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1.
Artigo em Inglês | MEDLINE | ID: mdl-32484159

RESUMO

The novel coronavirus-19 (COVID-19) pandemic has created uncertainty in the management of patients with severe aortic stenosis (AS). This population experiences high mortality from delays in treatment of valve disease but is largely overlapping with the population of highest mortality from COVID-19. We present strategies for managing patients with severe AS in the COVID-era. We suggest transitions to virtual assessments and consultation, careful pruning and planning of necessary testing, as well as fewer and shorter hospital admissions. These strategies center on minimizing patient exposure to COVID-19 and expenditure of human and health-care resources without significant sacrifice to patient outcomes during this public health emergency. Areas of innovation to improve our care during this time include increased use of wearable and remote devices to assess patient performance and vital signs, devices for facile cardiac assessment, and widespread use of clinical protocols for expedient discharge with virtual physical therapy and cardiac rehabilitation options.

2.
Am J Cardiol ; 125(12): 1879-1883, 2020 Jun 15.
Artigo em Inglês | MEDLINE | ID: mdl-32303339

RESUMO

Tricuspid valve disease (TVD), particularly tricuspid regurgitation, is a common valvular pathology that is associated with increased morbidity and mortality. The prevalence of TVD in hospitalized patients has not been well characterized. We used the National Inpatient Sample to determine the overall and age- and sex-specific prevalence and temporal trends in prevalence of TVD in hospitalized patients in the US. All-cause and heart failure (HF) hospitalizations in patients ≥50 years of age from January 2006 to September 2015 in the US were identified. Temporal trends in the prevalence of TVD were studied using Poisson regression. Of 194,184,433 all-cause and 38,083,773 HF hospitalizations in patients ≥50 years of age, 3,235,292 (1.7%) and 1,787,548 (4.7%) had a diagnosis of TVD, respectively. From 2006 to 2015, the prevalence of TVD in all hospitalizations and in HF hospitalizations increased from 1.7% to 2.0% and from 3.9% to 5.7%, respectively (ptrend <0.001 for both), particularly in those ≥85 years of age and in women. In patients with TVD, primary reasons for hospitalizations were HF (20.8%), infections (10.1%), arrhythmias (9.8%), respiratory conditions (8.4%), and coronary artery disease/acute myocardial infarction (8.2%). In-hospital mortality and length of stay in patients with TVD remained unchanged, whereas costs of hospitalization increased during the study period. In conclusion, the prevalence of TVD in all hospitalized patients and in those hospitalized with HF has increased over the past several years, particularly in those ≥85 years of age and in women. Approximately 1 in 5 hospitalizations with a diagnosis of TVD is due to HF.

3.
J Am Soc Echocardiogr ; 33(4): 461-468, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32248906

RESUMO

BACKGROUND: Evaluation of aortic stenosis (AS) requires calculation of aortic valve area (AVA), which relies on the assumption of a circular-shaped left ventricular outflow tract (LVOT). However, the LVOT is often elliptical, and the circular assumption underestimates the true LVOT area (LVOTA). Biplane imaging using transthoracic echocardiography allows direct planimetry of LVOTA. The aim of this study was to assess the feasibility of obtaining LVOTA using this technique and its impact on the discordance between AVA and gradient criteria in AS grading. METHODS: We prospectively studied 134 patients (median age, 80 years; interquartile range, 73-87 years; 39% women) with AS, including 82 (61%) with severe AS and 52 (39%) with mild or moderate AS. LVOTA was traced using direct planimetry (LVOTAbiplane) and compared with LVOTA calculated using the circular assumption (LVOTAcirc). In a subset of patients who underwent cardiac computed tomography, direct planimetry of LVOTA was used as a reference standard. RESULTS: LVOTAbiplane was significantly larger than LVOTAcirc (4.20 cm2 [interquartile range, 3.66-4.90 cm2] vs 3.73 cm2 [interquartile range, 3.14-4.15 cm2], P < .001). Among 30 patients who underwent cardiac computed tomography, LVOTAbiplane had better agreement with LVOTA by direct planimetry than LVOTAcirc (mean bias, -0.45 ± 0.63 vs -1.02 ± 0.63 cm2; P < .0001). Of 82 patients with severe AS (AVA ≤ 1 cm2 using LVOTAcirc), 40 (49%) had discordant mean gradient (<40 mm Hg). By using LVOTAbiplane, patients with discordant AVA and mean gradient decreased from 49% to 27% (P = .004), and 29% of patients with severe AS were reclassified with moderate AS, with the highest percentage of reclassification in the group with low-gradient AS with preserved left ventricular ejection fraction. CONCLUSIONS: Direct planimetry using biplane imaging avoids the inherent underestimation of LVOTA using the circular assumption. LVOTA obtained by biplane planimetry can lead to better concordance between AVA and mean gradient and classification of AS severity.

4.
Ann Thorac Surg ; 109(2): 437-444, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31473178

RESUMO

BACKGROUND: To review the efficacy of a minimally invasive surgical technique for mitral valve (MV) repair, we analyzed a nonresectional technique for degenerative mitral regurgitation. METHODS: A retrospective analysis was performed on 101 consecutive patients who underwent a minimally invasive MV repair for severe degenerative mitral regurgitation between 2014 and 2017. All patients underwent a right lateral minithoracotomy and femoral cannulation and were repaired by a nonresectional technique using neochord loop implantation and ring annuloplasty. Patients were followed with longitudinal echocardiograms. RESULTS: The median age was 58 years (interquartile range [IQR], 49-64), and 31% were women. The procedure was successfully performed using a right minithoracotomy in all patients except for 1 who required an extended thoracotomy. A median of 4 neochords were placed. The median length was 16 mm (IQR, 14-18), and ring size was 34 mm (IQR, 32-36). Concomitant procedures included left atrial appendage exclusion in 10 patients (10%) and patent foramen ovale closure in 13 (13%). Median cardiopulmonary bypass time was 152 minutes (IQR, 142-164), and aortic cross-clamp time was 90 minutes (IQR, 81-98). Operative mortality was 0% and 1-year survival 100%. At 3 years freedom from recurrent at least moderate mitral regurgitation was 100%, and no patient required a valve-related reoperation. At 1 year the median left atrial diameter decreased by 15% (44 vs 37 mm, P < .001), the left ventricular end-diastolic diameter decreased by 14% (53 vs 46 mm, P < .001), and MV gradients remained low (3.1 vs 2.9 mmHg, P = .54). CONCLUSIONS: Minimally invasive MV repair using a nonresectional technique can be performed for severe degenerative mitral regurgitation with a low complication rate, excellent durability, and promising left ventricular reverse remodeling.


Assuntos
Anuloplastia da Valva Mitral/métodos , Insuficiência da Valva Mitral/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos , Estudos Retrospectivos , Resultado do Tratamento
5.
JAMA Cardiol ; 2019 Nov 20.
Artigo em Inglês | MEDLINE | ID: mdl-31746963

RESUMO

Importance: Pulmonary hypertension (pHTN) is associated with increased risk of mortality after mitral valve surgery for mitral regurgitation. However, its association with clinical outcomes in patients undergoing transcatheter mitral valve repair (TMVr) with a commercially available system (MitraClip) is unknown. Objective: To assess the association of pHTN with readmissions for heart failure and 1-year all-cause mortality after TMVr. Design, Setting, and Participants: This retrospective cohort study analyzed 4071 patients who underwent TMVr with the MitraClip system from November 4, 2013, through March 31, 2017, across 232 US sites in the Society of Thoracic Surgery/American College of Cardiology Transcatheter Valve Therapy registry. Patients were stratified into the following 4 groups based on invasive mean pulmonary arterial pressure (mPAP): 1103 with no pHTN (mPAP, <25 mm Hg [group 1]); 1399 with mild pHTN (mPAP, 25-34 mm Hg [group 2]); 1011 with moderate pHTN (mPAP, 35-44 mm Hg [group 3]); and 558 with severe pHTN (mPAP, ≥45 mm Hg [group 4]). Data were analyzed from November 4, 2013, through March 31, 2017. Interventions: Patients were stratified into groups before TMVr, and clinical outcomes were assessed at 1 year after intervention. Main Outcomes and Measures: Primary end point was a composite of 1-year mortality and readmissions for heart failure. Secondary end points were 30-day and 1-year mortality and readmissions for heart failure. Linkage to Centers for Medicare & Medicaid Services administrative claims was performed to assess 1-year outcomes in 2381 patients. Results: Among the 4071 patients included in the analysis, the median age was 81 years (interquartile range, 73-86 years); 1885 (46.3%) were women and 2186 (53.7%) were men. The composite rate of 1-year mortality and readmissions for heart failure was 33.6% (95% CI, 31.6%-35.7%), which was higher in those with pHTN (27.8% [95% CI, 24.2%-31.5%] in group 1, 32.4% [95% CI, 29.0%-35.8%] in group 2, 36.0% [95% CI, 31.8%-40.2%] in group 3, and 45.2% [95% CI, 39.1%-51.0%] in group 4; P < .001). Similarly, 1-year mortality (16.3% [95% CI, 13.4%-19.5%] in group 1, 19.8% [95% CI, 17.0%-22.8%] in group 2, 22.4% [95% CI, 18.8%-26.1%] in group 3, and 27.8% [95% CI, 22.6%-33.3%] in group 4; P < .001) increased across pHTN groups. The association of pHTN with mortality persisted despite multivariable adjustment (hazard ratio per 5-mm Hg mPAP increase, 1.05; 95% CI, 1.01-1.09; P = .02). Conclusions and Relevance: These findings suggest that pHTN is associated with increased mortality and readmission for heart failure in patients undergoing TMVr using the MitraClip system for severe mitral regurgitation. Further efforts are needed to determine whether earlier intervention before pHTN develops will improve clinical outcomes.

6.
Sci Transl Med ; 11(509)2019 09 11.
Artigo em Inglês | MEDLINE | ID: mdl-31511424

RESUMO

Aortic stenosis (AS) management is classically guided by symptoms and valvular metrics. However, the natural history of AS is dictated by coupling of the left ventricle, aortic valve, and vascular system. We investigated whether metrics of ventricular and vascular state add to the appreciation of AS state above valve gradient alone. Seventy patients with severe symptomatic AS were prospectively followed from baseline to 30 days after transcatheter aortic valve replacement (TAVR). Quality of life (QOL) was assessed using the Kansas City Cardiomyopathy Questionnaire. Left ventricular stroke work (SWLV) and vascular impedance spectrums were calculated noninvasively using in-house models based on central blood pressure waveforms, along with hemodynamic parameters from echocardiograms. Patients with higher preprocedural SWLV and lower vascular impedance were more likely to experience improved QOL after TAVR. Patients fell into two categories: those who did and those who did not exhibit increase in blood pressure after TAVR. In patients who developed hypertension (19%), vascular impedance increased and SWLV remained unchanged (impedance at zeroth harmonic: Z 0, from 3964.4 to 4851.8 dyne·s/cm3, P = 0.039; characteristic impedance: Z c, from 376.2 to 603.2 dyne·s/cm3, P = 0.033). SWLV dropped only in patients who did not develop new hypertension after TAVR (from 1.58 to 1.26 J; P < 0.001). Reduction in valvular pressure gradient after TAVR did not predict change in SWLV (r = 0.213; P = 0.129). Reduction of SWLV after TAVR may be an important metric in management of AS, rather than relying solely on the elimination of transvalvular pressure gradients.

7.
J Am Coll Cardiol ; 74(12): 1532-1540, 2019 09 24.
Artigo em Inglês | MEDLINE | ID: mdl-31537261

RESUMO

BACKGROUND: Transcatheter aortic valve replacement (TAVR) has emerged as a safe and effective therapeutic option for patients with severe aortic stenosis (AS) who are at prohibitive, high, or intermediate risk for surgical aortic valve replacement (SAVR). However, in low-risk patients, SAVR remains the standard therapy in current clinical practice. OBJECTIVES: This study sought to perform a meta-analysis of randomized controlled trials (RCTs) comparing TAVR versus SAVR in low-risk patients. METHODS: Electronic databases were searched from inception to March 20, 2019. RCTs comparing TAVR versus SAVR in low-risk patients (Society of Thoracic Surgeons Predicted Risk of Mortality [STS-PROM] score <4%) were included. Primary outcome was all-cause death at 1 year. Random-effects models were used to calculate pooled risk ratio (RR) and corresponding 95% confidence interval (CI). RESULTS: The meta-analysis included 4 RCTs that randomized 2,887 patients (1,497 to TAVR and 1,390 to SAVR). The mean age of patients was 75.4 years, and the mean STS-PROM score was 2.3%. Compared with SAVR, TAVR was associated with significantly lower risk of all-cause death (2.1% vs. 3.5%; RR: 0.61; 95% CI: 0.39 to 0.96; p = 0.03; I2 = 0%) and cardiovascular death (1.6% vs. 2.9%; RR: 0.55; 95% CI: 0.33 to 0.90; p = 0.02; I2 = 0%) at 1 year. Rates of new/worsening atrial fibrillation, life-threatening/disabling bleeding, and acute kidney injury stage 2/3 were lower, whereas those of permanent pacemaker implantation and moderate/severe paravalvular leak were higher after TAVR versus SAVR. There were no significant differences between TAVR versus SAVR for major vascular complications, endocarditis, aortic valve re-intervention, and New York Heart Association functional class ≥II. CONCLUSIONS: In this meta-analysis of RCTs comparing TAVR versus SAVR in low-risk patients, TAVR was associated with significantly lower risk of all-cause death and cardiovascular death at 1 year. These findings suggest that TAVR may be the preferred option over SAVR in low-risk patients with severe AS who are candidates for bioprosthetic AVR.


Assuntos
Estenose da Valva Aórtica/cirurgia , Valva Aórtica/cirurgia , Implante de Prótese de Valva Cardíaca/métodos , Humanos , Ensaios Clínicos Controlados Aleatórios como Assunto , Medição de Risco , Índice de Gravidade de Doença , Substituição da Valva Aórtica Transcateter
8.
Interv Cardiol Clin ; 7(3): 405-413, 2018 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-29983151

RESUMO

Rheumatic mitral stenosis remains a common disease in the developing world. Percutaneous mitral balloon valvuloplasty is an important therapy for rheumatic mitral stenosis. Echocardiography plays a critical role in the diagnosis of rheumatic mitral stenosis and the assessment of suitability for and guidance of percutaneous mitral valvuloplasty.


Assuntos
Valvuloplastia com Balão/métodos , Estenose da Valva Mitral/terapia , Cardiopatia Reumática/terapia , Cateterismo Cardíaco/métodos , Ecocardiografia/métodos , Definição da Elegibilidade , Humanos
9.
J Am Soc Echocardiogr ; 31(2): 117-147, 2018 02.
Artigo em Inglês | MEDLINE | ID: mdl-29254695

RESUMO

The American College of Cardiology collaborated with the American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, European Association for Cardio-Thoracic Surgery, Heart Valve Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons to develop and evaluate Appropriate Use Criteria (AUC) for the treatment of patients with severe aortic stenosis (AS). This is the first AUC to address the topic of AS and its treatment options, including surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR). A number of common patient scenarios experienced in daily practice were developed along with assumptions and definitions for those scenarios, which were all created using guidelines, clinical trial data, and expert opinion in the field of AS. The 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines(1) and its 2017 focused update paper (2) were used as the primary guiding references in developing these indications. The writing group identified 95 clinical scenarios based on patient symptoms and clinical presentation, and up to 6 potential treatment options for those patients. A separate, independent rating panel was asked to score each indication from 1 to 9, with 1-3 categorized as "Rarely Appropriate," 4-6 as "May Be Appropriate," and 7-9 as "Appropriate." After considering factors such as symptom status, left ventricular (LV) function, surgical risk, and the presence of concomitant coronary or other valve disease, the rating panel determined that either SAVR or TAVR is Appropriate in most patients with symptomatic AS at intermediate or high surgical risk; however, situations commonly arise in clinical practice in which the indications for SAVR or TAVR are less clear, including situations in which 1 form of valve replacement would appear reasonable when the other is less so, as do other circumstances in which neither intervention is the suitable treatment option. The purpose of this AUC is to provide guidance to clinicians in the care of patients with severe AS by identifying the reasonable treatment and intervention options available based on the myriad clinical scenarios with which patients present. This AUC document also serves as an educational and quality improvement tool to identify patterns of care and reduce the number of rarely appropriate interventions in clinical practice.


Assuntos
American Heart Association , Anestesiologia/normas , Estenose da Valva Aórtica/cirurgia , Cardiologia/normas , Diagnóstico por Imagem/normas , Sociedades Médicas , Cirurgia Torácica/normas , Angiografia , Estenose da Valva Aórtica/diagnóstico , Ecocardiografia/normas , Europa (Continente) , Humanos , Imagem Cinética por Ressonância Magnética/normas , Tomografia Computadorizada por Raios X , Estados Unidos
10.
JACC Cardiovasc Interv ; 10(23): 2414-2422, 2017 12 11.
Artigo em Inglês | MEDLINE | ID: mdl-29217004

RESUMO

OBJECTIVES: The authors sought to evaluate the impact of transapical (TA) transcatheter aortic valve replacement (TAVR) on mortality, left ventricular (LV) ejection fraction (LVEF) improvement, and functional recovery in patients with LV dysfunction. BACKGROUND: LV injury inherent to TA access for structural heart disease interventions may be particularly detrimental to the LV, functional recovery, and survival in patients with LV dysfunction. METHODS: The study included patients enrolled within the PARTNER I (Placement of Aortic Transcatheter Valves) trial that underwent transfemoral (TF) or TA TAVR. Analyses of clinical outcomes were stratified by the presence of baseline LV dysfunction (LVEF<50%) and adjusted for the propensity of receiving TA TAVR. RESULTS: Of 2,084 subjects, 1,057 underwent TA TAVR. TA access was associated with increased 2-year all-cause mortality in those with (adjusted hazard ratio [HRadjusted]: 1.52; 95% confidence interval [CI]: 1.12 to 2.07; p = 0.008) and without (HRadjusted: 1.38; 95% CI: 1.10 to 1.74; p = 0.006) LV dysfunction. TA TAVR portended increased 2-year cardiac mortality in subjects with LVEF<50% (HRadjusted: 1.92; 95% CI: 1.21 to 3.05; p = 0.006), but not with LVEF≥50% (HRadjusted: 1.29; 95% CI: 0.87 to 1.90; p = 0.21). In those with LVEF<50%, greater improvements in LVEF (TF-TA difference +4.04%, 95% CI: 2.39% to 5.69%; p < 0.0001) and 6-min walk distance (TF-TA difference +45.1 m, 95% CI: 18.4 to 71.9 m; p = 0.001) occurred within 30 days after TF versus TA TAVR. CONCLUSIONS: Compared with TF TAVR, TA TAVR is associated with a disproportionate risk of cardiac mortality in patients with LV dysfunction and with delayed and less robust improvement in LV function and overall functional status. Caution is warranted when considering TA access for structural heart disease interventions, particularly in patients with LV dysfunction. (Placement of Aortic Transcatheter Valves [PARTNER]; NCT00530894).


Assuntos
Estenose da Valva Aórtica/cirurgia , Valva Aórtica/cirurgia , Substituição da Valva Aórtica Transcateter/mortalidade , Disfunção Ventricular Esquerda/fisiopatologia , Função Ventricular Esquerda , Idoso , Idoso de 80 Anos ou mais , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/fisiopatologia , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/mortalidade , Estenose da Valva Aórtica/fisiopatologia , Distribuição de Qui-Quadrado , Tomada de Decisão Clínica , Ecocardiografia , Feminino , Humanos , Estimativa de Kaplan-Meier , Modelos Lineares , Masculino , Pontuação de Propensão , Modelos de Riscos Proporcionais , Recuperação de Função Fisiológica , Sistema de Registros , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Volume Sistólico , Fatores de Tempo , Substituição da Valva Aórtica Transcateter/efeitos adversos , Substituição da Valva Aórtica Transcateter/métodos , Resultado do Tratamento , Disfunção Ventricular Esquerda/diagnóstico por imagem , Disfunção Ventricular Esquerda/mortalidade
11.
Future Cardiol ; 13(5): 433-441, 2017 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-28828892

RESUMO

Calcific aortic stenosis (AS) is one of the most common acquired valvular heart diseases in industrialized nations. It is a slowly progressive disease and with the aging population, the prevalence of AS is expected to increase. Doppler echocardiography is used to classify patients based on severity of stenosis. Research efforts on how to better identify and risk-assess these patients are currently underway using advanced imaging modalities and serum biomarkers. Thus far, medications for AS prevention have been unsuccessful. As technology progresses, the assessment of AS will transition from one heavily weighed on echocardiographic gradients to one of active surveillances with multimodality imaging, serum biomarkers and genetic assessment.

12.
Catheter Cardiovasc Interv ; 90(1): 164-168, 2017 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-27545308

RESUMO

We report a case of acute aorto-right ventricular fistula following transcatheter bicuspid aortic valve replacement and subsequent percutaneous closure. The diagnosis and treatment of this rare complication is illustrated through multi-modality imaging. We hypothesize that the patient's heavily calcified bicuspid aortic valve anatomy led to asymmetric deployment of the transcatheter aortic valve replacement (TAVR) prosthesis, traumatizing the right sinus of Valsalva at the distal edge of the TAVR stent and ultimately fistulized to the right ventricle. The patient acutely decompensated with heart failure five days after TAVR and underwent emergent intervention. The aorto-right ventricular fistula was closed using an 18-mm septal occluder device with marked clinical recovery. Transcatheter closure is a viable treatment option for acute aorto-right ventricular fistula. © 2016 Wiley Periodicals, Inc.


Assuntos
Doenças da Aorta/terapia , Valva Aórtica/anormalidades , Cateterismo Cardíaco , Cardiopatias/terapia , Doenças das Valvas Cardíacas/cirurgia , Substituição da Valva Aórtica Transcateter/efeitos adversos , Fístula Vascular/terapia , Doenças da Aorta/diagnóstico por imagem , Doenças da Aorta/etiologia , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/fisiopatologia , Valva Aórtica/cirurgia , Aortografia/métodos , Cateterismo Cardíaco/instrumentação , Angiografia por Tomografia Computadorizada , Ecocardiografia Doppler em Cores , Ecocardiografia Tridimensional , Ecocardiografia Transesofagiana , Cardiopatias/diagnóstico por imagem , Cardiopatias/etiologia , Insuficiência Cardíaca/etiologia , Doenças das Valvas Cardíacas/diagnóstico por imagem , Doenças das Valvas Cardíacas/fisiopatologia , Hemodinâmica , Humanos , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Imagem Multimodal , Dispositivo para Oclusão Septal , Substituição da Valva Aórtica Transcateter/instrumentação , Resultado do Tratamento , Fístula Vascular/diagnóstico por imagem , Fístula Vascular/etiologia
13.
J Am Heart Assoc ; 5(3): e002712, 2016 Mar 15.
Artigo em Inglês | MEDLINE | ID: mdl-27068627

RESUMO

BACKGROUND: Acute kidney injury (AKI) occurs commonly after transcatheter aortic valve replacement (TAVR) and is associated with markedly increased postoperative mortality. We previously identified plasma metabolites predictive of incident chronic kidney disease, but whether metabolite profiles can identify those at risk of AKI is unknown. METHODS AND RESULTS: We performed liquid chromatography-mass spectrometry-based metabolite profiling on plasma from patients undergoing TAVR and subjects from the community-based Framingham Heart Study (N=2164). AKI was defined by using the Valve Academic Research Consortium-2 criteria. Of 44 patients (mean age 82±9 years, 52% female) undergoing TAVR, 22 (50%) had chronic kidney disease and 9 (20%) developed AKI. Of 85 metabolites profiled, we detected markedly concordant cross-sectional metabolic changes associated with chronic kidney disease in the hospital-based TAVR and Framingham Heart Study cohorts. Baseline levels of 5-adenosylhomocysteine predicted AKI after TAVR, despite adjustment for baseline glomerular filtration rate (odds ratio per 1-SD increase 5.97, 95% CI 1.62-22.0; P=0.007). Of the patients who had AKI, 6 (66.7%) subsequently died, compared with 3 (8.6%) deaths among those patients who did not develop AKI (P=0.0008) over a median follow-up of 7.8 months. 5-adenosylhomocysteine was predictive of all-cause mortality after TAVR (hazard ratio per 1-SD increase 2.96, 95% CI 1.33-6.58; P=0.008), independent of baseline glomerular filtration rate. CONCLUSIONS: In an elderly population with severe aortic stenosis undergoing TAVR, metabolite profiling improves the prediction of AKI. Given the multifactorial nature of AKI after TAVR, metabolite profiles may identify those patients with reduced renal reserve.


Assuntos
Lesão Renal Aguda/mortalidade , Estenose da Valva Aórtica/terapia , Cateterismo Cardíaco/mortalidade , Implante de Prótese de Valva Cardíaca/mortalidade , Metabolômica , S-Adenosil-Homocisteína/sangue , Lesão Renal Aguda/diagnóstico , Lesão Renal Aguda/etiologia , Idoso , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/sangue , Estenose da Valva Aórtica/diagnóstico , Estenose da Valva Aórtica/mortalidade , Biomarcadores/sangue , Cateterismo Cardíaco/efeitos adversos , Cromatografia Líquida , Feminino , Implante de Prótese de Valva Cardíaca/efeitos adversos , Humanos , Estimativa de Kaplan-Meier , Modelos Lineares , Modelos Logísticos , Masculino , Espectrometria de Massas , Massachusetts/epidemiologia , Metabolômica/métodos , Análise Multivariada , Razão de Chances , Valor Preditivo dos Testes , Prevalência , Medição de Risco , Fatores de Risco , Resultado do Tratamento
14.
J Am Soc Echocardiogr ; 28(11): 1259-66, 2015 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-26307374

RESUMO

BACKGROUND: Left ventricular outflow tract (LVOT) geometry is variable and often elliptical, which can affect aortic valve area calculation in patients with aortic stenosis (AS). Specific differences in LVOT geometry and dynamics between patients with AS and normal control subjects have not been described. The aim of this study was to test the hypothesis that differences in LVOT geometry in patients with AS might relate to variable LVOT remodeling and stiffness relative to normal control subjects. METHODS: In 54 patients with severe AS and 33 control subjects without AS, LVOT geometry, dynamics, remodeling, and stiffness were assessed by three-dimensional transesophageal echocardiography. LVOT stiffness was measured by calculating the distensibility coefficient, defined as the percentage change in LVOT area relative to change in left ventricular pressure. LVOT remodeling was assessed by measuring the posterior LVOT wall thickness. Multivariate linear regression analysis was used to determine independent associations with peak systolic LVOT ellipticity. LVOT area by three-dimensional transesophageal echocardiographic planimetry was compared with areas obtained assuming circular or elliptical geometry. RESULTS: At end-diastole, LVOT geometry was similar between patients with AS and normal control subjects. In patients with AS, however, the percentage change in cross-sectional area (7.5% vs 14.7%, P < .001) from end-diastole to peak systole was lower compared with normal control subjects, while peak systolic ellipticity index was higher in patients with AS (1.18 vs 1.08, P < .001). Compared with control subjects, patients with AS had lower distensibility coefficients (4.7 ± 1.9 × 10(4) vs 12.5 ± 5.3 × 10(4) mm Hg(-1), P < .001) and higher posterior LVOT wall thickness (3.5 ± 0.8 vs 2.3 ± 0.5 mm, P < .001). In multivariate analysis, posterior LVOT wall thickness and distensibility coefficient were independently associated with peak systolic LVOT ellipticity index. LVOT area underestimation by transthoracic echocardiography was higher in patients with AS when assuming circular geometry (20% vs 12%, P = .001). CONCLUSIONS: The LVOT is less distensible and undergoes remodeling in severe AS. These changes lead to greater peak systolic ellipticity and greater LVOT cross-sectional area underestimation relative to normal control subjects. These findings have important implications for the assessment of AS severity.


Assuntos
Estenose da Valva Aórtica/complicações , Estenose da Valva Aórtica/diagnóstico por imagem , Ecocardiografia Tridimensional/métodos , Ventrículos do Coração/diagnóstico por imagem , Obstrução do Fluxo Ventricular Externo/diagnóstico por imagem , Obstrução do Fluxo Ventricular Externo/etiologia , Idoso de 80 Anos ou mais , Diagnóstico Diferencial , Técnicas de Imagem por Elasticidade/métodos , Feminino , Humanos , Interpretação de Imagem Assistida por Computador/métodos , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Sensibilidade e Especificidade , Índice de Gravidade de Doença , Remodelação Ventricular
15.
Future Cardiol ; 11(2): 219-28, 2015 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-25760880

RESUMO

The concept of a multidisciplinary Heart Team approach to treating cardiovascular disease has garnered increasing interest in recent years. This team-based approach has been a cornerstone of practice in other medical fields, such as oncology and solid organ transplantation. Advances in technology and new therapeutic strategies now offer multiple treatment options to patients with complex coronary artery or valvular heart disease, making therapeutic decision-making more challenging. There is a growing literature that use of a Heart Team for management of these complex cardiovascular diseases has demonstrated great merit. While the composition and implementation of Heart Team will vary, this multidisciplinary team-based approach will become the standard of care in cardiovascular medicine in the future.


Assuntos
Fibrilação Atrial/terapia , Doença da Artéria Coronariana/terapia , Doenças das Valvas Cardíacas/terapia , Equipe de Assistência ao Paciente/organização & administração , Humanos
16.
Heart ; 101(6): 463-71, 2015 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-25586156

RESUMO

OBJECTIVES: The aims of this study were to evaluate the effect of left ventricular (LV) dysfunction on clinical outcomes after transcatheter aortic valve replacement (TAVR) and standard therapy for severe aortic stenosis (AS) and to assess LV ejection fraction (LVEF) recovery and its impact on subsequent clinical outcomes. METHODS: Cohort B of the Placement of AoRtic TraNscathetER Valves trial randomised 342 inoperable patients with severe AS to TAVR or standard therapy. We defined LV dysfunction as an LVEF <50% and LVEF improvement as an absolute increase in LVEF ≥10% at 30 days. RESULTS: Baseline LV dysfunction did not affect survival after TAVR but was associated with increased cardiac mortality at 1 year with standard therapy (59.3% vs 45.8% with normal LVEF; HR=1.71 (95% CI 1.08 to 2.71); p=0.02). In those with LV dysfunction, LVEF improvement occurred in 48.7% and 30.4% of TAVR and standard therapy patients, respectively (p=0.08), and was independently predicted by relative wall thickness and receipt of TAVR. LVEF improvement with standard therapy portended reduced all-cause mortality at 1 year (28.6% vs 65.6% without LVEF improvement; HR=0.32 (95% CI 0.11 to 0.93); p=0.03) but not at 2 years. CONCLUSIONS: In inoperable patients with severe AS, mild-to-moderate LV dysfunction is associated with higher cardiac mortality with standard therapy but not TAVR. A subset of patients undergoing standard therapy with LV dysfunction demonstrates LVEF improvement and favourable 1-year but not 2-year survival. TAVR improves survival and should be considered the standard of care for inoperable patients with AS and LVEF >20%. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Unique Identifier #NCT00530894.


Assuntos
Estenose da Valva Aórtica/fisiopatologia , Estenose da Valva Aórtica/cirurgia , Volume Sistólico , Substituição da Valva Aórtica Transcateter , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/complicações , Feminino , Humanos , Masculino , Fatores de Tempo , Disfunção Ventricular Esquerda/complicações , Disfunção Ventricular Esquerda/fisiopatologia
18.
J Cardiovasc Comput Tomogr ; 8(2): 131-40, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-24661826

RESUMO

BACKGROUND: Paravalvular regurgitation (PVR) is an important predictor of mortality after transcatheter aortic valve replacement (TAVR). Aortic valve (AV) calcification is strongly associated with PVR. OBJECTIVES: This study proposes a new metric to quantify AV total calcium burden and its composition in large calcium nodules (CNs) and explores its relation with PVR after TAVR. METHODS: In 133 patients that underwent TAVR, calcium burden of the AV was quantified with multidetector row CT as calcium mass. Each CN was characterized. The AV CN score (AVCNS) was defined as AV calcium mass × mass of the largest CN. PVR was assessed with echocardiography at 1 month. Logistic regression analysis was conducted to identify predictors of PVR. RESULTS: Mean age was 84.1 ± 7.6 years (56% women). TAVR access was transapical in 56%. Procedural success was achieved in 92%. In-hospital mortality was 5%. At follow-up, the prevalence of absent/trace, mild, moderate, and severe PVR was 58%, 31%, 11%, and 0%, respectively. The only independent predictors of at least mild PVR were AVCNS (odds ratio [OR], 2.269; 95% CI, 1.433-3.593; P < .001), number of CNs on aortic annulus (OR, 1.822; 95% CI, 1.137-2.921; P = .013), and aortic annulus area (OR, 1.112; 95% CI, 1.010-1.223; P = .030). This model showed an area under the curve of 0.895 (95% CI, 0.830-0.960) for PVR prediction. CONCLUSIONS: AVCNS, a variable that comprises the total burden of AV calcification as well as calcification agglomeration in form of large nodules, is a novel and powerful independent predictor of PVR after TAVR.


Assuntos
Insuficiência da Valva Aórtica/etiologia , Estenose da Valva Aórtica/terapia , Valva Aórtica/patologia , Calcinose/terapia , Cateterismo Cardíaco/efeitos adversos , Implante de Prótese de Valva Cardíaca/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/fisiopatologia , Insuficiência da Valva Aórtica/diagnóstico , Insuficiência da Valva Aórtica/mortalidade , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/mortalidade , Estenose da Valva Aórtica/fisiopatologia , Área Sob a Curva , Calcinose/diagnóstico por imagem , Calcinose/mortalidade , Calcinose/fisiopatologia , Cateterismo Cardíaco/mortalidade , Ecocardiografia Doppler em Cores , Feminino , Implante de Prótese de Valva Cardíaca/métodos , Implante de Prótese de Valva Cardíaca/mortalidade , Mortalidade Hospitalar , Humanos , Modelos Logísticos , Masculino , Tomografia Computadorizada Multidetectores , Razão de Chances , Valor Preditivo dos Testes , Prevalência , Curva ROC , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de Doença , Fatores de Tempo , Resultado do Tratamento
19.
Circ Cardiovasc Interv ; 6(6): 604-14, 2013 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-24221391

RESUMO

BACKGROUND: The Placement of Aortic Transcatheter Valves (PARTNER) trial demonstrated similar survival after transcatheter and surgical aortic valve replacement (TAVR and SAVR, respectively) in high-risk patients with symptomatic, severe aortic stenosis. The aim of this study was to evaluate the effect of left ventricular (LV) dysfunction on clinical outcomes after TAVR and SAVR and the impact of aortic valve replacement technique on LV function. METHODS AND RESULTS: The PARTNER trial randomized high-risk patients with severe aortic stenosis to TAVR or SAVR. Patients were stratified by the presence of LV ejection fraction (LVEF) <50%. All-cause mortality was similar for TAVR and SAVR at 30-days and 1 year regardless of baseline LV function and valve replacement technique. In patients with LV dysfunction, mean LVEF increased from 35.7±8.5% to 48.6±11.3% (P<0.0001) 1 year after TAVR and from 38.0±8.0% to 50.1±10.8% after SAVR (P<0.0001). Higher baseline LVEF (odds ratio, 0.90 [95% confidence interval, 0.86, 0.95]; P<0.0001) and previous permanent pacemaker (odds ratio, 0.34 [95% confidence interval, 0.15, 0.81]) were independently associated with reduced likelihood of ≥10% absolute LVEF improvement by 30 days; higher mean aortic valve gradient was associated with increased odds of LVEF improvement (odds ratio, 1.04 per 1 mm Hg [95% confidence interval, 1.01, 1.08]). Failure to improve LVEF by 30 days was associated with adverse 1-year outcomes after TAVR but not SAVR. CONCLUSIONS: In high-risk patients with severe aortic stenosis and LV dysfunction, mortality rates and LV functional recovery were comparable between valve replacement techniques. TAVR is a feasible alternative for patients with symptomatic severe aortic stenosis and LV dysfunction who are at high risk for SAVR. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00530894.


Assuntos
Estenose da Valva Aórtica/cirurgia , Valva Aórtica/cirurgia , Cateterismo Cardíaco/métodos , Procedimentos Cirúrgicos Cardíacos/métodos , Implante de Prótese de Valva Cardíaca/métodos , Próteses Valvulares Cardíacas , Disfunção Ventricular Esquerda/fisiopatologia , Idoso , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/epidemiologia , Estenose da Valva Aórtica/mortalidade , Comorbidade , Feminino , Seguimentos , Humanos , Estimativa de Kaplan-Meier , Masculino , Marca-Passo Artificial , Recuperação de Função Fisiológica/fisiologia , Fatores de Risco , Volume Sistólico/fisiologia , Taxa de Sobrevida , Resultado do Tratamento , Disfunção Ventricular Esquerda/epidemiologia
20.
JACC Heart Fail ; 1(6): 480-7, 2013 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-24621999

RESUMO

OBJECTIVES: The aim of this study was to evaluate the effects of losartan on left ventricular (LV) hypertrophy and fibrosis in patients with nonobstructive hypertrophic cardiomyopathy (HCM). BACKGROUND: Despite evidence that myocardial hypertrophy and fibrosis are mediated by angiotensin II and are important determinants of morbidity and mortality in patients with HCM, no prior studies have evaluated the effects of angiotensin receptor blockers on LV hypertrophy and fibrosis with cardiac magnetic resonance imaging. METHODS: In double-blind fashion, 20 patients (3 women, 17 men; age: 51 ± 13 years) with HCM were randomly assigned to receive placebo (n = 9) or losartan 50 mg twice a day (n = 11) for 1 year. Cardiac magnetic resonance imaging was performed at baseline and 1 year to measure LV mass and extent of fibrosis as assessed by late gadolinium enhancement. RESULTS: There was a trend toward a significant difference in the percent change in LV mass (median [interquartile range]: +5% [-4% to +21%] with placebo vs. -5% [-11% to -0.9%] with losartan; p = 0.06). There was a significant difference in the percent change in extent of late gadolinium enhancement, with the placebo group experiencing a larger increase (+31% ± 26% with placebo vs. -23% ± 45% with losartan; p = 0.03). CONCLUSIONS: This pilot study suggests attenuation of progression of myocardial hypertrophy and fibrosis with losartan in patients with nonobstructive HCM. Confirmation of these results in a larger trial is required to confirm a place for angiotensin receptor blockers in the management of patients with HCM. (Effect of Losartan in Patients With Nonobstructive Hypertrophic Cardiomyopathy; NCT01150461).


Assuntos
Bloqueadores do Receptor Tipo 1 de Angiotensina II/administração & dosagem , Cardiomiopatia Hipertrófica/complicações , Hipertrofia Ventricular Esquerda/tratamento farmacológico , Losartan/administração & dosagem , Miocárdio/patologia , Método Duplo-Cego , Esquema de Medicação , Feminino , Fibrose/tratamento farmacológico , Humanos , Hipertrofia Ventricular Esquerda/complicações , Angiografia por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Estudos Prospectivos
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