Patient positioning during the radiographic procedure affects the radiological signs of acetabular retroversion - A systematic review.

Young adults presenting with non-traumatic hip pain may suffer from acetabular retroversion (AR). The previous studies have suggested that patient positioning during the radiographic procedure, that is, pelvic tilt and/or rotation may alter the appearance of the acetabulum. The purpose of this systematic review was to explore and collate existing literature on the correlation between pelvic positioning in weight-bearing anterior-posterior radiographs and the radiographic signs of AR, namely, the ischial spine sign (ISS) the cross-over sign (COS) and posterior wall sign (PWS). The preferred reporting items for systematic reviews and meta-analysis guidelines were followed. MEDLINE, EMBASE, PubMed, The Cochrane Library, and CINAHL were searched. The search string included the following keywords: Pelvic, tilt, rotation, positioning, inclination, incidence, AR, ISS, COS, PWS, and acetabular version. Two authors independently screened the studies identified in the search, extracted data, and critically assessed included studies for quality using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. In total, 2289 publications were screened. Fifteen articles were found eligible for full-text screening, and four articles met the inclusion criteria. Although the studies varied methodologically, all reported that pelvic positioning impacted radiographic signs of AR investigated. One study suggested that more than 9° of pelvic inclination would result in positive COS. No other benchmark values on the degree of pelvic tilt and rotation that would compromise the diagnosis of AR, that is, the detection of ISS, COS, and PWS were reported. At present, literature reporting on the correlation between patient positioning and AR is sparse. Four studies met the inclusion criteria, and they all reported a link between pelvic positioning and the radiographic appearance of AR.

Pressure-flow responses to exercise in aortic stenosis, mitral regurgitation and diastolic dysfunction.

BACKGROUND: Haemodynamic exercise testing is important for evaluating patients with dyspnoea on exertion and preserved ejection fraction. Despite very different pathologies, patients with pressure (aortic stenosis (AS)) and volume (mitral regurgitation (MR)) overload and diastolic dysfunction after recent acute myocardial infarction (AMI) reach similar filling pressure levels with exercise. The pressure-flow relationships (the association between change in cardiac output (∆CO) and change in pulmonary arterial wedge pressure (∆PAWP) may provide insight into haemodynamic adaptation to exercise in these groups. METHODS AND RESULTS: One hundred sixty-eight subjects aged >50 years with a left ventricular ejection fraction of ≥50% underwent invasive exercise testing. They were enrolled in four different studies: AS (40 patients), AMI (52 patients), MR (43 patients) and 33 healthy subjects. Haemodynamic data were measured at rest, at 25 W, 75 W and at peak exercise. In all groups, PAWP increased with exercise. The greatest increase was observed in patients with AMI (from 12.7±3.9 mm Hg to 33.1±8.2 mm Hg, p<0.0001) and patients with AS (from 11.8±3.9 mm Hg to 31.4±6.1 mm Hg, p<0.0001), and the smallest was observed in healthy subjects (from 8.3±2.4 mm Hg to 21.1±7.5 mm Hg, p<0.0001). In all groups, the relative pressure increase was greatest at the beginning of the exercise. CO increased most in healthy patients (from 5.3±1.1 to 16.0±3.0 L/min, p<0.0001) and least in patients with AS (from 5.3±1.2 L/min to 12.4±2.6 L/min, p<0.0001). The pressure-flow relationships (∆PAWP/∆CO) and differed among groups (p=0.02). In all groups, the pressure-flow relationship was steepest in the initial phase of the exercise test. The AMI and AS groups (2.3±1.2 mm Hg/L/min and 3.0±1.3 mm Hg/L/min, AMI and AS, respectively) had the largest overall pressure-flow relationship; the healthy group had the smallest initially and at peak exercise (1.3±1.1 mm Hg/L/min) followed by MR group (1.9±1.4 mm Hg/L/min). CONCLUSION: The pressure-flow relationship was steepest in the initial phase of the exercise test in all groups. The pressure-flow relationship differs between groups. TRIAL REGISTRATION NUMBERS: NCT01974557, NCT01046838, NCT02961647 and NCT02395107.

First-phase ejection fraction: association with remodelling and outcome in aortic valve stenosis.

BACKGROUND: First-phase ejection fraction (EF1), the left ventricular (LV) ejection fraction (EF) until the time of peak transaortic velocity, is a novel marker of subclinical LV dysfunction able to predict adverse events in aortic stenosis (AS). This study investigated the association between end-systolic wall stress (ESWS) and EF1 in severe AS, as well as the prognostic value of EF1 in severe asymptomatic AS. METHODS: Two prospectively gathered cohorts of 94 asymptomatic patients and 108 symptomatic patients scheduled for aortic valve replacement (AVR), all with severe AS (aortic valve area <1 cm2) were stratified according to the median value of EF1 (33%). EF1 was defined as the EF at peak transaortic velocity. Asymptomatic patients were followed up for 3 years for the combined end-point of death, AVR or admission with heart failure. RESULTS: EF1 correlated with EF and was inversely associated with ESWS. In multivariate regression analysis, ESWS (p<0.001) and replacement fibrosis measured by MRI (p=0.02) were associated with EF1. Among asymptomatic patients, EF1 above the median was associated with the combined primary endpoint (HR=0.53 (95% CI 0.33 to 0.87)), while global longitudinal strain and EF were not. Among 42 patients with discordant AS (mean gradient <40 mm Hg), EF1 above median was associated with the primary endpoint (HR 0.28 (95% CI 0.12 to 0.61)). CONCLUSION: EF1 is an afterload-dependent measure that is associated with events in patients with asymptomatic severe AS. The afterload dependency of EF1 may be useful in timing of risk stratification in patients with discordant AS. TRIAL REGISTRATION NUMBERS: NCT02395107 and NCT02316587.

The association between aortic valve calcification, cardiovascular risk factors, and cardiac size and function in a general population.

To determine the presence and extent of aortic valve calcification (AVC) quantified by non-contrast cardiac computed tomography (NCCT), to determine the association between traditional cardiovascular risk factors and AVC score, and to evaluate the association between AVC and cardiac size and function assessed by echocardiography, in a general population aged 65-75 years. A random sample of 2060 individuals were invited to undergo NCCT through which their AVC score was assessed. Individuals with an AVC score ≥ 300 arbitrary units (AU) were invited for a transthoracic echocardiography together with age-matched controls. Descriptive statistics and multiple regression analyses were performed to identify risk factors associated with AVC and to describe associations between AVC score and echocardiographic findings. Of 2060 individuals invited 664 males and 636 females participated. Among those, 455 (68.5%) of males and 358 (56.3%) of females had AVC scores > 0 AU. The median AVC score was 6 AU (IQR 0-3064). Seventy-seven (11.6%) males and 20 (3.1%) females had an AVC score ≥ 300 AU. In a multiple regression analysis, age, sex, prior cardiovascular disease, smoking, and hypertension were associated with AVC score, while diabetes, hypercholesterolemia and kidney function were not. Individuals with AVC ≥ 300 AU had higher peak and mean aortic valve gradient, smaller indexed aortic valve area, greater left ventricular mass, and larger left atrial (LA) volume. In a random population sample of individuals aged 65-75 years, AVC was common and associated with most known cardiovascular risk factors. AVC ≥ 300 AU was associated with concentric remodeling and LA dilatation.

Sex differences in aortic valve calcification in severe aortic valve stenosis: association between computer tomography assessed calcification and valvular calcium concentrations.

AIMS: The aims of this study were to investigate the correlation and sex differences between total valve calcium, valve calcium concentration, and aortic valve calcification (AVC) in explanted valves from patients with severe aortic valve stenosis undergoing aortic valve replacement (AVR). METHODS AND RESULTS: Sixty-nine patients with severe aortic stenosis (AS) scheduled for elective AVR underwent echocardiography and cardiac computed tomography (CT) prior to surgery (AVCin vivo) and CT of the explanted aortic valve (AVCex vivo). Explanted valves were prepared in acid solution, sonicated, and analysed with Arsenazo III dye to estimate total valve calcium and valve calcium concentration. Median AVCex vivo was 2082 (1421-2973) AU; mean valve calcium concentration was 1.43 ± 0.42 µmol Ca2+/mg tissue; median total valve calcium 156 (111-255) mg Ca2+, and valve calcium density 52 (35-81) mg/cm2. AVC displayed a strong correlation with total valve calcium (R2 = 0.98, P < 0.001) and a moderate correlation with valve calcium concentration (R2 = 0.62, P < 0.001). Valvular calcium concentration was associated with sex, aortic valve area, and mean gradient. After adjusting for age and estimated glomerular filtration rate, sex and mean gradient remained associated with valve calcium concentrations. CONCLUSION: AVC score provides a strong estimate for total valve calcium but to a lesser degree calcium concentration in the valve tissue of patients with severe AS. Females presented lower valvular calcium concentrations than males irrespective of AS severity, adding evidence and providing support to the important point that sex differences in valvular calcium concentration in AS does not reflect valvular size.

Lumbar artery aneurysm: A rare manifestation of vasculopathy in a patient with neurofibromatosis type 1.

Lumbar artery aneurysms are rare but important to diagnose, since rupture can have serious consequences due to life-threatening hemorrhage. A 49-year-old male with Neurofibromatosis type 1 (NF-1) was admitted to the emergency room with abrupt onset of severe abdominal pain. Ultrasound examination was normal, noncontrast CT revealed a tapered retroperitoneal mass adjacent to the right psoas muscle. A multiphased contrast-enhanced CT scan raised suspicion of an arterial lumbar aneurysm and was confirmed by selective catheter based angiography. The patient underwent successful treatment with endovascular coiling and the patient was discharged within a few days after an uneventful course.

Association between left ventricular diastolic function and right ventricular function and morphology in asymptomatic aortic stenosis.

BACKGROUND: Aortic stenosis (AS) is a progressive disease in which left ventricular (LV) diastolic dysfunction is common. However, the association between diastolic dysfunction and right ventricular (RV) loading conditions and function has not been investigated in asymptomatic AS patients. METHODS AND FINDINGS: A total of 41 patients underwent right heart catheterization and simultaneous echocardiography at rest and during maximal supine exercise, stratified according to resting diastolic function. Cardiac chamber size and morphology was assessed using cardiac magnetic resonance imaging (cMRI). RV stroke work index, pulmonary artery (PA) compliance, PA elastance, PA pulsatility index, and right atrial pressure (RAP) were calculated at rest and maximal exercise. Ten patients (24%) had normal LV filling pattern, 20 patients (49%) had grade 1, and 11 patients (27%) had grade 2 diastolic dysfunction. Compared to patients with normal diastolic filling pattern, patients with diastolic dysfunction had lower RV end-diastolic volume (66 ± 11 ml/m2 vs. 79 ± 15 ml/m2, p = 0.02) and end-systolic volume (25 ± 7 ml/m2 vs. 32 ± 9 ml/m2, p = 0.04). An increase in mean RAP to ≥15 mmHg following exercise was not seen in patients with normal LV filling, compared to 4 patients (20%) with mild and 7 patients (63%) with moderate diastolic dysfunction (p = 0.003). PA pressure and PA elastance was increased in grade 2 diastolic dysfunction and correlated with RV volume and maximal oxygen consumption (r = -0.71, p < 0.001). CONCLUSIONS: Moderate diastolic dysfunction is associated with increased RV afterload (elastance), which is compensated at rest, but is associated with increased RAP and inversely related to maximal oxygen consumption during maximal exercise.

End-systolic wall stress in aortic stenosis: comparing symptomatic and asymptomatic patients.

Aims: In aortic stenosis (AS), there is poor association between symptoms and conventional markers of AS severity or left ventricular (LV) systolic function. This may reflect that symptoms arise from LV diastolic dysfunction or that aortic valve area (AVA) and transvalvular gradient do not reflect afterload. We aimed to study the impact of afterload (end-systolic wall stress [ESWS]) on the presence of symptoms in AS and to test whether symptoms are related to increased ESWS or LV remodelling. Methods and results: In a prospective study, ESWS was estimated by measuring LV wall thickness from MRI and estimated LV end systolic pressure from echocardiographic mean gradient and systolic blood pressure in 78 patients with severe AS scheduled for aortic valve replacement and 91 patients with asymptomatic severe AS. Symptomatic patients had lower indexed AVA (0.40±0.11 vs 0.45±0.09 cm2/m2, p=0.009). They had undergone more extensive remodelling (MRI LV mass index [LVMi]: 85±24 vs 69±17 g/m2, p<0.0001), had higher tricuspid regurgitant gradient (24±8 mm Hg vs 19 ± 7 mm Hg, p=0.0001) and poorer global longitudinal strain (-15.6±3.8 vs -19.9±3.2%, p<0.0001). ESWS was higher among symptomatic patients (96±51 vs 76±25 kdynes/cm2, p=0.003). Multivariate logistic regression identified echocardiographic relative wall thickness, tricuspid gradient, mitral deceleration time, early diastolic strain rate, MRI LVMi, MRI LV end-diastolic volume index and ESWS as independently associated with being symptomatic. Conclusion: ESWS can be estimated from multimodality imaging combining MRI and echocardiography. It is correlated with LV remodelling and neurohormonal activation and is independently associated with symptomatic status in AS.

Postoperative atrial fibrillation after aortic valve replacement is a risk factor for long-term atrial fibrillation.

OBJECTIVES: Postoperative atrial fibrillation (POAF) is a common complication following cardiac surgery. However, knowledge on the rate of long-term atrial fibrillation (LTAF) after POAF remains unclear. We investigated predictors of POAF in patients with aortic stenosis undergoing surgical aortic valve replacement, and assessed the rate of LTAF during follow-up. METHODS: We prospectively included 96 adult patients with severe aortic stenosis undergoing surgical aortic valve replacement. Patients with previous atrial fibrillation (AF) were excluded. Patients underwent echocardiography, cardiac computed tomography and magnetic resonance imaging immediately prior to surgery. Surgical aortic clamp time and postoperative C-reactive protein (CRP) were documented. POAF was defined as AF recorded within 7 days of surgery. Through chart review, patients were followed up for documented episodes of LTAF occurring more than 7 days after surgery. RESULTS: POAF occurred in 51 patients (53%). It was associated with larger preoperative echocardiographic left atrial volume index (44 ± 12 vs 37 ± 8 ml/m2, P = 0.004), longer aortic clamp time [80 (70-102) vs 72 (62-65) min, P = 0.04] and higher CRP on first postoperative day [80 (64-87) vs 65 (44-83) mg/l, P = 0.001]. Multivariable logistic regression revealed that left atrial volume index [odds ratio (OR) 1.07, 95% confidence interval (CI) 1.02-1.13; P = 0.005] and postoperative CRP (OR 1.03, 95% CI 1.01-1.05; P = 0.006) were the only independent predictors of POAF. During 695 days (25th-75th percentile: 498-859 days) of follow-up, LTAF occurred in 11 patients of whom 10 were in the POAF group (hazard ratio 9.4, 95% CI 1.2-74; P = 0.03). CONCLUSIONS: POAF is predicted by left atrial volume index and postoperative CRP. Patients with POAF have a 9-fold increase risk of developing symptomatic LTAF during follow-up. CLINICAL TRIAL REGISTRATION NUMBER: ClinicalTrials.gov (NCT02316587).

Children centered care: Minimizing the need for anesthesia with a multi-faceted concept for MRI in children aged 4-6.

PURPOSE: To evaluate the need for general anesthesia (GA) in MRI in children aged 4-6 years, using a multi-faceted concept, Children Centered Care (CCC), compared to a standard setup. MATERIALS AND METHODS: In this prospective study of 81 children, we developed and tested a multi-faceted concept, CCC, for MRI in children aged 4-6 without GA, comparing it to a standard setup. The CCC included: 1) an interactive app, 2) a trained pediatric team, 3) a children's lounge with a toy-scanner, and 4) a child-friendly multimedia environment in the MRI room. Patients were included from February-September 2016 and 2017. The use of GA was evaluated, image quality was assessed and a cost-benefit analysis was done. RESULTS: We included 40 children in the control group and 41 in the CCC group. Mean age was 5.8 years and 48 (59%) were males. Neuro and orthopedic imaging accounted for 58 (72%) and 22 (27%), respectively. With the CCC setup 39/41 (95%) completed a diagnostic MRI without GA compared to 17/40 (43%) in the control group (p < 0.001). Image quality was not different between the groups (p = 0.37). The setup proved cost-effective with a payback time of two years in a Danish setting with 250 eligible patients per year. CONCLUSION: With the multi-faceted concept CCC, the use of GA for MRI in children aged 4-6 was markedly reduced to 5%, image quality was maintained and the setup was cost-effective.

Exercise Hemodynamics After Aortic Valve Replacement for Severe Aortic Stenosis.

BACKGROUND: Severe aortic stenosis (AS) is often accompanied by diastolic dysfunction. After aortic valve replacement (AVR), the left ventricle often undergoes considerable reverse remodeling. Despite this, diastolic dysfunction may persist after AVR. The aims of this study were to determine the incidence of elevated left ventricular (LV) filling pressure at rest and during exercise among patients with severe AS after AVR and to describe factors related to elevated LV filling pressure, especially its association with LV and left atrial remodeling and myocardial fibrosis. METHODS: Thirty-seven patients undergoing AVR were included. Echocardiography, cardiac computed tomography, and magnetic resonance imaging were performed before AVR. An LV biopsy sample was obtained during AVR and analyzed for collagen fraction. One year after AVR, right heart catheterization with exercise was performed. A mean pulmonary capillary wedge pressure (PCWP) ≥ 28 mm Hg during exercise was considered elevated. RESULTS: Twelve patients (32%) had elevated exercise PCWP 1 year after AVR. Exercise PCWP was highest among patients undergoing concomitant coronary artery bypass graft surgery (30 ± 7 vs 25 ± 6 mm Hg, P = .04) and among patients with preoperative stroke volume index < 35 mL/m2 (28 ± 8 vs 23 ± 4 mm Hg, P < .05). Baseline LV ejection fraction was lower among patients with elevated PCWP (56 ± 8% vs 64 ± 8%, P = .01), and coronary calcium score was significantly higher (median 870 AU [interquartile range, 454-2,491 AU] vs 179 AU [interquartile range, 63-513 AU], P = .02). Conversely, exercise PCWP was not related to the presence of high LV wall mass or to the severity of AS. Among patients undergoing isolated AVR, there was a correlation between LV interstitial volume fraction and PCWP (r = 0.57, P = .01) and mean pulmonary artery pressure (r = 0.51, P = .03) during exercise. CONCLUSIONS: Elevated filling pressure during exercise was seen in one third of patients after AVR in this population and was seen primarily among patients with coexisting ischemic heart disease or diffuse myocardial fibrosis but was unrelated to preoperative severity of AS and LV remodeling.

Hemodynamic Characteristics in Significant Symptomatic and Asymptomatic Primary Mitral Valve Regurgitation at Rest and During Exercise.

BACKGROUND: In severe asymptomatic primary mitral valve regurgitation without risk factors, surgery strategy is controversial. We sought to clarify whether being symptomatic corresponds to the hemodynamic burden and reduced exercise capacity. A better understanding of this may contribute to optimize timing of surgery. METHODS AND RESULTS: Subjects with asymptomatic (New York Heart Association functional class I, n=29) or symptomatic (New York Heart Association functional class II and III, n=28) significant primary mitral valve regurgitation (effective regurgitant orifice, ≥0.30 cm2; left ventricular ejection fraction, >60%) were included. Right heart catheterization during rest and exercise, echocardiography, magnetic resonance imaging, and peak oxygen consumption test was performed. Symptomatic subjects had significantly higher pulmonary capillary wedge pressure at rest (14±4 versus 11±3 mm Hg; P=0.003) and at maximal exercise (30±6 versus 25±7 mm Hg; P=0.02) and higher mean pulmonary artery pressure (PAP) at rest (22±7 versus 18±4 mm Hg; P=0.005) and maximal exercise (46±8 versus 39±7 mm Hg; P=0.005) than asymptomatic subjects. Among asymptomatic subjects with normal resting value, exercise testing revealed a systolic PAP >60 mm Hg in 34%. Also the reverse response with minimal increase in pulmonary capillary wedge pressure and mean PAP during exercise was seen, especially in asymptomatic subjects. Among symptomatic subjects, we found a significant inverse correlation between resting mean PAP and left ventricular ejection fraction (r=-0.52; P=0.02) and right ventricular ejection fraction (r=-0.67; P<0.01). Peak oxygen consumption was equal and normal in both groups and correlated with left ventricular stroke volume but not with pulmonary capillary wedge pressure. CONCLUSIONS: Symptoms in patients with severe mitral valve regurgitation relate to congestion (pulmonary capillary wedge pressure and PAP), but not to peak oxygen consumption, which is determined by forward left ventricular stroke volume. Exercise testing reveals a higher mitral valve regurgitation burden in apparently asymptomatic patients. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT02961647.

Layer-specific deformation analysis in severe aortic valve stenosis, primary mitral valve regurgitation, and healthy individuals validated against invasive hemodynamic measurements of heart function.

AIM: Speckle tracking echocardiography is considered valuable in assessing left ventricular (LV) function. The method has been refined to assess deformation in different myocardial layers, but the effect of volume vs pressure overload on this pattern is unknown. The aim was to test whether layer-specific myocardial strain (LSS) obtained by speckle tracking echocardiography exhibits different patterns in conditions with different loading conditions. METHODS AND RESULTS: Forty patients with asymptomatic severe aortic stenosis (AS) (AVA 0.81 ± 0.15 cm2 , LV ejection fraction [LVEF] 66% ± 7%), 43 patients with asymptomatic or mildly symptomatic significant primary mitral regurgitation (MR) (effective regurgitant orifice (ERO) 0.51 (IQR 0.37-0.67) cm2 , LVEF 70% ± 7%), and 23 healthy individuals (LVEF 65% ± 6%) were enrolled. Echocardiography and right heart catheterization were performed in all patients. In MR, strain values in each myocardial layer (endocardial/global longitudinal strain (GLS)/epicardial) were higher (25.0% ± 3.4%/21.6% ± 2.9%/18.8% ± 2.6%) compared to healthy individuals (22.6% ± 3.2%/19.6% ± 2.9%/17.1% ± 2.6%) and AS (20.5% ± 2.8%/17.7% ± 2.5%/14.0% ± 5.6%), P < .001. All 3 groups exhibited a similar LSS pattern with highest values in the endocardial and lowest values in the epicardial layer. The epicardial-endocardial strain ratio was lower in AS (0.72 ± 0.04) than in MR (0.75 ± 0.04, P = .04). Global longitudinal strain (GLS) correlated significantly with LV wall stress (r = .39, P = .0003) but not with LV stroke work or contractility. CONCLUSION: Layer-specific myocardial strain (LSS) patterns differed in patients with severe AS, significant MR, and healthy individuals with highest values in MR. Strain irrespective of layer assessed was associated with LV wall stress but seemed less related to contractility and unrelated to stroke work in the setting of normal LVEF.

Postoperative Reverse Remodeling and Symptomatic Improvement in Normal-Flow Low-Gradient Aortic Stenosis After Aortic Valve Replacement.

BACKGROUND: Severe aortic stenosis (AS) most often presents with reduced aortic valve area (<1 cm2), normal stroke volume index (≥35 mL/m2), and either high mean gradient (≥40 mm Hg; normal-flow high-gradient AS) or low mean gradient (normal-flow low-gradient [NFLG] AS). The benefit of aortic valve replacement (AVR) among NFLG patients is controversial. We compared the impact of NFLG condition on preoperative left ventricular (LV) remodeling and myocardial fibrosis and postoperative remodeling and symptomatic benefit. METHODS AND RESULTS: Eighty-seven consecutive patients with reduced aortic valve area and normal stroke volume index undergoing AVR underwent echocardiography, magnetic resonance imaging, a 6-minute walk test, and measurement of natriuretic peptides before and 1 year after AVR. Myocardial fibrosis was assessed from magnetic resonance imaging. Patients were stratified as NFLG or normal-flow high-gradient. In total, 33 patients (38%) had NFLG. Before AVR, they were characterized by similar symptom burden but less severe AS measured by aortic valve area index (0.50±0.09 versus 0.40±0.08 cm2/m2; P<0.0001), lower LV mass index (74±18 versus 90±26 g/m2; P=0.01), but the same degree of myocardial fibrosis. After AVR, NFLG had a smaller reduction in LV mass index (-3±10 versus -±18 g/m2; P<0.0001) and a smaller reduction in natriuretic peptides. Both groups experienced similar symptomatic improvement. Normal-flow high-gradient condition independently predicted change in LV mass index. CONCLUSIONS: Patients with NFLG had less severe AS and LV remodeling than patients with normal-flow high-gradient. Furthermore, NFLG patients experienced less reverse remodeling but the same symptomatic benefit. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT02316587.

Relation of Left Atrial Size, Cardiac Morphology, and Clinical Outcome in Asymptomatic Aortic Stenosis.

Left atrial (LA) dilation in asymptomatic severe aortic stenosis (AS) may be an indicator of advanced disease. We aimed to investigate the association between LA volume index and left ventricular (LV) morphology assessed with cardiac magnetic resonance imaging (cMRI), and to assess the association with cardiac events. Ninety-two asymptomatic patients with aortic valve area <1 cm2, aortic peak jet velocity >3.5 m/s, and ejection fraction ≥50% were prospectively enrolled and divided according to echocardiographic-derived LA volume index <35 ml/m2. Patients underwent echocardiography, cMRI, exercise testing, and were followed for the composite end point of death, readmission, or aortic valve replacement. Aortic valve area index was similar (0.45 ± 0.08 cm2/m2 vs 0.45 ± 0.09 cm2/m2, p = 0.85) in patients with a dilated and normal LA. On cMRI patients with dilated LA were characterized by higher LV mass index (73 ± 17 g/m2 vs 66 ± 16 g/m2, p = 0.03), increased right ventricle (70 ± 14 ml/m2 vs 63 ± 12 ml/m2, p = 0.01) and LV end-diastolic volume index (84 ± 18 ml/m2 vs 77 ± 16 ml/m2, p = 0.05), and higher brain natriuretic peptide. Late enhancement pattern was similar. During follow-up 20 events were recorded in patients with LA dilation compared with 8 in patients with normal LA (adjusted hazard ratio 2.77, 95% confidence interval 1.19 to 6.46, p = 0.02); also B-type natriuretic peptide >125 pg/ml was associated with adverse outcome (adjusted hazard ratio 3.63, 95% confidence interval interval 1.28 to 10.32, p = 0.02). LA dilation is associated with LV remodeling and provides prognostic information in severe asymptomatic AS.

Association Between Left Atrial Dilatation and Invasive Hemodynamics at Rest and During Exercise in Asymptomatic Aortic Stenosis.

BACKGROUND: Transition from an asymptomatic to symptomatic state in severe aortic stenosis is often difficult to assess. Identification of a morphological sign of increased hemodynamic load may be important in asymptomatic aortic stenosis to identify patients at risk. METHODS AND RESULTS: Thirty-nine patients with asymptomatic severe aortic stenosis (aortic valve area <1 cm2, peak jet velocity >3.5 m/s) underwent exercise testing with simultaneous invasive hemodynamic monitoring and Doppler echocardiography. Cardiac index, pulmonary artery pressure, and pulmonary capillary wedge pressure (PCWP) were recorded. Patients were followed up for the composite end point of death, unplanned hospitalization, or aortic valve replacement. Patients were stratified into 2 groups according to left atrial (LA) volume index ≥35 mL/m2. In 25 patients (64%) LA volume index was ≥35 mL/m2. Aortic valve area was similar between groups (0.81±0.15 versus 0.84±0.18 cm2; P=0.58). PCWP was higher at rest and during exercise in patients with LA volume index ≥35 mL/m2 (P<0.01), despite similar cardiac index. At rest, PCWP was <12 mm Hg in 11 patients (44%) with LA dilatation, whereas PCWP was <25 mm Hg in 1 patient (4%) with exercise. LA volume index and E/e' predicted exercise PCWP>30 mm Hg with areas under the receiver operating curve of 0.75 and 0.84, respectively. During follow-up, 14 cardiac events were recorded. LA volume was associated with a hazard ratio of 1.90 (95% confidence interval, 0.92-4.15). CONCLUSIONS: LA size reflects hemodynamic burden in patients with asymptomatic severe aortic stenosis. Quantitative measurements of LA and diastolic function are associated with left ventricular filling pressures with exercise and could be used to identify asymptomatic patients with increased hemodynamic burden. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT02395107.

Association between aortic valve calcification measured on non-contrast computed tomography and aortic valve stenosis in the general population.

BACKGROUND: Aortic valve calcification (AVC) measured on non-contrast computed tomography (CT) has shown correlation to severity of aortic valve stenosis (AS) and mortality in patients with known AS. The aim of this study was to determine the association of CT verified AVC and subclinical AS in a general population undergoing CT. METHODS: CT scans from 566 randomly selected male participants (age 65-74) in the Danish cardiovascular screening study (DANCAVAS) were analyzed for AVC. All participants with a moderately or severely increased AVC score (≥300 arbitrary units (AU)) and a matched control group were invited for a supplementary echocardiography. AS was graded by indexed aortic valve area (AVAi) on echocardiography as moderate 0.6-0.85 cm(2)/m(2) and severe < 0.6 cm(2)/m(2), respectively. ROC- and regression analyses were performed. RESULTS: Due to prior valve surgery, and artifacts from ICD leads 16 individuals were excluded from the AVC scoring. Moderate or severe increased AVC was observed in 10.7% (95% CI: 8.4-13.7). Echocardiography was performed in 101 individuals; 32.7% (95% CI: 21.8 to 46.0) with moderate or high AVC score had moderate or severe AS, while none with no or low AVC. A ROC analysis defined an AVC score ≥588 AU to be suggestive of moderate or severe AS (AUC 0.89 ± 0.04, sensitivity 83% and specificity 87%). In the univariate analyses, AVC was the only variable significantly associated with AS. CONCLUSIONS: This study indicates an association between CT verified AVC and subclinical AS.