Your browser doesn't support javascript.
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 133
Filtrar
1.
J Am Coll Cardiol ; 75(8): 857-866, 2020 Mar 03.
Artigo em Inglês | MEDLINE | ID: mdl-32130920

RESUMO

BACKGROUND: Early in the prevention and treatment of bioprosthetic valve thrombosis (BPVT), anticoagulation is effective, but the long-term outcome after BPVT is unknown. OBJECTIVES: The goal of this study was to assess the long-term outcomes of patients with BPVT treated with anticoagulation. METHODS: This analysis was a matched cohort study of patients treated with warfarin for suspected BPVT at the Mayo Clinic between 1999 and 2017. RESULTS: A total of 83 patients treated with warfarin for suspected BPVT (age 57 ± 18 years; 45 men [54%]) were matched to 166 control subjects; matching was performed according to age, sex, year of implantation, and prosthesis type and position. Echocardiography normalized in 62 patients (75%) within 3 months (interquartile range [IQR]: 1.5 to 6 months) of anticoagulation; 21 patients (25%) did not respond to warfarin. Median follow-up after diagnosis was 34 months (IQR: 17 to 54 months). There was no difference in the primary composite endpoint between the patients with BPVT and the matched control subjects (log-rank test, p = 0.79), but the former did have a significantly higher rate of major bleeding (12% vs. 2%; p < 0.0001). BPVT recurred (re-BPVT) in 14 (23%) responders after a median of 23 months (IQR: 11 to 39 months); all but one re-BPVT patient responded to anticoagulant therapy. Patients with BPVT had a higher probability of valve re-replacement (68% vs. 24% at 10 years' post-BPVT; log-rank test, p < 0.001). CONCLUSIONS: BPVT was associated with re-BPVT and early prosthetic degeneration in a significant number of patients. Indefinite warfarin anticoagulation should be considered after a confirmed BPVT episode, but this strategy must be balanced against an increased risk of bleeding.

2.
Heart ; 2020 Feb 17.
Artigo em Inglês | MEDLINE | ID: mdl-32066613

RESUMO

OBJECTIVE: To determine whether echocardiography-derived left ventricular filling pressure influences survival in patients with severe aortic stenosis (AS) undergoing aortic valve replacement (AVR). METHODS: We retrospectively reviewed 1383 consecutive patients with severe AS, normal ejection fraction and interpretable filling pressure undergoing AVR. Left ventricular filling pressure was determined according to current guidelines using mitral inflow, mitral annular tissue Doppler, estimated right ventricular systolic pressure and left atrial volume index. Cox proportional hazards regression was used to assess the influence of various parameters on mortality. RESULTS: Age was 75±10 years and 552 (40%) were female. Left ventricular filling pressure was normal in 325 (23%), indeterminate in 463 (33%) and increased in 595 (43%). Mean follow-up was 7.3±3.7 years, and mortality was 1.2%, 4.2% and 18.9% at 30 days and 1 and 5 years, respectively. Compared with patients with normal filling pressure, patients with increased filling pressure were older (78±9 vs 70±12, p<0.001), more often female (45% vs 35%, p=0.002) and were more likely to have New York Heart Association class III-IV symptoms (35% vs 24%, p=0.004), coronary artery disease (55% vs 42%, p<0.001) and concentric left ventricular hypertrophy (63% vs 37%, p<0.001). After correction for other factors, increased left ventricular filling pressure remained an independent predictor of mortality after successful AVR (adjusted HR 1.45 (95% CI 1.16 to 1.81), p=0.005). CONCLUSIONS: Preoperative increased left ventricular filling pressure is common in patients with AS undergoing AVR and has important prognostic implications, regardless of symptom status. Future prospective studies should consider whether patients with increased filling pressure would benefit from earlier operation.

3.
Eur Heart J ; 41(12): 1273-1282, 2020 Mar 21.
Artigo em Inglês | MEDLINE | ID: mdl-32047900

RESUMO

AIMS: Right ventricular dysfunction (RVD) is an important determinant of functional status and survival in various diseases states. Data are sparse on the epidemiology and outcome of patients with severe RVD. This study examined the characteristics, aetiology, and survival of patients with severe RVD. METHODS AND RESULTS: Retrospective study of consecutive patients with severe RVD diagnosed by transthoracic echocardiography (TTE) between 2011 and 2015 in a single tertiary referral institution. Patients with prior cardiac surgery, mechanical assist devices, and congenital heart disease were excluded. Primary endpoint was all-cause mortality. In 64 728 patients undergoing TTE, the prevalence of ≥mild RVD was 21%. This study focused on the cohort of 1299 (4%) patients with severe RVD; age 64 ± 16 years; 61% male. The most common causes of severe RVD were left-sided heart diseases (46%), pulmonary thromboembolic disease (18%), chronic lung disease/hypoxia (CLD; 17%), and pulmonary arterial hypertension (PAH; 11%). After 2 ± 2 years of follow-up, 701 deaths occurred, 66% within the first year of diagnosis. The overall probability of survival at 1- and 5 years for the entire cohort were 61% [95% confidence interval (CI) 58-64%] and 35% (95% CI 31-38%), respectively. In left-sided heart diseases, 1- and 5-year survival rates were 61% (95% CI 57-65%) and 33% (95% CI 28-37%), respectively; vs. 76% (95% CI 68-82%) and 50% (95% CI 40-59%) in PAH, vs. 71% (95% CI 64-76%) and 49% (95% CI 41-58%) in thromboembolic diseases, vs. 42% (95% CI 35-49%) and 8% (95% CI 4-15%) in CLD (log-rank P < 0.0001). Presence of ≥moderate tricuspid regurgitation portended worse survival in severe RVD. CONCLUSION: One-year mortality of patients with severe RVD was high (∼40%) and dependent on the aetiology of RVD. Left-sided heart diseases is the most common cause of severe RVD but prognosis was worst in CLD.

4.
Hepatology ; 2020 Feb 20.
Artigo em Inglês | MEDLINE | ID: mdl-32080875

RESUMO

Hepatologists often determine whether transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR) is preferred for patients with cirrhosis and severe aortic stenosis (AS). The goal of this cohort study was to compare outcomes following TAVR and SAVR in patients with cirrhosis to inform the preferred intervention. Prospectively collected data on 105 consecutive patients with cirrhosis and AS who underwent TAVR (n = 55) or SAVR (n = 50) between 2008 and 2016 were reviewed retrospectively. Two control groups were included: 2,680 patients without cirrhosis undergoing TAVR and SAVR and 17 patients with cirrhosis who received medical therapy alone. Among 105 patients with cirrhosis, the median Society of Thoracic Surgeons (STS) score was 3.8% (1.5, 6.9,) and the median Model for End-Stage Liver Disease (MELD) score was 11.6 (9.4, 14.0). The TAVR group had similar in-hospital (1.8% versus 2.0%) and 30-day mortality (3.6% versus 4.2%) as the SAVR group. During the median follow-up of 3.8 (95% confidence interval [CI], 3.0-6.9) years, there were 63 (60%) deaths. MELD score (adjusted hazard ratio [AHR], 1.13; 95% CI, 1.05-1.21; P = 0.002 ) was an independent predictor of long-term survival. In the subgroup of patients with MELD score <12, the TAVR group had reduced survival compared to the SAVR group (median survival of 2.8 versus 4.4 years; P = 0.047). However, in those with MELD score ≥12, survival after TAVR, SAVR, and medical therapy was similar (1.3 versus 2.1 versus 1.6 years, respectively; P = 0.53). Conclusion: In select patients with cirrhosis, both TAVR and SAVR have acceptable and comparable short-term outcomes. MELD score, but not STS score, independently predicts long-term survival after TAVR and SAVR. For patients with MELD score <12, SAVR is a preferred procedure; however, neither procedure appears superior to medical therapy in patients with MELD score ≥12.

5.
BMC Cardiovasc Disord ; 20(1): 33, 2020 Jan 30.
Artigo em Inglês | MEDLINE | ID: mdl-32000672

RESUMO

BACKGROUND: Aortic stenosis (AS) causes left ventricular (LV) pressure overload, leading to adverse LV remodeling and dysfunction. Identifying early subclinical markers of LV dysfunction in patients with significant AS is critical as this could provide support for earlier intervention, which may result in improved long-term outcomes. We therefore examined the impact of severe AS and its consequent increase in LV afterload on myocardial deformation and rotational mechanics by 2-dimensional (2D) and 3-dimensional (3D) speckle-tracking echocardiography. METHODS: We prospectively measured various strain parameters in 168 patients (42% female, mean age 72 ± 12 years) with severe AS and LV ejection fraction (EF) ≥50%, and compared them to normal values found in literature. 2D and 3D images were analyzed for global longitudinal strain (GLS), global circumferential strain (GCS), global radial strain (GRS), basal rotation, apical rotation, and peak systolic twist. We further assessed the degree of concordance between 2D and 3D strain, and examined their association with measures of LV preload and afterload. RESULTS: Patients with severe AS exhibited significantly lower GLS and GRS but higher GCS, apical rotation, and twist by 2D and 3D echocardiography compared with published normal values (P = 0.003 for 3D twist, P < 0.001 for all others). Agreement between 2D- and 3D-GLS by concordance correlation coefficient was 0.49 (95% confidence interval: 0.39-0.57). GLS was correlated with valvulo-arterial impedance, a measure of LV afterload (r = 0.34, p < 0.001 and r = 0.23, p = 0.003, respectively). CONCLUSION: Patients with severe AS demonstrated lower-than-normal GLS and GRS but appear to compensate with higher-than-normal GCS, apical rotation, and twist in order to maintain a preserved LVEF. GLS showed a modest correlation with valvulo-arterial impedance.

8.
Heart ; 2020 Jan 24.
Artigo em Inglês | MEDLINE | ID: mdl-31980440

RESUMO

OBJECTIVE: A subset of patients at the time of transcatheter mitral valve repair (TMVR) will have normal left atrial pressure (LAP) (<13 mm Hg) despite having severe mitral regurgitation (MR). The goal of this study was to determine clinical characteristics and outcomes in patients with normal LAP undergoing TMVR. METHODS: A single-centre retrospective cohort of consecutive patients who underwent transcatheter edge-to-edge mitral valve clip and continuous LAP monitoring between 5/1/2014 and 5/1/2018 was analysed. One-year mortality was compared by Kaplan-Meier survival curves. Multivariable analysis was performed to identify predictors of normal LAP and 1 year mortality. RESULTS: Of the 204 patients undergoing TMVR, 65% were men and the mean age was 81. Of these patients, 31 (15%) had normal LAP (mean LAP 10.5 mm Hg, mean V wave 16.5 mm Hg) and 173 had elevated LAP (mean LAP 19 mm Hg, mean V wave 32.5 mm Hg). The prevalence of severe MR was not different between groups, although the normal LAP group had significantly lower effective regurgitant orifice area and regurgitant volume. Other notable baseline characteristics including prior cardiac surgery, atrial fibrillation, hypertension, diabetes, congestive heart failure, body mass index, mechanism of MR and ejection fraction were similar between groups. However, there was an increased prevalence of chronic lung disease (CLD) (45.2% vs 17.3%, p<0.001) in the normal LAP group. On multivariate analysis, the only significant predictor of normal LAP was the presence of CLD (OR 4.79 (1.83-12.36), p=0.001) and 1-year mortality was significantly higher in the normal LAP group (32.3% vs 12.7%, p=0.006). After adjustment for comorbidities, normal LAP was no longer a predictor of 1-year mortality (RR 1.62 (0.64-4.06), p=0.32); however, CLD (RR 3.44 (1.37-8.67), p=0.01) remained a statistically significant predictor. CONCLUSION: Normal LAP at the time of TMVR is associated with a higher incidence of CLD which independently predicts increased 1-year mortality. In patients with CLD and apparently severe MR, measurement of LAP may help identify those with lower likelihood of benefit from TMVR.

9.
Mayo Clin Proc ; 95(1): 69-76, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31902431

RESUMO

OBJECTIVE: To assess the impact of stroke volume index (SVI) and left ventricular ejection fraction (LVEF) on prognosis in patients with severe aortic stenosis, comparing those undergoing transcatheter aortic valve replacement (TAVR) and those with surgical AVR (SAVR). PATIENTS AND METHODS: A total of 742 patients from the CoreValve US Pivotal High-Risk Trial randomized to TAVR (n=389) or SAVR (n=353) from February 2011 to September 2012 were stratified by an SVI of 35 mL/m2 and LVEF of 50% for comparing all-cause mortality at 1 year. RESULTS: The prevalence of an SVI of less than 35 mL/m2 in patients who underwent TAVR and SAVR was 35.8% (125 of 349) and 31.3% (96 of 307), respectively; LVEF of less than 50% was present in 18.1% (63 of 348) and 19.6% (60 of 306), respectively. Among patients with an SVI of less than 35 mL/m2, 1-year mortality was similar between patients with TAVR and SAVR (16.3% vs 22.2%; P=.25). However, in those with an SVI of 35 mL/m2 or greater, 1-year mortality was lower in those with TAVR than SAVR (10.3% vs 17.3%; P=.03). In patients with an LVEF of less than 50%, mortality was not affected by AVR approach (P>.05). In patients with an LVEF of 50% or higher, TAVR was associated with lower mortality than SAVR when SVI was preserved (9.8% vs 18.6%; P=.01). Mortality was not affected by SVI within the same AVR approach when LVEF was 50% or higher. CONCLUSION: In patients with severe aortic stenosis at high risk, there is a significant interaction between AVR approach and the status of SVI and LVEF. When LVEF or SVI was reduced, prognosis was similar regardless of AVR approach. In those with preserved LVEF or SVI, TAVR was associated with a better prognosis than SAVR. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01240902.

10.
Am J Cardiol ; 125(6): 941-947, 2020 Mar 15.
Artigo em Inglês | MEDLINE | ID: mdl-31964503

RESUMO

There is a significant increase in transvalvular gradients after transcatheter aortic valve implantation (TAVI) in some patients; however, mechanisms underlying the greater than expected gradients are unknown. We sought to determine the incidence and mechanisms of greater than expected gradients post-TAVI. A total of 424 patients who underwent TAVI at our institution between November 2008 and August 2015 and had at least 1 follow-up echocardiogram were included in the study. Greater than expected gradients were defined as mean systolic Doppler gradients ≥20 mm Hg. The primary end-point was incidence and mechanisms of mean systolic Doppler gradients ≥20 mm Hg. A total of 36 (8%) patients had mean systolic Doppler gradients ≥20 mm Hg. The mechanisms of mean systolic Doppler gradients ≥20 mm Hg were: patient prosthesis mismatch in 15 (42%) patients, high cardiac output in 13 (36%), prosthetic and periprosthetic regurgitation in 11 (31%), stenosis in 5 (14%), and multiple mechanisms in 8 (22%). Patients with mean systolic Doppler gradients ≥20 mm Hg had higher cardiac re-hospitalization rate, but no difference in mortality or major cardiovascular events when compared with the normal gradient group. Smaller prosthetic valve size (p <0.0001) and larger body mass index (p = 0.02) were associated with mean systolic Doppler gradients ≥20 mm Hg; warfarin therapy at discharge had no effect on gradients. In conclusion, about 8% patients had mean systolic Doppler gradients ≥20 mm Hg following TAVI, and patient-prosthesis mismatch was the most common mechanism. The mean systolic Doppler gradients ≥20 mm Hg after TAVI are not benign and warrant careful surveillance.

11.
Heart ; 106(4): 280-286, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31439661

RESUMO

OBJECTIVES: To examine the prognostic significance of atrial fibrillation (AF) versus sinus rhythm (SR) on the management and outcomes of patients with severe aortic stenosis (AS). METHODS: 1847 consecutive patients with severe AS (aortic valve area ≤1.0 cm2 and aortic valve systolic mean Doppler gradient ≥40 mm Hg or peak velocity ≥4 m/s) and left ventricular ejection fraction ≥50% were identified. The independent association of AF and all-cause mortality was assessed. RESULTS: Age was 76±11 years and 46% were female; 293 (16%) patients had AF and 1554 (84%) had SR. In AF, 72% were symptomatic versus 71% in SR. Survival rate at 5 years for AF (41%) was lower than SR (65%) (age- and sex-adjusted HR=1.66 (1.40-1.98), p<0.0001). In multivariable analysis, factors associated with mortality included age (HR per 10 years=1.55 (1.42-1.69), p<0.0001), dyspnoea (HR=1.58 (1.33-1.87), p<0.0001), ≥ moderate mitral regurgitation (HR=1.63 (1.22-2.18), p=0.001), right ventricular systolic dysfunction (HR=1.88 (1.52-2.33), p<0.0001), left atrial volume index (HR per 10 mL/m2=1.13 (1.07-1.19), p<0.0001) and aortic valve replacement (AVR) (HR=0.44 (0.38-0.52), p<0.0001). AF was not a predictor of mortality independent of variables strongly correlated HR=1.02 (0.84-1.25), p=0.81). The 1-year probability of AVR following diagnosis of severe AS was lower in AF (49.8%) than SR (62.5%) (HR=0.73 (0.62-0.86), p<0.001); among patients with AF not referred for AVR, symptoms were frequently attributed to AF instead of AS. CONCLUSION: AF was associated with poor prognosis in patients with severe AS, but apparent differences in outcomes compared with SR were explained by factors other than AF including concomitant cardiac abnormalities and deferral of AVR due to attribution of cardiac symptoms to AF.

12.
JACC Cardiovasc Imaging ; 13(2 Pt 1): 357-369, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30878438

RESUMO

OBJECTIVES: This study sought to determine the prevalence of reduced contractility and uncompensated wall stress in patients with aortic stenosis (AS) with preserved or reduced left ventricular ejection fraction (LVEF) and their impact on survival. BACKGROUND: LVEF in AS is determined not only by contractility but also by loading conditions. METHODS: Patients with first diagnosis (time 0) of severe AS (aortic valve area [AVA]≤1 cm2) with prior echo study (-3±1 years) were identified. Contractility was evaluated by plotting midwall fractional shortening (mFS) against circumferential end-systolic wall stress (cESS), stratified by LVEF of 60% at time 0. The temporal changes (from -3 years to time 0) and prognostic value of LVEF, contractility, and wall stress were assessed. RESULTS: Of 445 patients, 290 (65%) had LVEF ≥60% (median: 66% [interquartile range {IQR}: 63% to 69%]) and 155 patients (35%) had LVEF <60% (median: 47% [IQR: 34% to 55%]). Median AVA was 1.27 cm2 (IQR: 1.13 to 1.43 cm2) at -3 years and 0.90 cm2 (IQR: 0.83 to 0.96 cm2) at time 0. Decreased contractility was already present at -3 years (49 [17%] vs. 59 [38%]; LVEF ≥60% vs. <60%; p < 0.001) and became more prevalent at time 0 (69 [24%] vs. 106 [68%]; p < 0.001). Overall, wall stress was well controlled in both groups at -3 years (1 [0%] vs. 12 [8%]; p < 0.001) but deteriorated over time in patients with LVEF <60% (time 0: 0 [0%] vs. 26 [17%]; p < 0.001). During a median follow-up of 3.4 years, LVEF <60%, decreased contractility and high wall stress were associated with worse survival (p < 0.01 for all). Decreased contractility remained incremental to LVEF in patients with LVEF ≥60% (p < 0.01), but less so when LVEF was <60% (p = 0.11). CONCLUSIONS: In patients with severe AS, LVEF <60% is associated with a poor prognosis, being linked with decreased contractility and/or high wall stress. Decreased contractility is also present in a subset of patients with LVEF ≥60% and provides incremental prognostic value. These abnormalities already exist before AVA reaches 1.0 cm2.

13.
Circ Cardiovasc Interv ; 12(12): e007635, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31833417

RESUMO

BACKGROUND: Mechanical injury in the conduction system requiring permanent pacemaker (PPM) associated with transcatheter aortic valve replacement (TAVR) procedure is a common complication. The objective of this study was to use ambulatory monitor BodyGuardian to assess late occurrence of atrioventricular block (AVB) after TAVR. METHODS: This prospective study evaluated 365 patients who underwent TAVR at Mayo Clinic, Rochester, Minnesota between June 2016 and August 2017. Patients who received PPM for bradycardia after TAVR before discharge were considered as the PPM group. Those not requiring PPM received a BodyGuardian system (BodyGuardian group) for 30 days of continuous monitoring. Primary end point was Mobitz II or third-degree atrioventricular block (II/III AVB) at 30-day follow-up. RESULTS: Of 365 patients, 74 who had a PPM or an implantable cardioverter-defibrillator before TAVR and 94 who were enrolled in other studies were excluded. Of 197 patients enrolled in the study, 70 (35.5%) received PPM and 127 had BodyGuardian before the hospital dismissal. Eleven of 127 (8.6%) BodyGuardian group required PPM within 30 days after TAVR for late occurrence of symptomatic bradycardia. In total, 33 of 197 (16.7%) patients developed II/III AVB (24 before and 9 after discharge). Thirty-four patients had preexisting right bundle branch block. Of them, 16 (47%) developed II/III AVB. Of 53 patients who developed new left bundle branch block after TAVR, 14% progressed to II/III AVB within 30 days. CONCLUSIONS: In patients without a standard post-TAVR pacing indication, yet a potential risk to develop AVB, a strategy of 30-day monitoring identifies additional patients who require permanent pacing.

14.
JACC Cardiovasc Interv ; 12(21): 2145-2154, 2019 Nov 11.
Artigo em Inglês | MEDLINE | ID: mdl-31699376

RESUMO

OBJECTIVES: The aim of this study was to test the hypothesis that the acute left ventricular (LV) unloading effect of transcatheter aortic valve replacement (TAVR) would improve right ventricular (RV) function and RV-pulmonary artery (PA) coupling in patients with severe aortic stenosis (AS). BACKGROUND: RV dysfunction is an ominous prognostic marker in patients undergoing TAVR, suggesting that relief of obstruction might be less beneficial in this cohort. However, the left ventricle and right ventricle influence each other through ventricular interaction, which could lead to improved RV function through LV unloading. METHODS: Prospective invasive hemodynamic measurements with simultaneous echocardiography were performed in symptomatic patients with severe AS before and immediately after TAVR. RESULTS: Forty-four patients (mean age 81 ± 8 years, 27% women) with severe AS underwent TAVR. At baseline, right atrial, PA mean (27 ± 7 mm Hg), and pulmonary capillary wedge (16 ± 4 mm Hg) pressures were mildly elevated, with a low normal cardiac index (2.3 l/min/m2). Pulmonary vascular resistance was mildly elevated (222 ± 133 dynes · s/cm5) and PA compliance mildly reduced (3.4 ± 01.4 ml/mm Hg). Following TAVR, aortic valve area increased (from 0.8 ± 0.3 to 2.7 ± 1.1 cm2; p < 0.001) with a reduction in mean aortic gradient (from 37 ± 11 to 7 ± 4 mm Hg; p < 0.001) and an increase in cardiac index (from 2.3 ± 0.5 to 2.5 ± 0.6 l/min/m2; p = 0.03). LV stroke work, end-systolic wall stress, and systolic ejection period decreased by 23% to 27% (p < 0.001 for all), indicating substantial LV unloading. RV stroke work (from 16 ± 7 to 18 ± 7 mm Hg · ml; p = 0.04) and tricuspid annular systolic velocities (from 9.5 ± 2.0 to 10.4 ± 3.5 cm/s; p = 0.01) increased, along with a decrease in PVR (194 ± 113 dynes · s/cm5; p = 0.03), indicating improvement in RV-PA coupling. Increased RV stroke work following TAVR directly correlated with the magnitude of increase in aortic valve area (r = 0.58; p < 0.001). CONCLUSIONS: Acute relief in obstruction to LV ejection with TAVR is associated with improvements in RV function and RV-PA coupling. These findings provide new insights into the potential benefits of LV unloading with TAVR on RV dysfunction in patients with severe AS.

15.
J Am Coll Cardiol ; 74(20): 2480-2492, 2019 Nov 19.
Artigo em Inglês | MEDLINE | ID: mdl-31727286

RESUMO

BACKGROUND: The natural history of stage B aortic regurgitation (AR) is unknown. OBJECTIVES: This study sought to examine determinants, rate, and consequences of progression of AR. METHODS: Consecutive patients with ≤moderate chronic AR quantified by effective regurgitant orifice area (EROA) and regurgitant volume (RVol) from 2004 to 2017 who had ≥1 subsequent echocardiogram with quantitation were included. RESULTS: Of 1,077 patients (66 ± 15 years of age), baseline trivial/mild AR was noted in 196 (18%), mild-to-moderate AR in 465 (43%), and moderate AR in 416 (39%); 10-year incidence of progression to ≥moderate-severe AR (stage C/D; progressors) was 12%, 30%, and 53%, respectively. At 4.1-year follow-up (interquartile range: 2.1 to 7.2 years), there were 228 progressors (21%), whose annualized progression rates within 3 years before diagnosis of ≥moderate-severe AR were 4.2 mm2/year for EROA and 9.9 ml/year for RVol. Baseline AR severity and dimensions of sinotubular junction and annulus were associated with progression (all p ≤ 0.007); hypertension and systolic blood pressure were not. Progressors had faster chamber remodeling, functional class decline, and more aortic valve/aortic surgery. At medium-term follow-up, 242 patients (22%) died; poor survival was linked to age, comorbidities, functional class, resting heart rate, and left ventricular (LV) ejection fraction (p ≤ 0.003), not LV end-systolic dimension index. Survival after progression to stage C/D AR was associated with LV end-systolic dimension index (adjusted p = 0.02). CONCLUSIONS: Progression from stage B to stage C/D AR was observed in 21% patients. Repeat echocardiography for trivial/mild, mild-to-moderate, and moderate AR at every 5, 3, and 1 years, respectively, was reasonable. EROA, RVol, annulus, and sinotubular junction should be routinely measured to estimate progression rates and identify patients at high risk of progression, which was associated with adverse consequences.

16.
Circulation ; 140(15): 1251-1260, 2019 Oct 08.
Artigo em Inglês | MEDLINE | ID: mdl-31589485

RESUMO

BACKGROUND: Mitral stenosis frequently coexists in patients with severe aortic stenosis. Mitral stenosis severity evaluation is challenging in the setting of combined aortic stenosis and mitral stenosis because of hemodynamic interactions between the 2 valve lesions. The impact of aortic valve replacement (AVR) for severe aortic stenosis on mitral stenosis is unknown. This study aimed to assess the effect of AVR on mitral stenosis hemodynamics and the clinical outcomes of patients with severe aortic stenosis with and without mitral stenosis. METHODS: We retrospectively investigated patients who underwent surgical AVR or transcatheter AVR for severe aortic stenosis from 2008 to 2015. Mean transmitral gradient by Doppler echocardiography ≥4 mm Hg was identified as mitral stenosis; patients were then stratified according to mitral valve area (MVA, by continuity equation) as >2.0 cm2 or ≤2.0 cm2. MVA before and after AVR in patients with mitral stenosis were evaluated. Clinical outcomes of patients with and without mitral stenosis were compared using 1:2 matching for age, sex, left ventricular ejection fraction, method of AVR (surgical AVR versus transcatheter AVR) and year of AVR. RESULTS: Of 190 patients with severe aortic stenosis and mitral stenosis (age 76±9 years, 42% men), 184 were matched with 362 with severe aortic stenosis without mitral stenosis. Among all mitral stenosis patients, the mean MVA increased after AVR by 0.26±0.59 cm2 (from 2.00±0.50 to 2.26±0.62 cm2, P<0.01). MVA increased in 105 (55%) and remained unchanged in 34 (18%). Indexed stroke volume ≤45 mL/m2 (odds ratio [OR] 2.40; 95% CI, 1.15-5.01; P=0.020) and transcatheter AVR (OR, 2.36; 95% CI, 1.17-4.77; P=0.017) were independently associated with increase in MVA. Of 107 with significant mitral stenosis (MVA ≤2.0 cm2), MVA increased to >2.0 cm2 after AVR in 52 (49%, pseudo mitral stenosis) and remained ≤2.0 cm2 in 55 (51%, true mitral stenosis). During follow-up of median 2.9 (0.7-4.9) years, true mitral stenosis was an independent predictor of all-cause mortality (adjusted hazard ratio, 1.88; 95% CI, 1.20-2.94; P<0.01). CONCLUSIONS: MVA improved after AVR in nearly half of patients with severe aortic stenosis and mitral stenosis. MVA remained ≤2.0 cm2 (true mitral stenosis) in nearly half of patients with severe aortic stenosis and significant mitral stenosis; this was associated with worse survival among patients undergoing AVR for severe aortic stenosis.

17.
J Am Soc Echocardiogr ; 32(11): 1426-1435.e1, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31466850

RESUMO

BACKGROUND: Patient selection for transcatheter edge-to-edge mitral valve repair (TMVR) remains challenging because of heterogenous mitral valve pathology and highly variable anatomy. The aim of this study was to investigate whether quantitative three-dimensional (3D) transesophageal echocardiographic modeling parameters are associated with optimal mitral regurgitation (MR) reduction in patients undergoing TMVR. METHODS: Fifty-nine patients underwent 3D transesophageal echocardiography during TMVR. Volumetric data sets were retrospectively analyzed using mitral valve quantitative 3D modeling software (Mitral Valve Navigator). Optimal MR reduction was defined as less than moderate residual MR. Logistic regression was used to correlate 3D transesophageal echocardiographic quantitative data to procedural success. RESULTS: Thirty-five patients had primary MR, 24 had mixed or secondary MR, and all patients had grade ≥ 3/4 MR before the procedure. Optimal MR reduction was achieved in 40 of 59 patients (68%). Univariate correlates of optimal MR reduction in patients with primary MR were lower mitral leaflet tenting volume (P = .049) and lower tenting height (P = .025); tenting height < 3 mm and tenting volume < 0.7 mL were associated with increased likelihood of optimal MR reduction (92% vs 48% [P = .01] and 81% vs 47% [P = .03], respectively). In mixed or secondary MR, annular height ≥ 5.5 mm was associated with increased likelihood of optimal MR reduction (94% vs 38%; P = .03). During follow-up, redo TMVR or surgical mitral valve replacement occurred exclusively in patients with suboptimal anatomy defined by 3D transesophageal echocardiography (10% vs 0%, P = .045). CONCLUSIONS: Quantitative 3D echocardiographic data are associated with favorable response to TMVR and could help optimize patient selection.

18.
Mayo Clin Proc ; 94(10): 2032-2039, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31279540

RESUMO

OBJECTIVE: To define mortality associated with isolated tricuspid regurgitation (TR) and identify risk factors associated with decreased survival. PATIENTS AND METHODS: We conducted a retrospective cohort study of residents of southeastern Minnesota with moderate-severe or more severe isolated TR diagnosed between January 1, 2005, and April 15, 2015. Isolated TR was defined as TR in the absence of left-sided heart disease or pulmonary hypertension. Patients with an ejection fraction of less than 50%, right ventricular systolic pressure greater than 45 mm Hg, moderate or more severe left-sided valve disease, congenital cardiac anomalies, previous valve operation, tricuspid stenosis, flail leaflet, carcinoid, and rheumatic disease were excluded. Five-year survival was compared with age- and sex-matched Minnesota census bureau data. Multivariate regression was used to identify variables associated with mortality. RESULTS: Over a 10-year period, 289 patients with isolated TR were identified. The mean ± SD age was 79.2±10.6 years, 70.6% (204) were women, atrial fibrillation was present in 74.0% (214), and 24.6% (71) had an intracardiac device. By 5 years after diagnosis, 51.5% had been hospitalized for heart failure. Observed 5-year mortality was 47.8% compared with 36.3% in the census data (P=.005). After adjusting for age and other comorbidities, multivariate regression identified a dilated inferior vena cava (≥2.1 cm) without respiratory variation on echocardiography (hazard ratio, 1.93; 95% CI, 1.13-3.31; P=.02) and creatinine level greater than 1.6 mg/dL (hazard ratio, 1.8; 95% CI, 1.16-2.8; P=.009) as associated with increased mortality. CONCLUSION: Patients with isolated TR are frequently hospitalized for heart failure and experience excess mortality. Elevated right atrial pressure and renal dysfunction are associated with mortality. This poor outcome may have implications for timing of intervention.


Assuntos
Insuficiência da Valva Tricúspide/mortalidade , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Humanos , Masculino , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida
20.
Heart ; 105(16): 1244-1250, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31092546

RESUMO

OBJECTIVE: This study aimed to identify characteristics, spectrum of tricuspid regurgitation (TR) severity and treatment patterns in patients considered for intervention of severe TR at a tertiary centre. The population being considered for TR intervention is currently not well defined and the role of transcatheter interventions is unclear. METHODS: The study involved 87 patients with severe TR considered for intervention from 1 March 2016 to 12 November 2018 at Mayo Clinic. Patients receiving medications alone were compared with those receiving intervention to identify patterns in demographics, clinical/echocardiographic associations and survival. RESULTS: Mean age was 80±9 (56% female), 93% had atrial fibrillation and 64% had chronic kidney disease ≥3 a. Follow-up was 331±276 days; 95% were symptomatic with 6 min walk distance of 270±110 m. Loop diuretics were used in 93%; aldosterone antagonists in 35%. Mean tricuspid annular plane systolic excursion was 15.6±3.8 mm, effective regurgitant orifice area (EROA) 82±32 mm2 and stroke volume index 39±11 mL/m2; 48% had at least moderate right ventricular (RV) dysfunction, and 75% did not undergo intervention. Patients receiving intervention showed trends towards larger EROA (93±33 vs 75±31 mm2), better right ventricular function and more severe symptoms. Overall group 30-day and 1-year survival were 100% and 76%, respectively. CONCLUSIONS: Patients with severe TR considered for intervention are commonly elderly with atrial fibrillation, advanced TR and RV dysfunction; 75% were treated with medications alone and not offered intervention. Patients with greater EROA, better RV function and more severe symptoms were more likely to receive intervention. These findings have implications for future trial design.

SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA