Abstract Aortic Stenosis Research Articles

Evolution of Biological Parameters in Patients with Severe Aortic Stenosis Undergoing TAVI - Results at One Month

Abstract Aortic stenosis is one of the most common valve diseases in patients over 60 years of age. Lack of prompt surgical correction by conventional valve replacement or interventional transcatheter aortic valve implantation (TAVI) increases the risk of morbidity and mortality, in the context of worsening clinical picture. Since the first interventional transcatheter valve implantation procedure in 2012 and to date, the evolution of technology and refinement of medical techniques has led to the refinement of the treatment method and thus to the improvement of the prognosis of patients with aortic stenosis undergoing TAVI after only one month.

Transcatheter aortic valve implantation with self-expandable prosthesis in the Republic of Moldova. The one year follow-up of the first ten patients

Aortic stenosis (AS) is a valvular heart disease commonly found in the elderly patients. Treatment should be initiated prompt after the diagnosis of symptomatic AS, due to its poor prognosis and a high death rate. Transcatheter aortic valve implantation (TAVI) is the elective treatment for elderly patients with AS and high surgical risk. This study aims to evaluate the preand post-TAVI echocardiographic parameters and the major adverse cardiovascular events (MACE) within the first 30 days and at 1 year, in the first 10 patients subjected to TAVI in the Republic of Moldova.

Diagnostic Work-Up of the Aortic Patient: An Integrated Approach toward the Best Therapeutic Option.

Aortic stenosis (AS) is the most common valvular heart disease. In the last decade, transcatheter aortic valve implantation (TAVI) has become the standard of care for symptomatic patients at high surgical risk. Recently, indications to TAVI have also been extended to the low surgical risk and intermediate surgical risk populations. Consequently, in this setting, some aspects acquire greater relevance: surgical risk evaluation, clinical assessment, multimodality imaging of the valve, and management of coronary artery disease. Moreover, future issues such as coronary artery re-access and valve-in-valve interventions should be considered in the valve selection process. This review aims to summarize the principal aspects of a multidimensional (multidisciplinary) and comprehensive preprocedural work-up. The Heart Team is at the center of the decision-making process of the management of aortic valve disease and bears responsibility for offering each patient a tailored approach based on an individual evaluation of technical aspects together with the risks and benefits of each modality. Considering the progressive expansion in TAVI indication and technological progress, the role of a work-up and multidisciplinary Heart Team will be even more relevant.

Moderate gradient severe aortic stenosis: diagnosis, prognosis and therapy.

Aortic stenosis (AS) is defined as severe in the presence of: mean gradient ≥40 mmHg, peak aortic velocity ≥4 m/s, and aortic valve area (AVA) ≤1 cm2 (or an indexed AVA ≤0.6 cm2/m2). However, up to 40% of patients have a discrepancy between gradient and AVA, i.e. AVA ≤1 cm2 (indicating severe AS) and a moderate gradient: >20 and <40 mmHg (typical of moderate stenosis). This condition is called ‘low-gradient AS’ and includes very heterogeneous clinical entities, with different pathophysiological mechanisms. The diagnostic tools needed to discriminate the different low-gradient AS phenotypes include colour-Doppler echocardiography, dobutamine stress echocardiography, computed tomography scan for the definition of the calcium score, and recently magnetic resonance imaging. The prognostic impact of low-gradient AS is heterogeneous. Classical low-flow low-gradient AS [reduced left ventricular ejection fraction (LVEF)] has the worst prognosis, followed by paradoxical low-flow low-gradient AS (preserved LVEF). Conversely, normal-flow low-gradient AS is associated with a better prognosis. The indications of the guidelines recommend surgical or percutaneous treatment, depending on the risk and comorbidities of the individual patient, both for patients with classic low-flow low-gradient AS and for those with paradoxical low-flow low-gradient AS.

Aortic stiffness in degenerative aortic stenosis

Aortic stenosis (AS) is one of the most common cardiovascular diseases. The prevalence of AS and vascular stiffness are significantly associated with age. Elevated arterial stiffness is an independent risk factor for cardiovascular events. The pathogenetic and clinical relationship of degenerative AS and aortic stiffness is poorly known. This review reflects the current understanding of the relationship between degenerative AS and aortic stiffness. The existing evidence on the effects of surgical and endovascular correction of the defect on aortic stiffness is described. The potential predictors of AS prognosis and outcomes of valve replacement are discussed. Unresolved issues and directions for further research are clarified.

Renin-Angiotensin System Blockade in Aortic Stenosis: Implications Before and After Aortic Valve Replacement.

Aortic stenosis (AS) is a common valvular heart disease in the aging population that is characterized by a variable period of asymptomatic phase before development of symptoms and severe AS. Mortality and morbidity is substantial even after aortic valve replacement, in part related to persistent left ventricular hypertrophy, diastolic dysfunction, and heart failure. Renin‐angiotensin system (RAS) blockade therapy is associated with modulation of adverse left ventricular remodeling, reduction in myocardial hypertrophy, and fibrosis, resulting in clinical improvements in patients with congestive heart failure There are emerging data to suggest benefit of RAS blockade in patients with AS before and after AVR with regard to potentially slower progression of aortic valve calcification, left ventricular mass and survival benefit in favor of RAS blockade group before AVR, and also survival benefit in patients after AVR. We review the available data to understand the role of RAS blockade before AVR and in patients undergoing surgical AVR and transcatheter AVR. There are significant survival advantages of RAS inhibition in patients with AS undergoing surgical AVR or transcatheter AVR. On the basis of existing literature, adequately powered randomized trials are needed to evaluate the role of RAS inhibition in patients with AS.

The contemporary role of echocardiography in the assessment and management of aortic stenosis.

Aortic stenosis (AS) represents a major healthcare issue because of its ever-increasing prevalence, poor prognosis, and complex pathophysiology. Echocardiography plays a central role in providing a comprehensive morphological and hemodynamic evaluation of AS. The diagnosis of severe AS is currently based on three hemodynamic parameters including maximal jet velocity, mean pressure gradient (mPG) across the aortic valve, and aortic valve area (AVA). However, inconsistent grading of AS severity is common when the AVA is < 1.0cm2 but the mPG is < 40mmHg, also known as low-gradient AS (LGAS). Special attention should be paid to patients with symptomatic LGAS with low stroke volume and/or low ejection fraction because this entity is more difficult to diagnose and has a worse prognosis. Stress echocardiography testing plays an important role in this disease entity. Elderly patients with prohibitive comorbidities for surgical aortic valve replacement (AVR) were without procedural options until the advent of transcatheter AVR (TAVR), which has dramatically changed these circumstances. Along with computed tomography, echocardiography plays a vital role in the periprocedural assessment of the aortic valve and surrounding apparatus. This review describes the evolution of the role of echocardiography in the diagnosis and management of AS, the complexity of the aortic apparatus, and the increased need for expert use of three-dimensional echocardiography.

NEWLY DIAGNOSED AORTIC STENOSIS IN A WOMAN IN LABOR: WHAT WOULD YOU DO?

Aortic stenosis (AS) in pregnancy has high risk of maternal complications. Management during labor and delivery requires consideration of many factors including delivery method, anesthesia approach, hemodynamics, and vascular fluid shifts. A 30 year old immigrant, primagravid woman with AS

SYSTOLIC BLOOD PRESSURE POST TRANSCATHETER AORTIC VALVE REPLACEMENT PREDICTS MORTALITY

Aortic stenosis (AS) increases left ventricular (LV) afterload. Physiologically, it may be hypothesized that TAVR therapy would result in a reduction in afterload and an augmentation of systolic blood pressure (BP). We sought to determine BP outcomes post TAVR. 304 patients from our transcatheter

Medication Management of Patients Undergoing Transcatheter Aortic Valve Replacement.

Aortic stenosis (AS) is the most common form of valvular heart disease. A detailed diagnostic workup is necessary to promptly stage and classify disease severity to determine optimal management. Medical therapy and valvuloplasty are options that fail to delay or reverse disease progression. Surgical aortic valve replacement (SAVR) is curative but has significant limitations for some patient populations. A newer option, transcatheter aortic valve replacement (TAVR), has become more widely available to patients with intermediate- or high-operative risk. Periprocedural medication management is imperative for successful valve implantation and to minimize adverse events. Stroke remains one of the most common complications of TAVR and is associated with increased mortality. Thus, intra- and postprocedural antithrombotic therapy is required, although the regimen that best minimizes thromboembolic events and bleeding complications has yet to be defined. Patients undergoing TAVR with comorbid conditions requiring oral anticoagulation or individuals who develop subvalvular thromboses pose unique challenges. Antiplatelet and anticoagulant therapy should be carefully balanced. This article summarizes key literature supporting the pharmacologic management of patients receiving TAVR.

Relevance of G8 scale in referring elderly patients with aortic stenosis requiring a TAVI for a geriatric consultation.

Aortic stenosis (AS) may soon become a significant public health issue. Referring elderly suffering from aortic stenosis for a transcatheter aortic valve implantation (TAVI) versus surgical valve replacement might be difficult and requires a multidisciplinary staff. G8 is a geriatric screening scale for frailty, validated in oncogeriatry. We study sensibility and specificity of G8 used by cardiologists in comparison to a comprehensive geriatric assessment (CGA) performed by geriatrician. Prospective study, from February to July 2015, in Bordeaux university Hospital, France. Every elderly admitted for a TAVI had a G8 scale performed by cardiologist and CGA by a geriatrician in blind. Comorbidities were assessed using Cumulative Illness Rating Scale in his geriatric version (CIRS-G). CGA was abnormal if: MMSE <24/30 or GDS ≥7/15 or ADL ≤5/6 or IADL ≤7/8 or TUG ≥20 seconds or if malnutrition was noticed. G8 was abnormal if ≤14/17. We calculated sensibility, specificity, positive and negative predictive value in comparison to gold-standard CGA. 49 patients were included (55.1% women, mean age 84.8 years old). Nearly half of the patients (48.96%) had multiple comorbidities (CIRS G score >3 for at least three items excluding the cardiology item). 38 CGA were abnormal (77.55%) and 41 G8 (83.67%). G8 had a sensibility of 100% (IC 95% [0.9-1]), a specificity of 72.7% (IC 95% [0.43-0.9]), a positive predictive value of 92.6% and a negative prospective value of 100% (IC: 95%). G8 scale seems to be an efficient geriatric screening tool for frailty in elderly undergoing TAVI in comparison to CGA. Simple and useful, G8 scale could be performed by cardiologists in older patients with AS for identifying patients with a geriatric risk profile in consultation before surgery. Further studies with bigger samples are needed to confirm these results.

New treatments for symptomatic severe aortic stenosis

Aortic stenosis (AS) is the most frequent valvular heart disease in western industrialized countries. AS is caused by age related degenerative calcific disease. The mechanism is believed to be similar to that of atherosclerosis. The treatment of symptomatic AS is surgical replacement of the aortic valve. Medical treatment is often utilized in optimizing patients before surgery but has limited utility in treating symptoms. Transcatheter aortic valve replacement (TAVR) has become an established treatment for symptomatic severe AS. Careful patient selection, valve sizing, and meticulous technique result in good outcomes. Palliative management of symptomatic AS was appropriate for patients who were not candidates for aortic valve surgery. This new approach is discussed in this chapter.

Aspectos no cardiológicos de la estenosis aórtica en los más mayores. Revisión

Aortic stenosis (AS) is the most frequent valve disease in the elderly population Treatment is valve replacement either by open surgery, or in the case of patients at high surgical risk, by TAVI (Transcatheter Aortic Valve Implantation). However, almost 40% of patients who have undergone TAVI show poor health outcomes, either due to death or because their clinical status does not improved. This review examines the non-cardiac aspects of patients with AS, which may help answer three key questions in order to evaluate this condition pre-surgically: 1) Are the symptoms presented by the patient exclusively explained by the AS, or are there other factors or comorbidities that could justify or increase them?, 2) What possibilities for improvement of health status and quality of life has the patient after the valve replacement?, and 3) How can we reduce the risk of a futile valve replacement?

MANAGEMENT OF CRITICAL AORTIC STENOSIS IN PREGNANCY

Aortic stenosis (AS) is an important determinant of outcomes during pregnancy. Management must balance the risks and benefits to both the mother and fetus. A 29-year-old woman G2P1 with prior diagnosis of critical AS (a bicuspid valve diagnosed at age 4, mean gradient was 60 mmHg in 2004) was

EComment. Re: Is cardiac magnetic resonance imaging as accurate as echocardiography in the assessment of aortic valve stenosis?

Aortic stenosis (AS) is the most frequent degenerative valvular heart disease in Western countries and its prevalence increases with an ageing population [1]. Interestingly, Wong and colleagues [2] have analysed a very common clinical scenario of a 72-year old man with an incidental diagnosis of AS on routine transthoracic echocardiography to answer the question: “Is cardiac magnetic resonance (CMR) imaging as accurate as echocardiography in the assessment of aortic valve stenosis?” They selected and level-headedly examine 12 out of more than 200 papers to reach the answer and they conclude that CMR is as accurate as echocardiography in the evaluation of patients with aortic valve stenosis, and that CMR has better interand intraobserver reliability and demonstrates an advantage over echocardiography in the detection of severe AS with greater specificity and sensitivity. It must also be emphasized that dobutamine stress echocardiography may help to differentiate between severe AS and pseudo severe AS and to assess the presence of LV contractile or flow reserve, which has been associated with better prognosis in patients undergoing surgical aortic valve replacement [3]. The advent of new echocardiographic techniques, such as speckle tracking echocardiography has also enabled the detection of eventually associated early myocardial damage in the left ventricle and have a good correlations with the extent of myocardial scar assessed found at MR late gadolinium enhancement (LGE) [4]. The contrast enhanced CMR with the LGE evaluation or better still, the new technique of T1 mapping could evidence the presence of scar, replacement focal fibrosis or interstitial diffuse fibrosis that are associated with worse prognosis [5]. Overall, the final conclusion of the authors that “the final choice, however, is as likely to be influenced by the availability of magnetic resonance imaging and expertise in interpreting the results as on accuracy and reliability” clearly represent the everyday real-life scenario.

Role of Echocardiography Before Transcatheter Aortic Valve Implantation (TAVI)

Aortic stenosis (AS) is the most common primary valve disorder in the elderly with an increasing prevalence; transcatheter aortic valve implantation (TAVI) has become an accepted alternative to surgical aortic valve replacement (AVR) in the high risk or inoperable patient. Appropriate selection of patients for TAVI is crucial and requires a multidisciplinary approach including cardiothoracic surgeons, interventional cardiologists, anaesthetists, imaging experts and specialist nurses. Multimodality imaging including echocardiography, CT and MRI plays a pivotal role in the selection and planning process; however, echocardiography remains the primary imaging modality used for patient selection, intra-procedural guidance, post-procedural assessment and long-term follow-up. The contribution that contemporary transthoracic and transoesophageal echocardiography make to the selection and planning of TAVI is described in this article.

BONE METABOLISM MARKERS IN AORTIC STENOSIS AND THE ROLE OF VITAMIN D DEFICIENCY

Aortic stenosis (AS) is of the most prevalent acquired heart valve defects; the role calcium is serious in its development. One of the key mediators of calcium metabolism is vitamin D. Aim . To reveal the relation of the sufficiency of vitamin D with mineral bone density (MBD) and other biomarkers of calcification in AS patients. Material and methods. Totally, 89 patients studied, with severe AS (aortic valve flow velocity more than 4 m/s) at the age 40-76 year old. The controls were almost healthy participants, blood donors (n=31). All patients underwent 25(OH)D in serum measurement, of osteopontin, C-reactive protein and lipid profile, as bienergetic x-ray absorptiometry of lumbar spine and of proximal femur. Results. According to the data of absorptiometry, there was no osteoporosis or osteopenia in AS patients. However, the pressure gradient on aortic valve was related with MBD and T-criteria value. Vitamin D deficiency was found in 46% of patients. Content of 25(OH)D in serum of AS patients was lower and did not differ between bi- and tricuspid aortic valve patients. There was higher level of osteopontin in AS patients comparing to the controls. Decrease of 25(OH)D was associated with the decrease of osteopontin and atherogenety coefficient. There was no relation of the gradient on aortic valve and the level of vitamin D sufficiency. Conclusion . Vitamin D deficiency might impact pathogenesis of AS regardless the anatomic specifics of aortic valve. Its action probably is mediated by the regulation with proinflammatory cytokines, such as osteopontin.

Prediction of outcomes in patients with severe aortic stenosis after multiple valve surgery

Aortic stenosis (AS) occupies the first place in the list of diseases leading to valve replacement surgery. Biomarker NT-pro BNP was proved to have predictive power in people with coronary artery disease. However the relationship between NT-proBNP level and outcomes after single valve replacement and multiple valve surgery for severe AS is still controversial.

Prevalence, Treatment Eligibility and Postoperative Survival for Europeans with Aortic Stenosis

Aortic Stenosis (AS) is the most frequent valvular pathology in the developed world. Whilst much is known about its pathogenesis and treatment, a paucity of data exists on the prevalence and number of patients eligible for valve replacement.

Predictors of Left Ventricular Mass Regression Following Aortic Valve Replacement

Aortic stenosis (AS) is one of the most common valvular heart disease nowadays Independent factors affecting the postoperative outcome had been studied long time ago.