Proposing the ValvUS approach: integrating bedside tests and ultrasonography for severe valvular heart disease diagnosis

Sexual activity is an important component of patient and partner quality of life for men and women with cardiovascular disease (CVD), including many elderly patients.1 Decreased sexual activity and function are common in patients with CVD and are often interrelated to anxiety and depression.2,3 The intent of this American Heart Association Scientific Statement is to synthesize and summarize data relevant to sexual activity and heart disease in order to provide recommendations and foster physician and other healthcare professional communication with patients about sexual activity. Recommendations in this document are based on published studies, the Princeton Consensus Panel,4,5 the 36th Bethesda Conference,6–10 European Society of Cardiology recommendations on physical activity and sports participation for patients with CVD,11–13 practice guidelines from the American College of Cardiology/American Heart Association14–16 and other organizations,17 and the multidisciplinary expertise of the writing group. The classification of recommendations in this document are based on established ACCF/AHA criteria (Table). View this table: Table. Applying Classification of Recommendation and Level of Evidence Numerous studies have examined the cardiovascular and neuroendocrine response to sexual arousal and intercourse, with most assessing male physiological responses during heterosexual vaginal intercourse.18–24 During foreplay, systolic and diastolic systemic arterial blood pressure and heart rate increase mildly, with more modest increases occurring transiently during sexual arousal. The greatest increases occur during the 10 to 15 seconds of orgasm, with a rapid return to baseline systemic blood pressure and heart rate thereafter. Men and women have similar neuroendocrine, blood pressure, and heart rate responses to sexual activity.24,25 Studies conducted primarily in young married men showed that sexual activity with a person's usual partner is comparable to mild to moderate physical activity in the range of 3 to …

Background The prevalence of valvular heart disease is on the rise. Severe valvular diseases are generally associated with high mortality, and aortic stenosis (AS) is associated with halved survival after out-of-hospital cardiac arrest (OHCA). Despite the severity of the prognosis of valvular heart diseases, their association with the risk of OHCA is not well-elucidated. Purpose The study aimed to examine the association between valvular heart disease and OHCA. Method We conducted a study using data from the nationwide Danish Cardiac Arrest Registry. We included adult OHCA patients with presumed cardiac origin. We compared OHCA cases with and without valvular heart disease, stratified by valvular disease type (AS, aortic regurgitation (AR), mitral stenosis (MS), and mitral regurgitation (MR) or multiple valvular diseases (more than 1 concomitant type of valvular disease)). We calculated the hazard ratios of OHCA using time-varying Cox regression models fitted with a nested case-control design. For each case, we matched up to five controls based on age, sex, year of OHCA, and two comorbidities: ischemic heart disease and congestive heart failure. Results We included 43,967 OHCA cases and 219,772 controls matched from the general population. In the total case population, the median age was 72 years, 68% were male, 26% had ischemic heart disease, 21% had congestive heart failure, and 57% had cardiovascular risk factors. We identified 1862 (4.23%) cases with AS, 336 (<1%) with AR, 31 with MS (<1%), 710 with MR (1.6%), and 605 with multiple valvular diseases (1.4%). Compared with cardiac arrest cases without valvular disease, cases with valvular disease were more likely to have ischemic heart disease (e.g., AS vs controls: 6.5% vs 1.7%, p<0.001) and congestive heart failure (e.g., MR vs controls: 3.5% vs 1%, p<0,001; AS vs controls: 8.2% vs 2.8%, p<0.001). AS, MS (HR: 1.67 [95%CI: 1.12; 2.51]), MR (HR: 1.38 [95%CI: 1.27; 1.50]) and multiple valvular diseases (HR: 1.36 [95%CI: 1.24; 1.49]) were significantly associated with higher hazard of OHCA (Figure 1); the strongest association was seen for AS (HR: 1.66 [95% CI: 1.58; 1.76]) (Figure 1). AR was not significantly associated with OHCA (HR: 1.05 [95%CI: 0.94; 1.19]). Conclusion In this Danish nationwide cardiac arrest cohort, aortic stenosis, aortic regurgitation, and mitral regurgitation were associated with increased rates of OHCA. The association was strongest in aortic stenosis patients. Focus on risk factors of OHCA in patients with valvular heart disease is warranted.Figure 1

Valvular heart disease is associated with aging and the incidence is increasing as the population ages. Aortic stenosis and mitral regurgitation represent the majority of valvular disease in older adults. Severe valvular disease is associated with the development of heart failure, arrhythmia and death. Unfortunately, medical therapy is ineffective for the treatment of severe symptomatic valvular disease. As a result of advances in surgical techniques and catheter-based technologies, older adults who were once deemed ‘too old/sick’ are now being offered definitive treatment. However, the presence of comorbidities and frailty in the elderly make patient selection difficult and prediction of overall response to therapy less reliable compared with younger patients. In the elderly, goals of therapy may differ, with an emphasis placed on quality of life, functionality, maintaining independence and palliation of severe symptoms rather than increased longevity. We review the epidemiology and treatment approaches for valvular heart disease in older adults.

Introduction: In Japan, the aging population is increasing, leading to a rapid rise in elderly patients with heart failure. To determine the post-test probability of valvular heart diseases, it is crucial to understand the pre-test probability and likelihood ratio. Hypothesis: Therefore, we surveyed the prevalence of valvular diseases among elderly individuals in a large-scale echocardiographic database of echocardiology. Methods: We reviewed 4,023 patients (1,486 males and 2,537 females, 79.4±14.3 years) who underwent echocardiographic examinations at our hospital from October 2017 to September 2022. The prevalence of valvular heart diseases was calculated by dividing the number of patients with valvular diseases by the total number of patients surveyed. We analyzed the data by age, gender, and severity of valvular disease to determine the prevalence in each subgroup. Results: Among the 4,023 individuals included in the study, 2,652 elderly patients (65.9%) had valvular diseases: 808 cases of aortic stenosis (AS) (20.1%), 1,356 cases of aortic regurgitation (AR) (33.7%), 1,899 cases of mitral regurgitation (MR) (47.2%), and 52 cases of mitral stenosis (MS) (1.3%). A total of 981 individuals (24.4%) had moderate or severe valvular disease, including 225 patients of AS (5.6%), 178 patients of AR (4.4%), 560 patients of MR (13.9%), and 18 patients of MS (0.5%). In gender-specific analysis, women had a higher prevalence of valvular heart disease than men, with approximately 1.3 to 2.5 times higher incidence in average males. Conclusions: We investigated the prevalence of valvular heart disease in the elderly using a large-scale echocardiographic database and found that over 65% of elderly individuals had valvular heart disease. In particular, AS and MR had relatively high prevalence rates for moderate or severe valvular disease, highlighting the importance of screening through routine physical examinations and echocardiographic tests.

Valvular heart disease in women: the surgical perspective

Introduction: The presence of cerebral microbleeds (CMBs) has been described using MRI in patients with cardiovascular risk factors or prior stroke and could predict future cognitive dysfunction or cardiovascular mortality. CMBs are highly frequent (> 50%) in patients with infective endocarditis (IE). However, the association of CMBs and clinical factors in patients' valvular disease without IE remains unclear. Hypothesis: Valvular heart disease without IE confers a risk factor for microbleeds. Methods: We retrospectively examined data from the consecutive 96 patients ( 72 ± 9 years, 49 men) with severe valvular disease who underwent T2*-weighted brain MRI before cardiac surgery. The patients with neurological abnormalities or IE were excluded. Conventional echocardiography was performed to evaluate the left ventricular volume and valvular abnormalities. CMBs were coded by researchers blind to clinical details, who independently assessed the presence and location of CMBs using a standardized form. The study population consisted of 59 patients with severe aortic stenosis (AS) (group A) and 40 patients with severe aortic or mitral regurgitation (group B). Results: CMBs were found in 26 patients (27%), 14 (15%) had multiple CMBs. CMBs were most frequently seen in the lobar locations (69%), followed by deep or infratentorial locations (62%). No significant relationship was found between CMBs in dyslipidemia, diabetes mellitus, smoking status, anticoagulant, and antiplatelet therapy in both groups. In group A, the HAS-BLED score was higher in patients with CMBs, and the presence of CMBs was associated with hypertension (P<0.05); however, no significant differences were observed in the left ventricular mass index (LVMI), LV end-diastolic volume (LVEDV), any aortic valve severity parameters. In group B, there were significant differences in LVMI and LVEDV between patients with CMBs and those without (154 ± 40 g/m 2 vs 125 ± 32 g/m 2 , P < 0.01 ; 150 ± 39 ml vs 111 ± 38 ml, P<0.01). Conclusion: CMBs were frequently observed in severe valvular heart disease without IE. The presence of CMBs was independent of antiplatelet or anticoagulant therapy. In aortic or mitral regurgitation patients, LV remodeling may contribute to the development of CMBs.

Objective To observe the effect of levosimendan on postoperative hemodynamics in patients with severe valvular heart disease. Methods Sixty-six patients with severe valvular disease in Xinjiang Cardiovascular and Cerebrovascular Disease Hospital from April 2016 to December 2017 were enrolled. They were randomly divided into levosimendan group (n=33) to receive levosimendan and control group (n=33) to receive routine treatment with dopamine or dobutamine. The hemodynamic parameters were measured immediately and at 12, 24, 48 and 72 h after the surgery. Cardiac troponin I, creatine kinase MB and N-terminal pro brain natriuretic peptide were measured before and at 1, 3, 7 d after the operation. All adverse events were recorded. Results Compared with the parameters of the control group, the systemic vascular resistance index, central venous pressure, extra vascular lung water index and the serum of lactic acid of the levosimendan group significantly decreased, while the every cardiac index, left ventricular stroke work index and heart index significantly increased (all P<0.05), at 24, 48 and 72 h after the surgery. The level of cardiac troponin I in 3 and 7 d (t=16.27, P=0.01; t=18.15, P=0.00) and N-terminal pro brain natriuretic peptide in 1, 3 and 7 d (t=16.27, P=0.01; t=10.18, P=0.02; t=22.21, P=0.00) significantly decreased after the surgery. The ICU retention time, ventilation time, hospitalization time and acute kidney injury were significantly reduced in levosimendan group (t=8.62, P=0.03; t=10.28, P=0.02; t=14.12, P=0.00; t=3.99, P=0.04). Conclusions Levosimendan can significantly improve the hemodynamics and cardiac function of the patients with severe valvular heart disease, reduce the incidence of postoperative adverse events. Key words: Levosimendan; Heart valve diseases; Hemodynamics; Postoperative complications

Background: Valvular heart disease and other cardiac pathologies are associated with impending heart failure. An early diagnosis of these can help prevent the disabling ad disastrous effects and improve the prognosis. Aim: The prevalence of various pathologies associated with heart failure is not known. This study helps in recognizing various pathologies that can lead to heart failure, which if diagnosed early can improve the patient’s outcome. Materials and Methods: A total of 4560 patients were included in the study. All the patients were aged greater than 15 years. Patients with suspicion of heart failure on symptoms were ordered echocardiography. Transthoracic echo was done using echocardiography ultrasound machine using the British Society of Echocardiography guidelines. Echocardiography was done by registered sonologists. Echocardiograph were later read by cardiologists. Data was collected on Excel sheet. Echocardiographic results Of 9 690 patients, were admitted to the hospital during the year 2013 to year 2017 with the suspicion of heart failure based on symptoms echocardiogram was ordered. Among these 2448 patients had normal echocardiographic findings were as 4560 had valvular disease. Among the valvular disease patients 2951(64.71%) were females and 1609(35.2%) were males. Among these 2950(64.6%) had mild valvular disease 959(21.0%) had moderate valvular disease and 651(14.2) patients had severe valvular disease. Mitral stenosis occurred in 1200(26.3%) patients, mitral regurgitation in 2953(64.7%) patients, tricuspid stenosis in 40 (0.008%)patients ,tricuspid regurgitation in 1592(34.8%) patients, aortic stenosis in 81 (0.017%) patients and aortic regurgitation in 1957(42.9%) patients. Ischemic cardiomyopathy was present in 24 patients, dilated cardiomyopathy in 14 patients, rheumatic heart disease in 23 patients, ventricular septum defect in 5 patients ,Atrial septum defect in 2 patients , Apical aneurysm formation in 4 patients, Uremic cardiomyopathy on 3 patients, Grade 1 diastolic dysfunction in 2200 patients, Grade 3 diastolic dysfunction in 400 patients, Bicuspid aortic valve in 5 patients and restrictive cardiomyopathy in two patients, 1100 patients had a thin rim of pericardial effusion and were ordered Thyroid function tests. Conclusion: In the community heart failure is a common cause of death. Various pathologies of the heart are predictors of the outcome and hence early diagnosis can help in proper treatment and increased survival

The severity of stenosis or regurgitation, the presence of symptoms and the consequences on the left ventricle are the main drivers of decision-making for the management of valvular diseases in...

Background Delayed diagnosis of valvular heart disease carries a poor prognosis, and early identification is desirable. We undertook a retrospective analysis of echocardiographic and electronic health care record data from the largest single cardiovascular service in the UK, to identify the burden of acute presentations with previously undiagnosed valvular heart disease and to determine the geographical and demographic distribution. Methods and Results Automated text mining analysis was retrospectively applied to all echocardiographic examinations performed between 2015 and 2019 at Bart’s Health NHS trust, identifying 2043 reports containing text or numerical data indicating severe valvular lesions. Demographic and clinical data was integrated with the echocardiographic dataset, identifying the postcode and GP practices for with the highest proportion of patients with severe valvular disease that were diagnosed during acute inpatient admissions. 376 individuals had severe valvular lesions identified during acute admission, of which 269 (72%) had no previously documented echocardiogram. A cluster of 11 GP practices (9%, 11 of 117 practices) were identified as having a higher proportion of diagnoses of severe valvular disease on acute admissions [figure 1]. These 11 were plotted geographically, alongside correlating postcodes, to identify geographical hotspots [figure 2]. Analyses were undertaken using Matlab, R and ggplot2. Conclusions A geographical cluster of GP practices, centred around a single hospital, had a higher proportion of patients diagnosed with severe valvular disease during acute admissions without a previous echocardiogram. Outreach echocardiography provision in these regions could potentially identify patients with valvular disease before acute decompensation. Further work should focus on improving methodology to identify cases and investigating risk factors that predispose to diagnosis of severe valvular disease in extremis. Conflict of Interest none

Echocardiographic Detection of Heart Valve Disease in a Community Cohort Study of Asymptomatic Australians &gt;65 years With Cardiovascular Risk Factors

BackgroundData on the prevalence of valvular heart disease in very old individuals are scarce and based mostly on in-hospital series. In addition, the potential detrimental effect of valvular heart disease on the activities of daily living is unknown. The present study evaluated the prevalence of significant valvular heart disease and the impact of valvular heart disease on the activities of daily living in community dwelling nonagenarians. Nested within the Leiden 85-plus study, a population based follow-up study of the oldest old, a sample of 81 nonagenarians was recruited.MethodsThe left ventricular (LV) dimensions, function and the presence and severity of heart valvular disease were evaluated by echocardiography. Significant valvular heart disease included any mitral or aortic stenosis severity, moderate or severe mitral regurgitation, moderate or severe aortic regurgitation and moderate or severe tricuspid regurgitation. Activities of daily living were assessed using the Groningen Activity Restriction Scale (GARS).ResultsLV cavity diameters (end-diastolic diameter 47 ± 8 mm, end-systolic diameter 30 ± 8 mm) and systolic LV function (LV ejection fraction 66 ± 13%) were within normal for the majority of the participants. Significant valvular disease was present in 57 (70%) individuals, with mitral regurgitation and aortic regurgitation as the most frequent valve diseases (49% and 28% respectively). The GARS score between individuals with and without significant valvular heart disease was similar (36.2 ± 9.2 vs. 34.4 ± 13.2, p = 0.5).ConclusionsNonagenarian, outpatient individuals have a high prevalence of significant valvular heart disease. However, no relation was observed between the presence of significant valvular heart disease and the ability to perform activities of daily living.

Funding Acknowledgements Type of funding sources: None. Patients with cardiovascular diseases are at higher risk of Coronavirus disease 2019 (COVID-19) complications. The data if post-COVID-19 patients are more susceptible to postoperative cardiac surgery complications are scarce. There are limited pieces of information on the possible consequences for patients with severe valvular disease undergoing valvular cardiac surgery. The study aimed to assess the impact of COVID-19 on patients with severe valvular disease and its postoperative course and outcomes. Methods We retrospectively identified 34 severe valvular disease patients indicated for surgery that underwent cardiac valvular surgery post-COVID-19. Adverse cardiovascular events in post-COVID-19 (heart failure (HF) and paroxysmal atrial fibrillation (AF) were recorded. All patients underwent control echocardiography preoperatively to assess changes in ejection fraction (EF), right ventricular systolic pressure (RVSP), and diastolic filling (E/e’). The patients were also followed for the postoperative course and hospital outcomes. All these data were compared to a historical cohort of 94 non-COVID-19 patients. Results There were no differences in mean age in post-COVID 65.2±11.6 vs. non-COVID-19 group 63.9±11.7, p = 0.57 or sex 74.6% vs. 70.7% of males, p = 0.38 or BMI 28.9± 4.5 vs. 28.2 ± 3.9, p = 0.42, with borderline significance in Euroscore 3 ± 4 vs. 1.6 ± 1.8, p = 0.05. retrospectively. Post-COVID-19 patients had a significantly higher prevalence of symptomatic HF 43.3% vs. 21.4%, p = 0.03, and AF 37.1% vs. 17%, p = 0.02 on admission. There were no significant differences between post-COVID-19 and COVID-19 in EF 56.9 ± 10.2 vs. 53.5 ± 12.6, p = 0.2, RVSP 38.1 ± 13.1 vs. 44.9 ± 12.8, p = 0.1 or E/e’ 13.8 ± 4.4 vs. 56.9 ± 10.2, p = 0.9. There were no significant differences in postoperative outcomes when post-COVID-19 group was compared to the non-COVID-19 group, the incidence of pneumonia was 8.6 vs. 6.9, p = 0.7, sepsis 2.9 vs. 4.3, p = 0.58, stroke 0% vs. 6.4%, p = 0.14, acute kidney failure 2.9 vs. 1.1, p = 0.47, postoperative acute MI 2.9% vs. 0%, p = 0.1, and mortality 0% vs. 1.1%, p = 0.5, retrospectively. There was a significantly higher incidence of transfusion in the post-COVID-19 group 77.1% vs. 41.5%, p &amp;lt; 0.01. Hospital stay for post-COVID-19 patients was 8.8 ± 4.4, vs. 8.7 ± 4 days, p = 0.94, total hospital stay 13 ± 7.4, vs. 11.4 ± 4.5, p = 0.2 and ICU stay 31.4 ± 37.8, vs. 44.4 ± 32.4 hours, p = 0.13. Conclusions Patients with severe valvular heart disease after COVID-19 are prone to develop heart failure and atrial fibrillation. The post-COVID-19 period following cardiac surgery is not associated with increased postoperative complications.

Epidemiologic and clinical characteristics of Bartonella quintana and Bartonella henselae endocarditis: a study of 48 patients.

71-Year-Old Man With a New Heart Murmur