The Integration of Doppler Ultrasound With Two-Dimensional Echocardiography and the Noninvasive Cardiac Hemodynamic Revolution of the 1980s.

In the 1970s, as cardiac imaging matured from M-mode to two-dimensional echocardiography, investigators in Norway showed that continuous-wave Doppler ultrasonography could be used to accurately measure the mean gradient and pressure half-time for stenotic mitral valves. In the 1980s, continuous-wave Doppler was validated for measurement of the pressure gradient across stenotic aortic valves, and pulsed-wave Doppler combined with two-dimensional echocardiographic imaging was validated for noninvasive measurement of stroke volume and cardiac output. The combination of stroke volume measurement and measurement of the time-velocity integral of flow through the aortic valve was then validated as a means to accurately calculate valve area for patients with stenotic aortic valves or aortic prostheses. This integration of cardiac Doppler ultrasonography with two-dimensional echocardiographic cardiac imaging led to a revolution in noninvasive hemodynamic evaluations, which have replaced invasive hemodynamic evaluations in surgical decision making for most patients with native or prosthetic valvular stenosis.

Transcatheter aortic valve replacement: history and current status.

Despite the poor prognosis associated with severe, symptomatic aortic stenosis, treatment options were limited for a large subgroup of patients deemed high risk for surgical replacement. The introduction of transcatheter aortic valve replacement (TAVR) over the past 10 years marks a new and exciting era in the treatment of valvular disease in these high-risk and inoperable patients. In this review, we outline the historical development, key clinical trials, current outcomes and future directions of TAVR.

Aortic balloon valvuloplasty--review and case series.

Aortic balloon valvuloplasty (BAV) was initially devised in the 1980s as an alternative procedure to the surgical treatment of aortic stenosis, with the theory behind it being both minimally invasive as well as having a lower complication rate [Hara H, et al. Percutaneous balloon aortic valvuloplasty revisited: time for a renaissance? Circulation 2007 March;115(12):e334-8]. In practice however, the procedure was found to have a higher complication rate with only a modest haemodynamic improvement compared to the surgical approach. Most important of all it had an unacceptably high restenosis rate as a substitute for surgery [Otto CM, et al. 3-year outcome after balloon aortic balloon valvuloplasty: insights into prognosis of valvular aortic stenosis. Circulation 1994;89:642-50]. As a result, the procedure has fallen out of favour and has been abandoned at many health care facilities [Hara H, et al. Percutaneous balloon aortic valvuloplasty revisited: time for a renaissance? Circulation 2007 March;115(12):e334-8]. This article will review the management of patients with severe aortic stenosis that are unsuitable to undergo surgery.

Estenose aórtica no adulto / Aortic stenosis in the adult

Os autores realizam uma revisão bibliográfica sobre estenose aórtica no adulto abordando aspectos de fisiopatologia, história natural, diagnóstico e tratamento. o trabalho dá ênfase à estenose aórtica causada pelo processo de degeneração fibrocálcica valvar, visto ser esta a causa mais comum desse tipo de valvulopia nos adultos.

Paul Louis Duroziez (1826-1897) / Paul Louis Duroziez

El doble soplo crural intermitente como signo de la insuficiencia aórtica: "Las arterias femorales, que son auscultadas con menos frecuencia que las carótidas, ofrecen una valiosa información; son fácilmente compresibles y son más voluminosas que las arterias carótidas, y tienen la ventaja de estar más distantes del corazón...La arteria femoral merece un estudio cuidadoso." "Al comprimir la arteria femoral, se percibe un frémito y la auscultación percibe un soplo intermitente". "El doble soplo intermitente sobre las arterias femorales ha sido descripto en la insuficiencia aórtica, pero no se le ha dado el significado que merece. Es evidente que el segundo soplo está producido en las arterias de los miembros inferiores, por las que refluye la sangre en forma retrógrada, hacia el corazón". "Los ruidos de soplo producidos por la estenosis mitral, la estenosis tricuspídea, y la insuficiencia de la válvula pulmonar, pueden ser diferenciados del soplo de la insuficiencia aórtica con la ayuda del de doble soplo sobre las arterias femorales, el que existe sólo en esta última afección"

Paul Louis Duroziez (1826-1897) / Paul Louis Duroziez

El doble soplo crural intermitente como signo de la insuficiencia aórtica: "Las arterias femorales, que son auscultadas con menos frecuencia que las carótidas, ofrecen una valiosa información; son fácilmente compresibles y son más voluminosas que las arterias carótidas, y tienen la ventaja de estar más distantes del corazón...La arteria femoral merece un estudio cuidadoso." "Al comprimir la arteria femoral, se percibe un frémito y la auscultación percibe un soplo intermitente". "El doble soplo intermitente sobre las arterias femorales ha sido descripto en la insuficiencia aórtica, pero no se le ha dado el significado que merece. Es evidente que el segundo soplo está producido en las arterias de los miembros inferiores, por las que refluye la sangre en forma retrógrada, hacia el corazón". "Los ruidos de soplo producidos por la estenosis mitral, la estenosis tricuspídea, y la insuficiencia de la válvula pulmonar, pueden ser diferenciados del soplo de la insuficiencia aórtica con la ayuda del de doble soplo sobre las arterias femorales, el que existe sólo en esta última afección" (AU)

Subaortic stenosis revisited: the importance of the dynamic pressure gradient.

Brachfeld and Gorlin's revised concept of subaortic stenosis derived from their recognition that the large magnitudes of the pressure gradients were incompatible with the relatively mild anatomic lesions found at surgery in 3 of their patients, and the rapidity of their arterial pulse upstroke. They proposed that a gradient caused by a superimposed systolic stenosis was responsible for the large pressure gradients and the overestimation of the severity of the discrete subaortic stenosis (DSAS). A fourth patient had no anatomic cause for the pressure gradient, and findings compatible with hypertrophic cardiomyopathy (HCM). All 4 patients had septal hypertrophy which they felt was instrumental in the brisk pulse contour and dynamic gradients across the outflow tract. In the ensuing decades, imaging techniques have been developed which permit detailed studies of ventricular ejection patterns in dynamic gradients associated with HCM and DSAS. These studies have been interpreted variously. The prevailing view is that there is a dynamic obstruction that increases progressively in severity during systole, as proposed by Brachfeld and Gorlin. An opposing view is that dynamic gradients can occur in the absence of any hindrance to ejection, and that these gradients instead result from rapid and complete emptying of the ventricle. Regardless of their cause, dynamic gradients are often superimposed upon gradients caused by DSAS and valvar aortic stenosis, leading to exaggerated estimates of severity. These dynamic gradients are uncovered when the anatomic cause of stenosis is removed, and seemingly increase the postoperative morbidity. A greater understanding of the significance of dynamic gradients and the mechanism(s) responsible for them should lead to more rational management of DSAS and HCM in the future.