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1.
J UOEH ; 42(3): 291-295, 2020.
Artigo em Japonês | MEDLINE | ID: mdl-32879194

RESUMO

We report a case of a 77-year-old male who had been diagnosed with normal-flow high-pressure gradient severe aortic stenosis (AS) two years previously. In accordance with his wishes, it was decided not to perform surgery. He visited our hospital with anorexia and weight loss and was diagnosed with gastric cancer. Echocardiography showed a change to paradoxical low-flow low-pressure gradient severe AS (PLFLPG AS). A decrease in stroke volume is typically associated with a smaller LV size, but the reason for a smaller LV size in PLFLPG AS remains unclear. In this case, the change to PLFLPG AS was thought to be due to a decrease in whole body oxygen consumption, and this may help to understand the pathology.


Assuntos
Estenose da Valva Aórtica/fisiopatologia , Idoso , Estenose da Valva Aórtica/complicações , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/patologia , Baixo Débito Cardíaco , Progressão da Doença , Ecocardiografia , Ventrículos do Coração/patologia , Humanos , Masculino , Consumo de Oxigênio , Índice de Gravidade de Doença , Neoplasias Gástricas/complicações , Volume Sistólico
4.
Int Heart J ; 61(5): 961-969, 2020 Sep 29.
Artigo em Inglês | MEDLINE | ID: mdl-32921672

RESUMO

Left ventricular (LV) remodeling with aortic stenosis (AS) appears to differ according to sex, but reverse remodeling after transcatheter aortic valve implantation (TAVI) has not been elucidated in a Japanese population. This study aims to determine whether any sex-related differences in LV or reverse remodeling after TAVI exist in the context of severe AS.Of 208 patients who received TAVI for severe AS in our institution, 100 (men, 42; mean age, 83.0 ± 4.9 years) underwent transthoracic echocardiography before and 3 months after TAVI. Despite similar valvular gradients, women with severe AS had lower indexed LV mass (LVMi) than did men (152.3 ± 35.4 versus 173.2 ± 44.6 g/m2, P = 0.005), with smaller indexed LV end-diastolic (LVEDVi) (50.2 ± 13.3 versus 61.4 ± 20.7 mL/m2, P = 0.001) and end-systolic (LVESVi; 17.9 ± 8.7 versus 24.3 ± 13.8 mL/m2, P = 0.006) volumes. After TAVI, women (-6.0% ± 14.4%) had higher reduction in the rate of change of relative wall thickness (RWT) than did men (4.4% ± 19.0%, P = 0.003). Men (-8.9% ± 3.9%) had higher reduction in the rate of change of LVEDVi than did women (1.5% ± 3.3%, P = 0.045). Incidence of LV reverse remodeling defined as a reduction in LVESV of >15% was significantly higher in men (50%) than in women (26%, P = 0.013).In addition to sex differences in the pattern of LV remodeling with AS, reverse LV remodeling after TAVI also differed between sexes.


Assuntos
Estenose da Valva Aórtica/cirurgia , Hipertrofia Ventricular Esquerda/diagnóstico por imagem , Remodelação Ventricular/fisiologia , Idoso , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/complicações , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/fisiopatologia , Ecocardiografia , Feminino , Humanos , Hipertrofia Ventricular Esquerda/etiologia , Hipertrofia Ventricular Esquerda/fisiopatologia , Japão , Masculino , Índice de Gravidade de Doença , Fatores Sexuais , Substituição da Valva Aórtica Transcateter , Resultado do Tratamento
5.
Medicine (Baltimore) ; 99(31): e21443, 2020 Jul 31.
Artigo em Inglês | MEDLINE | ID: mdl-32756159

RESUMO

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is an effective treatment to aortic stenosis in patients with advanced age. However, age is recognized as one of the most important risk factors. The aim of our study is to compare the outcome of TAVI between octogenarian patients and young patients. METHODS: Randomized controlled trials, cohort studies and propensity score matching studies will be included in our systematic review and meta-analysis to evaluate clinical outcome in octogenarian patients who undergo TAVI. PubMed, EMBASE, MEDLINE, Cochrane Library and Web of Science will be searched using a comprehensive strategy. The related conference proceedings and reference lists of the included studies will also be checked to identify additional studies. Retrieved records, extract information and assess the risk of bias will be screened by two reviewers independently. STATA software will be used to conduct data synthesis. There is no requirement of ethical approval and informed consent. RESULTS: This study will eventually be published in a peer reviewed journal in the form of a scientific paper. CONCLUSION: This study will provide a comprehensive review of the available evidence for the treatment of aortic stenosis in octogenarian patients underwent TAVI. We hope it will provide a relatively comprehensive reference for clinical practice and future relevant clinical trials. PROSPERO REGISTRATION NUMBER: CRD42020155189. STUDY PROTOCOL REGISTRY: The protocol has been registered in PROSPERO, which is an International Prospective Register of Systematic Reviews. The registration number is CRD42020155189. ETHICS AND DISSEMINATION: Ethics approval and patient consent are not required as this study is a systematic review and meta-analysis.


Assuntos
Estenose da Valva Aórtica/cirurgia , Substituição da Valva Aórtica Transcateter/efeitos adversos , Substituição da Valva Aórtica Transcateter/métodos , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/diagnóstico por imagem , Ecocardiografia/métodos , Feminino , Humanos , Imagem por Ressonância Magnética/métodos , Masculino , Ensaios Clínicos Controlados Aleatórios como Assunto , Fatores de Risco , Tomografia Computadorizada por Raios X/métodos , Resultado do Tratamento
6.
Int Heart J ; 61(4): 734-738, 2020 Jul 30.
Artigo em Inglês | MEDLINE | ID: mdl-32684607

RESUMO

Peri-procedural elevated B-type natriuretic peptide (BNP) is also associated with worse outcomes following transcatheter aortic valve implantation (TAVI). However, the mechanism of BNP regulation in patients with severe aortic stenosis (AS) remains unknown. Consecutive patients with severe AS who were referred for TAVI were enrolled in our prospective registry. BNP levels were correlated with other clinical variables. Ninety-six patients (84.7 ± 5.0 years old, 34% males) were investigated in this study. Plasma BNP averaged 353 ± 179 pg/mL. Log10 BNP had no significant correlation with severity of AS including aortic valve area and maximum flow velocity across the aortic valve (P > 0.05 for all), whereas a higher left ventricular end-diastolic dimension (LVDd) index was a significant factor associating with BNP >100 pg/mL with an odds ratio of 1.34 (95% confidence interval 1.06-1.52, P = 0.004) adjusted for several other echocardiographic parameters, with a cutoff of 30.8 mm/m2 (equivalent to LVDd 44 mm). In conclusion, among the patients with severe AS who undergo TAVI, even slight eccentric hypertrophy can cause a considerable increase in BNP level.


Assuntos
Estenose da Valva Aórtica/cirurgia , Peptídeo Natriurético Encefálico/sangue , Sistema de Registros , Substituição da Valva Aórtica Transcateter , Idoso , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/sangue , Estenose da Valva Aórtica/diagnóstico por imagem , Ecocardiografia , Feminino , Humanos , Masculino
7.
Angiology ; 71(9): 817-824, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32672103

RESUMO

Transcatheter aortic valve replacement (TAVR) is associated with clinically significant cerebral microembolism and cognitive status changes. There are no data on the impact of TAVR on retinal layers. We assessed the influence of TAVR on the retinal nerve fiber layer, ganglion cell complex (GCC), and macular thickness (MT) measured by spectral domain optical coherence tomography (SD-OCT). Elderly patients (n = 50) with severe aortic stenosis undergoing TAVR were included in this study (mean age: 78.5 ± 6.9 years). Retinal nerve fiber layer, GCC, and MT were measured with SD-OCT by an ophthalmologist before and on the first day and in the first month after TAVR. The average MT was significantly increased on the first day after TAVR compared with the basal value (P = .04). Ganglion cell complex thickness was significantly thinner on the first day after TAVR than the basal value in the inner inferior quadrant and outer temporal quadrant of the left eye (P = .03 and .04, respectively). Postoperative changes observed on the first day compared with the preoperative period returned to basal values in the first month. In conclusion, TAVR did not cause permanent changes in retinal layers.


Assuntos
Estenose da Valva Aórtica/cirurgia , Retina/patologia , Substituição da Valva Aórtica Transcateter/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/diagnóstico por imagem , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fibras Nervosas/patologia , Retina/diagnóstico por imagem , Fatores de Risco , Fatores de Tempo , Tomografia de Coerência Óptica
8.
Methodist Debakey Cardiovasc J ; 16(2): 106-113, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32670470

RESUMO

Cardiac magnetic resonance (CMR) has emerged as the gold standard in assessing ventricular mass, volume, and systolic function. Due to these and other strengths, CMR has increasingly been used to study valvular heart disease (VHD) and resultant cardiac remodeling. By using CMR to assess flow, limitations in echocardiographic assessment of VHD can be overcome, particularly in regurgitant lesions. The following article reviews the current role of CMR imaging in studying disease severity and myocardial remodeling in patients with VHD.


Assuntos
Insuficiência da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/diagnóstico por imagem , Valva Aórtica/diagnóstico por imagem , Imagem por Ressonância Magnética , Insuficiência da Valva Mitral/diagnóstico por imagem , Valva Mitral/diagnóstico por imagem , Remodelação Ventricular , Valva Aórtica/fisiopatologia , Insuficiência da Valva Aórtica/fisiopatologia , Estenose da Valva Aórtica/fisiopatologia , Humanos , Valva Mitral/fisiopatologia , Insuficiência da Valva Mitral/fisiopatologia , Valor Preditivo dos Testes , Índice de Gravidade de Doença
10.
Am J Cardiol ; 128: 151-158, 2020 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-32650909

RESUMO

Normal-flow low-gradient severe aortic stenosis (NF-LG-SAS), defined by an aortic valve area (AVA) <1 cm², mean pressure gradient (MPG) <40 mm Hg and indexed stroke volume ≥35 ml/m², is the most prevalent form of low-gradient aortic stenosis (AS) with preserved ejection fraction (PEF). However, the true severity of AS in these patients is controversial. The aim of this Doppler echocardiographic study was to investigate changes over time in the hemodynamic severity of patients with NF-LG-SAS with PEF. We retrospectively identified 96 patients who had 2 Doppler echocardiographic examinations without an intervening event. After a median follow-up of 25 (interquartile range 15 to 52) months, progression was observed, with increased transaortic MPG (from 28 [25 to 33] to 39 [34 to 50] mm Hg; p<0.001), peak aortic jet velocity (from 3.46 [3.20 to 3.64] to 4.01 [3.70 to 4.39] m/s; p<0.001), and decreased AVA (from 0.87 [0.82 to 0.94] to 0.72 [0.62 to 0.81] cm²; p<0.001). Median annual rates of progression were 4.3 (1.7 to 8.1) mm Hg/year, 0.25 (0.08 to 0.44) m/s/year, and -0.05 (-0.10 to -0.02) cm²/year, respectively. There was no significant change in left ventricular ejection fraction over time (p = 0.74). At follow-up, 46 patients (48%) acquired the features of classical high-gradient severe AS (MPG ≥40 mm Hg). This study shows that most patients with NF-LG-SAS with PEF exhibit significant hemodynamic progression of AS severity without EF impairment. These findings suggest that NF-LG-SAS with PEF is an "intermediate" stage between moderate AS and classical high-gradient severe AS requiring close monitoring.


Assuntos
Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/fisiopatologia , Volume Sistólico , Idoso , Idoso de 80 Anos ou mais , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/patologia , Valva Aórtica/fisiopatologia , Velocidade do Fluxo Sanguíneo , Progressão da Doença , Ecocardiografia Doppler , Feminino , Humanos , Masculino , Tamanho do Órgão , Pressão , Estudos Retrospectivos , Índice de Gravidade de Doença
11.
Am J Cardiol ; 128: 84-91, 2020 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-32650929

RESUMO

Valvular atrial fibrillation (AF) is defined as AF in the presence of mitral stenosis or mechanical valve prosthesis. However, there are patients with AF who have significant native valvular heart disease (VHD) others than mitral stenosis that are classified as nonvalvular AF. The characteristics and prognostic implications of these entities have not been extensively studied. Of 1,885 AF patients referred for electrical cardioversion (64 ± 13years, 71% male), 171 (9.1%) had valvular AF (any grade of mitral stenosis or mechanical/biological valve prostheses) and 1,714 patients were identified as nonvalvular AF, of whom 329 (17.5%) had significant left-sided VHD. Patients with nonvalvular AF but with significant left-sided VHD were older, more frequently women and had more co-morbidities compared with the other groups. Furthermore, nonvalvular AF patients with significant left-sided VHD showed the worst left ventricular systolic function and largest left atrial volumes. During a median follow-up of 64 months (interquartile range: 33 to 96 months), 488 patients presented with the combined endpoint of all-cause mortality, heart failure hospitalization, and ischemic stroke. Patients with nonvalvular AF and with significant left-sided VHD had more events of heart failure whereas patients with valvular AF had higher all-cause mortality events. There were no differences in ischemic stroke events. Type of AF was not associated with outcomes after correcting for echocardiographic variables. In conclusion, the frequency of AF patients with significant VHD is relatively high. The consequences of VHD and AF on cardiac structure and function are more important determinants of adverse outcome than the type of AF.


Assuntos
Insuficiência da Valva Aórtica/epidemiologia , Estenose da Valva Aórtica/epidemiologia , Fibrilação Atrial/epidemiologia , Insuficiência da Valva Mitral/epidemiologia , Distribuição por Idade , Idoso , Anticoagulantes/uso terapêutico , Insuficiência da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/diagnóstico por imagem , Fibrilação Atrial/complicações , Fibrilação Atrial/terapia , Isquemia Encefálica/epidemiologia , Anuloplastia da Valva Cardíaca/estatística & dados numéricos , Causas de Morte , Ecocardiografia , Cardioversão Elétrica , Feminino , Insuficiência Cardíaca/epidemiologia , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Insuficiência da Valva Mitral/diagnóstico por imagem , Mortalidade , Prognóstico , Encaminhamento e Consulta , Sistema de Registros , Estudos Retrospectivos , Distribuição por Sexo , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle
12.
Arterioscler Thromb Vasc Biol ; 40(9): 2187-2194, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32640909

RESUMO

OBJECTIVE: Aortic stenosis may be complicated by an acquired von Willebrand syndrome that rarely causes significant bleeding, raising the question of why it does so in a few cases. To seek an explanation, we studied 5 severe bleeder aortic stenosis patients in a cohort of 49 patients, using the flowchart for inherited von Willebrand disease. Approach and Results: All 5 patients were lacking in large and intermediate VWF (von Willebrand factor) multimers, 3 had reduced plasma and platelet VWF levels, and none showed PFA100 closure. Two patients (those with most multimers missing) also had a short VWF half-life. Genetic analyses on the 3 patients with reduced platelet VWF levels revealed that one carried both the c.1164C>G and the c.7880G>A mutations, and another carried the c.3390C>T mutation, while the third had one of the 2 VWF alleles relatively less expressed than the other (25% versus 75%). No genetic alterations emerged in the other 2 patients. Successful replacement of the stenotic aortic valve, performed in the 2 patients with VWF mutations, did not correct their abnormal VWF multimer picture-unlike what happened in the aortic stenosis patients without bleeding symptoms. CONCLUSIONS: Our findings suggest that acquired von Willebrand syndrome can develop in patients with hitherto-undiagnosed inherited von Willebrand disease. Since von Willebrand disease is the most common bleeding disorder, this possibility should be considered in aortic stenosis patients-especially those with a more severe bleeding history and more disrupted VWF laboratory patterns-because they risk hemorrhage during aortic valve replacement.


Assuntos
Estenose da Valva Aórtica/cirurgia , Implante de Prótese Vascular/efeitos adversos , Hemostasia , Hemorragia Pós-Operatória/etiologia , Doenças de von Willebrand/complicações , Fator de von Willebrand/metabolismo , Idoso , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/complicações , Estenose da Valva Aórtica/diagnóstico por imagem , Biomarcadores/sangue , Estudos de Casos e Controles , Feminino , Predisposição Genética para Doença , Meia-Vida , Hemostasia/genética , Humanos , Masculino , Mutação , Fenótipo , Hemorragia Pós-Operatória/sangue , Hemorragia Pós-Operatória/diagnóstico , Valor Preditivo dos Testes , Multimerização Proteica , Estabilidade Proteica , Proteólise , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Fatores de Tempo , Resultado do Tratamento , Doenças de von Willebrand/sangue , Doenças de von Willebrand/diagnóstico , Doenças de von Willebrand/genética , Fator de von Willebrand/genética
13.
Asian Cardiovasc Thorac Ann ; 28(5): 276-278, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32479110

RESUMO

An 86-year-old female with severe aortic valve stenosis underwent transcatheter aortic valve replacement. A balloon-expandable valve was used, guided by a double-stiff guidewire that successfully straightened the aorta. During valve placement, the balloon shifted. After placement of the prosthetic valve, intraoperative transesophageal echocardiography revealed severe mitral regurgitation from the anterior mitral leaflet. Open conversion was performed immediately. A 5-mm hole was identified in the anterior leaflet, and direct closure was chosen for mitral valve repair. While transcatheter aortic valve replacement has gained popularity for patients with severe aortic stenosis and high operative risk, reports of mitral valve perforation are rare.


Assuntos
Estenose da Valva Aórtica/cirurgia , Valvuloplastia com Balão/efeitos adversos , Traumatismos Cardíacos/etiologia , Insuficiência da Valva Mitral/etiologia , Valva Mitral/lesões , Substituição da Valva Aórtica Transcateter/efeitos adversos , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/diagnóstico por imagem , Feminino , Traumatismos Cardíacos/diagnóstico por imagem , Traumatismos Cardíacos/cirurgia , Humanos , Valva Mitral/diagnóstico por imagem , Valva Mitral/cirurgia , Insuficiência da Valva Mitral/diagnóstico por imagem , Insuficiência da Valva Mitral/cirurgia , Índice de Gravidade de Doença , Resultado do Tratamento
15.
J Cardiovasc Magn Reson ; 22(1): 41, 2020 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-32475350

RESUMO

BACKGROUND: Transcatheter aortic valve replacement (TAVR) is increasingly used to treat patients with severe aortic stenosis (AS). Cardiovascular magnetic resonance imaging (CMR) provides reliable and reproducible estimates for assessment of cardiac structure and function after TAVR. The goal of this study was to conduct a systematic review and meta-analysis of the literature to assess left ventricular (LV) volumes, mass and function by CMR after TAVR. METHODS: Using Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines, we searched PubMed and Embase for studies reporting CMR findings before and at least 1 month after TAVR. Main factors of interest were LV end-diastolic volume index (LVEDVi), LV end-systolic volume index (LVESVi), LV mass index (LVMi), and left ventricular ejection fraction (LVEF). Standardized mean differences (SMD) were pooled by random effects meta-analytic techniques. RESULTS: Of 453 screened publications, 10 studies (published between 2012 and 2018) were included. A total of 305 patients completed pre- and post-TAVR follow-up CMR (mean age range 78.6-85.0 years, follow-up range 6-15 months). Random effects analysis showed TAVR resulted in reduced LVEDVi (SMD: -0.25, 95% CI: - 0.43 to - 0.07, P = 0.006), LVESVi (SMD: -0.24, 95% CI: - 0.44 to - 0.05, P = 0.01), LVMi (SMD: -0.82, 95% CI: - 1.0 to - 0.63, P < 0.001) and increased LVEF (SMD: 22, 95% CI: 6 to 38%, P = 0.006). Heterogeneity across studies was low (I2: 0%, Pheterogeneity > 0.05 for all). The median reduction was 4 ml/m2 (IQR: 3.1 to 8.2) for LVEDVi, 5 ml/m2 (IQR: 3.0 to 6.0) for LVESVi, and 15.1 g/m2 (IQR: 11.8 to 18.3) for LVMi. The median increase for LVEF was 3.4% (IQR 1.0 to 4.6%). CONCLUSIONS: CMR demonstrates reverse LV remodeling occurrs within 6-15 months after TAVR, with reductions in LVEDVi, LVESVi and LVMi, and increased LVEF.


Assuntos
Estenose da Valva Aórtica/cirurgia , Valva Aórtica/cirurgia , Ventrículos do Coração/diagnóstico por imagem , Imagem por Ressonância Magnética , Substituição da Valva Aórtica Transcateter , Função Ventricular Esquerda , Remodelação Ventricular , 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/fisiopatologia , Feminino , Ventrículos do Coração/fisiopatologia , Humanos , Masculino , Valor Preditivo dos Testes , Recuperação de Função Fisiológica , Fatores de Tempo , Substituição da Valva Aórtica Transcateter/efeitos adversos , Resultado do Tratamento
16.
J Cardiovasc Magn Reson ; 22(1): 45, 2020 06 15.
Artigo em Inglês | MEDLINE | ID: mdl-32536342

RESUMO

BACKGROUND: As the average age of patients with severe aortic stenosis (AS) who receive procedural intervention continue to age, the need for non-invasive modalities that provide accurate diagnosis and operative planning is increasingly important. Advances in cardiovascular magnetic resonance (CMR) over the past two decades mean it is able to provide haemodynamic data at the aortic valve, along with high fidelity anatomical imaging. METHODS: Electronic databases were searched for studies comparing CMR to transthoracic echocardiography (TTE) and transoesophageal echocardiography (TEE) in the diagnosis of AS. Studies were included only if direct comparison was made on matched patients, and if diagnosis was primarily through measurement of aortic valve area (AVA). RESULTS: Twenty-three relevant, prospective articles were included in the meta-analysis, totalling 1040 individual patients. There was no significant difference in AVA measured as by CMR compared to TEE. CMR measurements of AVA size were larger compared to TTE by an average of 10.7% (absolute difference: + 0.14cm2, 95% CI 0.07-0.21, p < 0.001). Reliability was high for both inter- and intra-observer measurements (0.03cm2 +/- 0.04 and 0.02cm2 +/- 0.01, respectively). CONCLUSIONS: Our analysis demonstrates the equivalence of AVA measurements using CMR compared to those obtained using TEE. CMR demonstrated a small but significantly larger AVA than TTE. However, this can be attributed to known errors in derivation of left ventricular outflow tract size as measured by TTE. By offering additional anatomical assessment, CMR is warranted as a primary tool in the assessment and workup of patients with severe AS who are candidates for surgical or transcatheter intervention.


Assuntos
Insuficiência da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/diagnóstico por imagem , Valva Aórtica/diagnóstico por imagem , Hemodinâmica , Imagem por Ressonância Magnética , Idoso , Idoso de 80 Anos ou mais , Valva Aórtica/fisiopatologia , Valva Aórtica/cirurgia , Insuficiência da Valva Aórtica/fisiopatologia , Insuficiência da Valva Aórtica/cirurgia , Estenose da Valva Aórtica/fisiopatologia , Estenose da Valva Aórtica/cirurgia , Tomada de Decisão Clínica , Ecocardiografia Transesofagiana , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Variações Dependentes do Observador , Valor Preditivo dos Testes , Prognóstico , Reprodutibilidade dos Testes , Índice de Gravidade de Doença
17.
J Cardiovasc Magn Reson ; 22(1): 46, 2020 06 22.
Artigo em Inglês | MEDLINE | ID: mdl-32564773

RESUMO

BACKGROUND: Myocardial fibrosis is a major determinant of outcome in aortic stenosis (AS). Novel fast real-time (RT) cardiovascular magnetic resonance (CMR) mapping techniques allow comprehensive quantification of fibrosis but have not yet been compared against standard techniques and histology. METHODS: Patients with severe AS underwent CMR before (n = 110) and left ventricular (LV) endomyocardial biopsy (n = 46) at transcatheter aortic valve replacement (TAVR). Midventricular short axis (SAX) native, post-contrast T1 and extracellular volume fraction (ECV) maps were generated using commercially available modified Look-Locker Inversion recovery (MOLLI) (native: 5(3)3, post-contrast: 4(1)3(1)2) and RT single-shot inversion recovery Fast Low-Angle Shot (FLASH) with radial undersampling. Focal late gadolinium enhancement was excluded from T1 and ECV regions of interest. ECV and LV mass were used to calculate LV matrix volumes. Variability and agreements were assessed between RT, MOLLI and histology using intraclass correlation coefficients, coefficients of variation and Bland Altman analyses. RESULTS: RT and MOLLI derived ECV were similar for midventricular SAX slice coverage (26.2 vs. 26.5, p = 0.073) and septal region of interest (26.2 vs. 26.5, p = 0.216). MOLLI native T1 time was in median 20 ms longer compared to RT (p < 0.001). Agreement between RT and MOLLI was best for ECV (ICC > 0.91), excellent for post-contrast T1 times (ICC > 0.81) and good for native T1 times (ICC > 0.62). Diffuse collagen volume fraction by biopsies was in median 7.8%. ECV (RT r = 0.345, p = 0.039; MOLLI r = 0.40, p = 0.010) and LV matrix volumes (RT r = 0.45, p = 0.005; MOLLI r = 0.43, p = 0.007) were the only parameters associated with histology. CONCLUSIONS: RT mapping offers fast and sufficient ECV and LV matrix volume calculation in AS patients. ECV and LV matrix volume represent robust and universally comparable parameters with associations to histologically assessed fibrosis and may emerge as potential targets for clinical decision making.


Assuntos
Estenose da Valva Aórtica/diagnóstico por imagem , Valva Aórtica/diagnóstico por imagem , Imagem Cinética por Ressonância Magnética , Miocárdio/patologia , Função Ventricular Esquerda , Idoso , Idoso de 80 Anos ou mais , Valva Aórtica/patologia , Valva Aórtica/fisiopatologia , Valva Aórtica/cirurgia , Estenose da Valva Aórtica/patologia , Estenose da Valva Aórtica/fisiopatologia , Estenose da Valva Aórtica/cirurgia , Biópsia , Feminino , Fibrose , Humanos , Masculino , Variações Dependentes do Observador , Valor Preditivo dos Testes , Reprodutibilidade dos Testes , Substituição da Valva Aórtica Transcateter , Remodelação Ventricular
18.
Int J Cardiovasc Imaging ; 36(10): 1897-1905, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32556718

RESUMO

This study applies L-wave measurements of mid-diastolic trans-mitral flow. Although considered to be a marker of elevated filling pressure or delayed myocardial relaxation, its clinical and prognostic value is yet to be completely elucidated. It has been shown that transcatheter aortic valve replacement (TAVR) induces reverse remodeling and improves diastolic function and prognosis in patients with severe aortic stenosis (AS). Our purpose was to evaluate the prognostic value of L-wave following TAVR. We examined clinical and echocardiographic data of patients undergoing TAVR. L-Wave presence and velocity were recorded at baseline and at 1 month and 6 months following TAVR. The effect of the procedure on L-wave measurements and its impact on mortality and other clinical outcomes were analyzed. A total of 502 patients (mean age 82.58 ± 5.9) undergoing TAVR were included. Patients with baseline L-wave (n = 68, 12%) had a smaller stroke volume index by 5.7 ± 2.3 ml/m2 (p = 0.01) as compared to patients without L-wave at baseline. L-waves disappeared In 35% and 70% of patients at 1 month and at 6 months respectively. Baseline L-wave velocity was 34.8 ± 11.5 (cm/s) and decreased significantly at follow-up examinations. Patients with persistent L-wave following TAVR had higher 3-year adjusted mortality rates (HR 5.7, 95% CI 3.7-8.9, p < 0.001). Multivariate analysis of survival was also statistically significant (p < 0.001). TAVR induces L-wave disappearance and a decrease in L-wave velocity in patients with severe AS. L-wave persistence following TAVR is an independent risk factor for mortality.


Assuntos
Estenose da Valva Aórtica/cirurgia , Valva Aórtica/cirurgia , Ecocardiografia Doppler de Pulso , Hemodinâmica , Substituição da Valva Aórtica Transcateter , 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 , Diástole , Feminino , Humanos , Masculino , Valor Preditivo dos Testes , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Substituição da Valva Aórtica Transcateter/efeitos adversos , Substituição da Valva Aórtica Transcateter/mortalidade , Resultado do Tratamento
19.
Int J Cardiovasc Imaging ; 36(10): 1917-1929, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32500398

RESUMO

PURPOSE: In echocardiography the severity of aortic stenosis (AS) is defined by effective orifice area (EOA), mean pressure gradient (mPGAV) and transvalvular flow velocity (maxVAV). The hypothesis of the present study was to confirm the pathophysiological presence of combined left ventricular hypertrophy (LVH), diastolic dysfunction (DD) and pulmonary artery hypertension (PAH) in patients with "pure" severe AS. METHODS AND RESULTS: Patients (n = 306) with asymptomatic (n = 133) and symptomatic (n = 173) "pure" severe AS (mean age 78 ± 9.5 years) defined by indexed EOA < 0.6 cm2 were enrolled between 2014 and 2016. AS patients were divided into 4 subgroups according to mPGAV and indexed left ventricular stroke volume: low flow (LF) low gradient (LG)-AS (n = 133), normal flow (NF) LG-AS (n = 91), LF high gradient (HG)-AS (n = 21) and NFHG-AS (n = 61). Patients with "pure" severe AS showed mean mPGAV of 31.7 ± 9.1 mmHg and mean maxVAV of 3.8 ± 0.6 m/s. Only 131 of 306 patients (43%) exhibited mPGAV > 40 mmHg and maxVAV > 4 m/s documenting incongruencies of the AS severity assessment by Doppler echocardiography. LVH was documented in 81%, DD in 76% and PAH in 80% of AS patients. 54% of "pure" AS patients exhibited all three alterations. Ranges of mPGAV and maxVAV were higher in patients with all three alterations compared to patients with less than three. 224 (73%) patients presented LG-conditions and 82 (27%) HG-conditions. LVH was predominant in NF-AS (p = 0.014) and PAH in LFHG-AS (p = 0.014). Patients' treatment was retrospectively assessed (surgery: n = 100, TAVI: n = 48, optimal medical treatment: n = 156). CONCLUSION: In patients with "pure" AS according to current guidelines the presence of combined LVH, DD and PAH as accepted pathophysiological sequelae of severe AS cannot be confirmed. Probably, the detection of these secondary cardiac alterations might improve the diagnostic algorithm to avoid overestimation of AS severity.


Assuntos
Estenose da Valva Aórtica/diagnóstico por imagem , Valva Aórtica/diagnóstico por imagem , Ecocardiografia Doppler , Hipertrofia Ventricular Esquerda/diagnóstico por imagem , Hipertensão Arterial Pulmonar/diagnóstico por imagem , Artéria Pulmonar/diagnóstico por imagem , Disfunção Ventricular Esquerda/diagnóstico por imagem , Idoso , Idoso de 80 Anos ou mais , Valva Aórtica/fisiopatologia , Valva Aórtica/cirurgia , Estenose da Valva Aórtica/fisiopatologia , Estenose da Valva Aórtica/terapia , Pressão Arterial , Doenças Assintomáticas , Fármacos Cardiovasculares/uso terapêutico , Estudos Transversais , Feminino , Implante de Prótese de Valva Cardíaca , Humanos , Hipertrofia Ventricular Esquerda/fisiopatologia , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Hipertensão Arterial Pulmonar/fisiopatologia , Artéria Pulmonar/fisiopatologia , Reprodutibilidade dos Testes , Estudos Retrospectivos , Índice de Gravidade de Doença , Substituição da Valva Aórtica Transcateter , Resultado do Tratamento , Disfunção Ventricular Esquerda/fisiopatologia , Função Ventricular Esquerda , Remodelação Ventricular
20.
Am J Cardiol ; 128: 210-215, 2020 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-32534732

RESUMO

The clinical and imaging differences between bicuspid aortic valve (BAV) and tricuspid aortic valve (TAV) patients with medically managed asymptomatic moderate-to-severe aortic stenosis (AS) have not been studied previously. We aim to characterize these differences and their clinical outcomes in this study. A retrospective observational study was conducted on 836 consecutive cases of isolated asymptomatic moderate-to-severe AS, with median follow-up of 3.4 years. Clinical and echocardiographic characteristics were compared between BAV and TAV patients. Subgroup analysis stratified by AS severity were performed. Survival analysis of all-cause mortality was performed using Kaplan-Meier curves and Cox proportional hazards model. Compared to BAV patients, TAV patients were older (76 ± 11 vs 55 ± 16 years, p <0.001) and had more co-morbidities including hypertension (78% vs 56%; p <0.001), diabetes (41% vs 24%; p <0.001), and chronic kidney disease (20% vs 3%; p = 0.001). TAV patients had less severe aortic valve disease than BAV patients, with a higher aortic valve area index (0.71 ± 0.20 cm2/m2 vs 0.61 ± 0.18 cm2/m2, p <0.001) and less aortic dilation (sinotubular junction: 23.7 ± 4.0 mm vs 26.9 ± 4.8 mm, p <0.001; mid-ascending aorta: 31.4 ± 4.7 mm vs 36.3 ± 6.3 mm, p <0.001). TAV patients were more likely to have eccentric left ventricular hypertrophy and less likely to have a normal geometry (p = 0.003). Competing risk analysis identified increased age (hazard ratio 1.03, 95% confidence interval 1.02 to 1.05, p <0.001) and LVEF (hazard ratio 0.98, 95% confidence interval 0.97 to 0.99, p <0.001) as independent risk factors of all-cause mortality. Valve morphology was not a significant independent risk factor for aortic valve replacement or mortality. In conclusion, asymptomatic TAV patients had more cardiovascular risk factors, less severe aortic valve disease, less sinotubular and mid-ascending aortic dilation, more severe LV remodeling.


Assuntos
Estenose da Valva Aórtica/diagnóstico por imagem , Valva Aórtica/anormalidades , Doenças Assintomáticas , Doenças das Valvas Cardíacas/diagnóstico por imagem , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Doenças da Aorta/diagnóstico por imagem , Doenças da Aorta/epidemiologia , Doenças da Aorta/fisiopatologia , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/fisiopatologia , Estenose da Valva Aórtica/complicações , Estenose da Valva Aórtica/epidemiologia , Estenose da Valva Aórtica/fisiopatologia , Estudos de Casos e Controles , Causas de Morte , Dilatação Patológica/diagnóstico por imagem , Dilatação Patológica/epidemiologia , Dilatação Patológica/fisiopatologia , Ecocardiografia , Feminino , Doenças das Valvas Cardíacas/complicações , Doenças das Valvas Cardíacas/epidemiologia , Doenças das Valvas Cardíacas/fisiopatologia , Implante de Prótese de Valva Cardíaca/estatística & dados numéricos , Humanos , Hipertrofia Ventricular Esquerda/diagnóstico por imagem , Hipertrofia Ventricular Esquerda/epidemiologia , Hipertrofia Ventricular Esquerda/fisiopatologia , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Mortalidade , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de Doença , Volume Sistólico
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