserved LVEF (>50%) were studied. Patients were divided into LF (stroke volume index <35 mL/m2) or NF, and high RVL or low RVL. Baseline clinical and echocardiographic profiles, as well as clinical outcomes, were compared. RESULTS: There were 149 (33.1%) patients with LF. Despite higher global impedance in LF (Zva 6.3±2.4 vs 3.9±0.9 mmHg/mL/m2; p<0.001) compared with NF, the RVL in LF AS was significantly lower (5.4±2.7 vs 9.8±5.1 mL/m2; p<0.001). On multivariable analysis, low RVL (≤7.51) remained independently associated with poor clinical outcomes on Cox regression (hazard ratio, 1.31; 95% confidence interval, 1.03-1.68), with 53.2% sensitivity and 70.3% specificity. This was comparable to other prognostic indices in AS. Kaplan-Meier curves demonstrated that low RVL was associated with increased mortality. CONCLUSIONS: Increased systemic arterial afterload may be important in the pathophysiology of LF AS. Low RVL was an independent predictor of poor clinical outcomes in medically managed severe AS. There may be a greater role in the attenuation of systemic arterial afterload in AS to improve outcomes.


Assuntos
Estenose da Valva Aórtica , Função Ventricular Esquerda , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/cirurgia , Estenose da Valva Aórtica/diagnóstico , Estenose da Valva Aórtica/cirurgia , Humanos , Estudos Retrospectivos , Índice de Gravidade de Doença , Volume Sistólico
6.
Heart Lung Circ ; 31(4): 469-479, 2022 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-34844903

RESUMO

BACKGROUND: There are differences in bicuspid aortic valve (BAV) characteristics between Asian and European populations, but little is known about the inter-ethnic differences in bicuspid valve function and aortic root dimensions within the diverse Asian population. METHODS: From 1992-2017, 562 patients with index echocardiographic diagnosis of BAV in a tertiary health care institution in Singapore were analysed according to their ethnic groups: Chinese, Malay, Indian, and Eurasian. Study outcomes included BAV complications (infective endocarditis, aortic dissection) and clinical outcomes (aortic valve surgery, aortic root surgery, all-cause mortality). Total events were defined as composite outcome of all BAV complications and outcomes. Aortic dimensions and aortic dilatation rates were also studied. RESULTS: There were 379 (67.5%) Chinese, 79 (14.0%) Malay, 73 (13.0%) Indian, and 31 (5.5%) Eurasian patients. Type 1 BAV (58.5%) was the most prevalent BAV morphology, with moderate-to-severe aortic stenosis (AS) (36.8%) being the most common complication in the overall population. There was a higher prevalence of type 0 BAV in Chinese and Indian groups, and type 1 BAV with fusion of left-right coronary cusp in Eurasian and Malay groups (p=0.082). There was no difference in significant AS among groups. The highest prevalence of moderate-to-severe aortic regurgitation was observed amongst the Eurasian group, followed by Chinese, Indian, and Malay groups (p=0.033). The Chinese group had the largest mean indexed diameters of the aortic root. Multivariable linear regression demonstrated that only the Chinese had significantly larger indexed diameters in the aortic annulus, sinotubular junction (STJ), and ascending aorta (AA), relative to the Eurasian group, after adjusting for age, sex, smoking, hypertension, hyperlipidaemia, diabetes, and aortic regurgitation. On follow-up echocardiography, there was a trend towards the highest dilatation rates of sinus of Valsalva and STJ amongst Indian, and AA amongst Malay groups. Kaplan-Meier curves showed the highest incidence of total events amongst Chinese, followed by Malay, Indian and Eurasian (log-rank=9.691; p=0.021) patients. CONCLUSION: There were differences in BAV morphology, valve dysfunction, aortopathy, and prognosis within the Asian population. Chinese patients had one of the highest prevalence of significant aortic regurgitation, with the largest aortic dimensions and worst outcomes compared with other Asian ethnicities. Closer surveillance is warranted in BAV patients within the Asian population.


Assuntos
Insuficiência da Valva Aórtica , Doença da Válvula Aórtica Bicúspide , Doenças das Valvas Cardíacas , Valva Aórtica/cirurgia , Insuficiência da Valva Aórtica/epidemiologia , Insuficiência da Valva Aórtica/etiologia , Doenças das Valvas Cardíacas/diagnóstico , Humanos , Estudos Retrospectivos
7.
Heart Lung Circ ; 30(1): 115-120, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31401051

RESUMO

BACKGROUND: Gender differences in valvular heart disease are increasingly recognised. A prior study has suggested better surgical outcomes in women with symptomatic aortic stenosis (AS). We investigate gender differences in medically managed severe AS. METHOD: We studied 347 patients with severe AS (aortic valve area index <0.6 cm2/m2) in terms of baseline clinical background, echocardiographic characteristics, and clinical outcomes. Appropriate univariate and multivariate models were employed, while Kaplan-Meier curves were constructed to compare mortality outcomes. RESULTS: In total, 205 (59%) patients were women. Despite higher incidences of hypertension (75.6% vs 47.3%) and diabetes mellitus (46.5% vs 29.5%) in women, women had improved survival (Kaplan-Meier log-rank = 6.24, p = 0.012). After adjusting for age (hazard ratio [HR], 1.034; 95% confidence interval [CI], 1.014-1.054), hypertension (HR, 1.469; 95% CI, 0.807-2.673), diabetes (HR, 1.219; 95% CI, 0.693-2.145), and indexed aortic valve area (HR 0.145, 95% CI 0.031-0.684) on multivariate analyses, female gender remained independently associated with lower mortality (HR, 0.561; 95%, CI 0.332-0.947). Women tended to have smaller body surface area (BSA), left ventricular (LV) internal diastolic diameter, and smaller LV outflow tract diameter but were similar to men in terms of LV ejection fraction, AS severity, and patterns of LV remodelling. CONCLUSIONS: Women appeared to have better outcomes compared to men in medically managed severe AS. These gender differences warrant further study and may affect prognosis, follow-up, and timing of valve surgery.


Assuntos
Estenose da Valva Aórtica/terapia , Valva Aórtica/cirurgia , Gerenciamento Clínico , Função Ventricular Esquerda/fisiologia , Idoso , Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/diagnóstico , Estenose da Valva Aórtica/epidemiologia , Diástole , Ecocardiografia , Feminino , Seguimentos , Humanos , Incidência , Masculino , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de Doença , Fatores Sexuais , Singapura/epidemiologia , Volume Sistólico/fisiologia , Taxa de Sobrevida/tendências
8.
Heart Lung Circ ; 29(12): 1773-1781, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-32362405

RESUMO

BACKGROUND: Atrial fibrillation (AF) results in the loss of atrial booster pump function and portends poorer outcome in aortic valve stenosis (AS). However, its characteristics and impact on medically managed AS remained under-recognised. We compared these patients with AF to sinus rhythm (SR). METHOD: In total, 347 consecutive patients with medically managed severe AS (aortic valve area <1 cm2) and preserved left ventricular ejection fraction (>50%) were studied, in terms of echocardiographic characteristics and clinical outcomes. Appropriate univariate and multivariate models were used, while Kaplan-Meier curves and Cox regression models were constructed to compare clinical outcomes (mortality, admissions for congestive cardiac failure, and stroke). RESULTS: Ninety (90) (25.9%) patients had AF. Patients with AF had lower body mass index (BMI 18.5±10.4 vs 23.8±6.2 g/m2; p<0.001), larger left ventricular mass index (LVMI 127.9±39.0 vs 116.7±36.5; p=0.017), and left atrial volume index (53.2±20.0 vs 31.0±9.2 mL/m2; p=0.004). Atrial fibrillation was associated with higher mortality (52.2% vs 37.4%; Kaplan-Meier log-rank 7.18; p=0.007), admissions for congestive cardiac failure (log-rank 6.42; p=0.011), and poorer composite outcomes (log-rank 6.29; p=0.012). The incidence of stroke in both groups were similar on follow-up (log-rank 0.08; p=0.776). After adjusting for age, BMI, LVMI, and left atrial volume index on Cox regression, AF remained independently associated with poorer composite clinical outcomes (hazard ratio, 1.66; 95% confidence interval 1.07-2.58). CONCLUSIONS: Atrial fibrillation remained an important comorbidity affecting a quarter of patients with medically managed severe AS. It was independently associated with poorer clinical outcomes and may thus aid in prognostication and management.


Assuntos
Estenose da Valva Aórtica/cirurgia , Fibrilação Atrial/cirurgia , Ecocardiografia/métodos , Frequência Cardíaca/fisiologia , Implante de Prótese de Valva Cardíaca/métodos , Volume Sistólico/fisiologia , Função Ventricular Esquerda/fisiologia , Idoso , Estenose da Valva Aórtica/complicações , Estenose da Valva Aórtica/diagnóstico , Fibrilação Atrial/complicações , Fibrilação Atrial/fisiopatologia , Feminino , Seguimentos , Humanos , Masculino , Prognóstico , Estudos Retrospectivos , Índice de Gravidade de Doença
9.
Eur Heart J ; 39(15): 1308-1313, 2018 04 14.
Artigo em Inglês | MEDLINE | ID: mdl-29029058

RESUMO

Background: Transcatheter aortic valve replacement (TAVR) has been shown safe and feasible in patients with bicuspid aortic valve (BAV) morphology. Evaluation of inter-ethnic differences in valve morphology and function and aortic root dimensions in patients with BAV is important for the worldwide spread of this therapy in this subgroup of patients. Comparisons between large European and Asian cohorts of patients with BAV have not been performed, and potential differences between populations may have important implications for TAVR. Aim: The present study evaluated the differences in valve morphology and function and aortic root dimensions between two large cohorts of European and Asian patients with BAV. Methods and results: Aortic valve morphology was defined on transthoracic echocardiography according to the number of commissures and raphe: type 0 = no raphe and two commissures, type 1 = one raphe and two commissures, type 2 = two raphes and one commissure. Aortic stenosis and regurgitation were graded according to current recommendations. For this study, aortic root dimensions were manually measured on transthoracic echocardiograms at the level of the aortic annulus, sinus of Valsalva (SOV), sinotubular junction (STJ), and ascending aorta (AA). Of 1427 patients with BAV (45.2 ± 18.1 years, 71.9% men), 794 (55.6%) were Europeans and 633 (44.4%) were Asians. The groups were comparable in age and proportion of male sex. Asians had higher prevalence of type 1 BAV with raphe between right and non-coronary cusps than Europeans (19.7% vs. 13.6%, respectively; P < 0.001), whereas the Europeans had higher prevalence of type 0 BAV (two commissures, no raphe) than Asians (14.5% vs. 6.8%, respectively; P < 0.001). The prevalence of moderate and severe aortic regurgitation was higher in Europeans than Asians (44.2% vs. 26.8%, respectively; P < 0.001) whereas there were no differences in BAV with normal function or aortic stenosis. After adjusting for demographics, comorbidities, and valve function, the dimensions of the aortic annulus [mean difference 1.17 mm/m2, 95% confidence interval (CI) 0.96-1.39], SOV (mean difference 1.86 mm/m2, 95% CI 1.47-2.24), STJ (mean difference 0.52 mm/m2, 95% CI 0.14-0.90) and AA (mean difference 1.05 mm/m2, 95% CI 0.57-1.52) were significantly larger among Asians compared with Europeans. Conclusions: This large multicentre registry reports for the first time that Asians with BAV showed more frequently type 1 BAV (with fusion between right and non-coronary cusp) and have larger aortic dimensions than Europeans. These findings have important implications for prosthesis type and size selection for TAVR.


Assuntos
Valva Aórtica/anormalidades , Valva Aórtica/anatomia & histologia , Valva Aórtica/patologia , Doenças das Valvas Cardíacas/etnologia , Doenças das Valvas Cardíacas/cirurgia , Adulto , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/cirurgia , Insuficiência da Valva Aórtica/epidemiologia , Insuficiência da Valva Aórtica/etnologia , Insuficiência da Valva Aórtica/cirurgia , Estenose da Valva Aórtica/epidemiologia , Estenose da Valva Aórtica/etnologia , Estenose da Valva Aórtica/cirurgia , Povo Asiático/etnologia , Doença da Válvula Aórtica Bicúspide , Ecocardiografia/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prevalência , Estudos Retrospectivos , Seio Aórtico/anatomia & histologia , Seio Aórtico/diagnóstico por imagem , Substituição da Valva Aórtica Transcateter/métodos , População Branca/etnologia
10.
Eur Heart J ; 38(9): 665-674, 2017 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-27807057

RESUMO

AIMS: Percutaneous transcatheter tricuspid valve therapy is an evolving treatment option for patients with significant tricuspid regurgitation (TR) deemed too fragile for open heart surgery. The present study proposes comprehensive anatomical evaluation of the tricuspid valve, right ventricle (RV), and vena cavae and its spatial relationships with the right coronary artery (RCA) using computed tomography (CT) and investigates the implications for suitability for current technologies. METHODS AND RESULTS: A total of 250 patients (mean age 80 ± 7.2 years, 52.4% men) undergoing CT were divided according to the presence of moderate or severe TR (≥3+, n = 40) and less than moderate TR (<3+, n = 210). Tricuspid valve annulus, RV, and vena cavae dimensions and the course of the RCA relative to the tricuspid annulus were evaluated. Patients with TR ≥ 3+ showed significantly larger dimensions of the tricuspid annulus, RV and vena cavae. In 64.8% of patients, the RCA coursed along the tricuspid valve annulus. Patients with TR <3+ showed more frequently a course of the RCA superior to the tricuspid annulus at the levels of the anterior and the posterior tricuspid leaflet compared with their counterparts (12.4% vs. 0%, P = 0.019). A less favourable course of the RCA (≤2.0 mm distance to the annulus) for current annuloplasty techniques was observed at the level of the anterior tricuspid and posterior leaflets in respective 12.5 and 27.5% of patients with TR ≥3+. CONCLUSION: The present study proposes a first systematic approach based on CT to define the patient suitability for current transcatheter tricuspid valve devices.


Assuntos
Insuficiência da Valva Tricúspide/patologia , Idoso , Anuloplastia da Valva Cardíaca/métodos , Angiografia por Tomografia Computadorizada/métodos , Vasos Coronários/anatomia & histologia , Vasos Coronários/diagnóstico por imagem , Ecocardiografia/métodos , Feminino , Implante de Prótese de Valva Cardíaca , Humanos , Masculino , Tomografia Computadorizada Multidetectores/métodos , Planejamento de Assistência ao Paciente , Substituição da Valva Aórtica Transcateter/métodos , Valva Tricúspide/diagnóstico por imagem , Valva Tricúspide/patologia , Insuficiência da Valva Tricúspide/diagnóstico por imagem , Insuficiência da Valva Tricúspide/cirurgia , Veia Cava Inferior/anatomia & histologia , Veia Cava Inferior/diagnóstico por imagem
11.
Eur Heart J ; 38(28): 2221-2226, 2017 Jul 21.
Artigo em Inglês | MEDLINE | ID: mdl-28077468

RESUMO

AIMS: Quantitative mitral regurgitation (MR) grading remains challenging. This study evaluated the concept of integrating echocardiography and computed tomography for grading MR severity. Specifically, an integrated parameter was developed that combines the true cross-sectional mitral regurgitant orifice area (ROA) assessed with multi-detector row computed tomography (MDCT) with flow data from echocardiography. METHODS AND RESULTS: Systolic MDCT data of 73 patients, referred for transcatheter aortic valve implantation (TAVI) who also had MR, were evaluated. The MDCT systolic phase with the smaller left ventricular volume and the largest mitral regurgitant orifice was selected. Using planimetry, the mitral ROA was measured. The mitral ROA was multiplied with the velocity time integral of the MR jet on echocardiography for the calculation of the integrated regurgitant volume (RVol). MDCT analysis showed a mean mitral ROA of 11.3 ± 7.4 mm2 and a mean integrated RVol of 21.4 ± 14.7 mL/beat, whereas echocardiography showed a mean effective ROA and RVol of MR of 13.3 ± 8.2 mm2 and 23.9 ± 13.6 mL/beat, respectively. Compared with echocardiography, grading based on integrated mitral RVol resulted in reclassification of 10% of the patients from severe to non-severe MR and 14% of the patients from non-severe to severe MR. CONCLUSIONS: Integrated mitral RVol is a quantitative parameter of MR severity by combining the true cross-sectional mitral ROA assessed with MDCT and Doppler mitral haemodynamics which resulted in a significant reclassification of MR grade in patients with severe aortic stenosis undergoing TAVR.


Assuntos
Estenose da Valva Aórtica/cirurgia , Insuficiência da Valva Mitral/patologia , Substituição da Valva Aórtica Transcateter , Idoso de 80 Anos ou mais , Estudos Transversais , Ecocardiografia/métodos , Feminino , Humanos , Masculino , Insuficiência da Valva Mitral/diagnóstico por imagem , Tomografia Computadorizada Multidetectores/métodos , Imagem Multimodal/métodos
12.
Eur Heart J ; 38(16): 1207-1217, 2017 Apr 21.
Artigo em Inglês | MEDLINE | ID: mdl-28369242

RESUMO

AIMS: The presence of hypo-attenuated leaflet thickening (HALT) and/or reduced leaflet motion on multi-detector row computed tomography (MDCT) has been proposed as a possible marker for early transcatheter aortic valve thrombosis. However, its association with abnormal valve haemodynamics on echocardiography (another potential marker of thrombosis) and clinical outcomes (stroke) remains unclear. The present study evaluated the prevalence of HALT on MDCT and abnormal valve haemodynamics on echocardiography. In addition, the occurrence of ischemic stroke and/or transient ischemic attack (TIA) was assessed. METHODS AND RESULTS: A total of 434 patients (mean age 80 ± 7 years, 51% male) who underwent transcatheter aortic valve replacement (TAVR) were evaluated. Transcatheter valve haemodynamics were assessed on echocardiography at discharge, 6 months, and thereafter yearly (up to 3 years post-TAVR). The presence of HALT and/or reduced leaflet motion was assessed on MDCT performed 35 days [interquartile range 19-210] after TAVR in 128 of these 434 patients. Possible TAVR valve thrombosis was defined by mean transvalvular gradient ≥20 mmHg and aortic valve area (AVA) ≤1.1cm2 on echocardiography or by the presence of HALT or reduced leaflet motion on MDCT. The occurrence of ischemic stroke/TIA at follow-up was recorded. HALT and/or reduced leaflet motion was present in 12.5% of 128 patients undergoing MDCT, and was associated with a slightly higher mean transvalvular gradient (12.4 ± 8.0 mmHg vs. 9.4 ± 4.3 mmHg; P = 0.026) and smaller AVA (1.49 ± 0.39 cm2 vs. 1.78 ± 0.45 cm2, P = 0.017). Only one patient with HALT on MDCT revealed abnormal valve haemodynamics on echocardiography. At 3-year follow-up, abnormal valve haemodynamics on echocardiography were observed in 3% of patients. HALT on MDCT and abnormal valve haemodynamics on echocardiography were not associated with increased risk of ischemic stroke/TIA. CONCLUSION: On MDCT, 12.5% of patients showed HALT or reduced leaflet motion, whereas only one of these patients had abnormal valve haemodynamics on echocardiography. Neither HALT nor increased transvalvular gradient were associated with stroke/TIA.


Assuntos
Doenças das Valvas Cardíacas/fisiopatologia , Hemodinâmica/fisiologia , Acidente Vascular Cerebral/etiologia , Trombose/fisiopatologia , Substituição da Valva Aórtica Transcateter , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/cirurgia , Feminino , Doenças das Valvas Cardíacas/etiologia , Próteses Valvulares Cardíacas , Humanos , Ataque Isquêmico Transitório/etiologia , Masculino , Tomografia Computadorizada Multidetectores , Estudos Prospectivos , Acidente Vascular Cerebral/fisiopatologia , Trombose/etiologia , Resultado do Tratamento
13.
Echocardiography ; 34(10): 1478-1485, 2017 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-28849595

RESUMO

AIMS: Transesophageal echocardiographic (TEE) findings of left atrial appendage (LAA) thrombus, spontaneous echo contrast (SEC), and LAA dysfunction are established risk factors of cardioembolic stroke. The semi-invasive nature of TEE limits its utility as a routine risk stratification tool. We aim to correlate TEE and transthoracic echocardiography (TTE) pulsed Doppler measurements of LAA flow velocities and use TTE measurements to predict TEE findings. METHODS AND RESULTS: We prospectively measured pulsed Doppler LAA flow velocities in 103 consecutive patients on TEE and TTE. There was a strong correlation between TEE and TTE LAA emptying velocity (LAA E) (r = .88, P < .001) and a moderate correlation between LAA filling velocities (r = .50, P < .001). TTE LAA E predicted the presence of thrombus or SEC independent of atrial fibrillation (AF). To predict the presence of thrombus or SEC, the optimal TTE LAA E cutoff was ≤30 cm/s in all patients (75% sensitive, 90% specific) and ≤31 cm/s in AF patients (80% sensitive, 79% specific). To predict LAA dysfunction (TEE E ≤ 20 cm/s), the optimal TTE LAA E cutoff was ≤27 cm/s (100% sensitive, 89% specific in all patients and 100% sensitive, 74% specific in AF patients). CONCLUSIONS: TTE assessment of LAA function is feasible and correlates well with the more invasive TEE method. It predicts the presence of thrombus, SEC, and LAA dysfunction on TEE. TTE LAA assessment has incremental value in thromboembolic risk stratification and should be utilized more frequently.


Assuntos
Apêndice Atrial/diagnóstico por imagem , Apêndice Atrial/fisiopatologia , Ecocardiografia Doppler de Pulso/métodos , Ecocardiografia Transesofagiana/métodos , Acidente Vascular Cerebral/diagnóstico , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos , Fatores de Risco
14.
Echocardiography ; 34(5): 638-648, 2017 May.
Artigo em Inglês | MEDLINE | ID: mdl-28370476

RESUMO

BACKGROUND/OBJECTIVES: In severe aortic stenosis (AS), deterioration of left ventricular ejection fraction (LVEF) to <50% is an AHA/ACC class I indication for valve replacement, regardless of symptoms. Controversy surrounds prognosis of low-flow AS compared to normal-flow, and no study has examined LVEF deterioration. We compared factors associated with LVEF deterioration (to <50%) and clinical outcomes. METHODS: Consecutive subjects with low-flow (stroke volume index <35 mL/m2 , n=56) and normal-flow (n=72) severe AS (aortic valve area <1 cm2 ) with preserved LVEF (>50%) and with paired echocardiography were studied. Univariate and multivariate analyses identified factors associated with LVEF deterioration. Clinical outcomes were determined on follow-up for more than 5 years. RESULTS: Significant LVEF deterioration (to <50%) was seen in 18% of low-flow (initial LVEF 63±8% to 32±9%) and 18% of normal-flow AS (61±7% to 31±12%). Independent factors in low-flow AS were hypertension (OR: 30.7, 95% CI: 2.0-467.6, P=.014) and higher end-systolic wall stress (OR: 1.086, 95% CI: 1.022-1.153, P=.008), compared to normal-flow, which were hypertension (OR: 15.9, 95% CI: 3.1-81.9, P=.001), higher septal E/E' ratio (OR: 1.16, 95% CI: 1.01-1.35, P=.043), lower septal S' velocity (OR: 0.204, 95% CI: 0.061-0.682, P=.010), and higher end-systolic wall stress (OR: 1.051, 95% CI: 1.001-1.104, P=.047). Overall, a third of the cohort experienced MACE, regardless of flow (log-rank 0.048, P=.827). However, aortic valve replacement (AVR) rates were lower in low-flow AS (20% vs 43%, P=.005). CONCLUSIONS: Low-flow AS despite normal LVEF appears similar to normal-flow in terms of LVEF deterioration and clinical outcomes in our Asian population. AVR rate was lower even though low-flow may not reflect less severe disease.


Assuntos
Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/etnologia , Ecocardiografia/estatística & dados numéricos , Volume Sistólico , Disfunção Ventricular Esquerda/diagnóstico por imagem , Idoso , Idoso de 80 Anos ou mais , Povo Asiático , Estudos de Coortes , Diagnóstico Diferencial , Feminino , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Prevalência , Valores de Referência , Reprodutibilidade dos Testes , Fatores de Risco , Sensibilidade e Especificidade , Índice de Gravidade de Doença , Singapura/epidemiologia , Taxa de Sobrevida
15.
Echocardiography ; 34(11): 1568-1574, 2017 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-28901639

RESUMO

BACKGROUND/OBJECTIVES: Controversy surrounds the prognosis and management of patients with paradoxical low-flow severe aortic stenosis (AS) with preserved left ventricular ejection fraction (LVEF). It was not certain if patients in a particular flow category remained in the same category as disease progressed. We investigated whether there were switches in categories and if so, their predictors. METHODS: Consecutive subjects (n = 203) with isolated severe AS and paired echocardiography (>180 days apart) were studied. They were divided into 4 groups, based on their flow categories and if they progressed on subsequent echocardiography to switch or remain in the same flow category. Univariate analyses of clinical and echocardiographic parameters identified predictors of these changes in flow category. RESULTS: One hundred eighteen were normal flow (SVI ≥ 35 mL/m2 ), while 85 were low flow on index echocardiography. In the patients with normal flow, 33% switched to low flow. This was associated with higher valvuloarterial impedance (Zva, P < .001) and lower systemic arterial compliance (SAC, P < .001) compared to index echocardiography, and predicted by higher initial Zva (optimized cutoff >4.77 mm Hg/mL/m2 , AUC = 0.81 [95% CI:0.75-0.87, P < .001]). In patients with low flow, 25% switched to normal flow, which was associated with lower Zva and higher SAC and the switch was predicted by a higher initial mean transaortic pressure gradient. CONCLUSIONS: A significant number of patients switched flow categories in severe AS with preserved LVEF on subsequent echocardiography. Changes in flow were reflected by respective changes in Zva and SAC. Identifying echocardiographic predictors of a switch in category may guide prognostication and management of such patients.


Assuntos
Estenose da Valva Aórtica/fisiopatologia , Ecocardiografia/métodos , Volume Sistólico/fisiologia , Função Ventricular Esquerda/fisiologia , Idoso , Feminino , Humanos , Masculino , Índice de Gravidade de Doença
20.
Int J Cardiol Heart Vasc ; 53: 101447, 2024 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-38979528

RESUMO

Introduction: Yeo's Index, product of the mitral leaflet separation index and dimensionless index, is a novel measure of the severity of rheumatic mitral stenosis (MS). We assess Yeo's index in patients with rheumatic MS with or without mixed valve disease. Methods: In a retrospective cohort study, Yeo's index was measured in 237 cases of rheumatic MS - 124 in a transthoracic echocardiography validation cohort using mitral valve area (MVA) by pressure half-time and planimetry as comparator and 113 in a transesophageal echocardiography (TEE) validation cohort using TEE three-dimensional MVA as comparator. Patients were considered to have mixed valve disease if they had MS and concomitant mitral regurgitation or aortic valve disease. Results: There were 113 patients with isolated MS and 124 patients with mixed valve disease. Overall, Yeo's index ≤ 0.26 cm showed 93.0 % sensitivity and 87.5 % specificity for identifying severe MS (MVA ≤ 1.5 cm2). In isolated MS, Yeo's index ≤ 0.26 cm showed sensitivity of 94.6 % and specificity of 90.0 % for identifying severe MS, while in mixed valve disease sensitivity was 90.6 % and specificity 86.7 %. Overall, Yeo's index ≤ 0.15 cm showed 83.6 % sensitivity and 94.3 % specificity for very severe MS (MVA ≤ 1.0 cm2). In isolated MS, the threshold of ≤0.15 cm showed sensitivity of 84.4 % and specificity of 92.6 % for very severe MS, while in mixed valve disease sensitivity was 81.3 % and specificity 95.3 %. The presence of atrial fibrillation did not influence the performance of Yeo's index. Conclusion: Yeo's Index accurately differentiates severity of rheumatic MS with or without mixed valve disease.

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