Asymptomatic Aortic Regurgitation Research Articles

Left Ventricular Mechanics in Asymptomatic Normotensive and Hypertensive Patients with Aortic Regurgitation

The aims of this study were to detect subclinical left ventricular (LV) dysfunction and to determine the impact of arterial hypertension on LV systolic function using speckle-tracking echocardiography in patients with chronic aortic regurgitation (AR). Sixty-eight patients with AR and 47 healthy controls were included in the study. LV rotation and longitudinal, radial, and circumferential strain were measured using speckle-tracking imaging. Longitudinal axis dysfunction was found in patients with moderate AR with hypertension but was not present in patients with moderate AR without hypertension. Radial strain in patients with moderate AR was unchanged, but reduced levels were noted at the apical level in patients with severe AR without hypertension and preserved in those with severe hypertensive AR. LV basal rotation was reduced in patients with severe AR, whereas apical rotation was increased in those with moderate AR. LV torsion was reduced in patients with severe AR. Patients with asymptomatic AR show subclinical LV longitudinal axis dysfunction, with moreattenuation demonstrated in hypertensive than in normotensive patients.

Subclinical Left Ventricular Dysfunction in Asymptomatic Severe Aortic Regurgitation Patients with Normal Ejection Fraction: A Combined Tissue Doppler and Velocity Vector Imaging Study

Our aim was to evaluate subclinical left ventricular (LV) dysfunction, by two novel echocardiographic techniques, velocity vector imaging (VVI)-derived strain imaging and tissue Doppler imaging (TDI), in patients with asymptomatic, severe aortic regurgitation (AR). Forty patients with severe AR with normal ejection fraction and 30 controls were included to the study. All patients underwent a standard echocardiography extended with TDI and VVI analyses. To evaluate the LV longitudinal and circumferential deformation, segmental systolic peak strain and strain rate (SRs) data were acquired from parasternal short axis, apical four-chamber, two-chamber, and long axis views, and additionally LV myocardial velocities, isovolumic myocardial acceleration (IVA), peak systolic velocity (Sa) and peak myocardial velocity during isovolumic contraction (IVV) assessed by TDI. IVA was the only TDI-derived parameter which was significantly impaired in AR patients (P = 0.0001). Both longitudinal and circumferential strain and SRs of the LV were significantly decreased in patients with severe AR (P = 0.0001). Longitudinal and circumferential strain/SRs and TDI-derived LV IVA were inversely correlated with LV end-diastolic diameter (P = 0.0001) and end-systolic diameter (P = 0.0001). TDI-derived IVA was also very well correlated with longitudinal deformation parameters (P = 0.0001). VVI- derived strain imaging and TDI-derived IVA may be used as adjunctive, reliable, noninvasive parameters for evaluating subclinical ventricular dysfunction in patients with chronic, severe AR. This may help to identify patients for closer follow-up and to determine the need for surgery before developing irreversible, severe heart failure.

Survival Benefit of Aortic Valve Replacement in Older Patients With Asymptomatic Chronic Severe Aortic Regurgitation

According to American College of Cardiology/American Heart Association guidelines, isolated aortic valve replacement (AVR) is a class III indication for patients with asymptomatic chronic severe aortic regurgitation (AR), left ventricular (LV) ejection fraction (EF) greater than 50%, LV end-diastolic dimension less than 70 mm, and LV end-systolic dimension less than 50 mm. We screened our echocardiographic database for all chronic severe AR patients between 1993 and 2007. Chart reviews were performed to collect clinical, demographic, and pharmacological data. Mortality was analyzed as a function of AVR. In all, 123 patients were found to have chronic severe asymptomatic AR; they had a mean age of 60 +/- 17 years and mean LVEF of 60% +/- 15%. A subgroup of 79 patients was found to have asymptomatic severe AR with an LVEF greater than 50%, LV end-diastolic dimension less than 70 mm, and LV end-systolic dimension less than 50 mm. By Kaplan-Meier analysis, patients not undergoing AVR had 1-, 5-, and 10-year survival rates of 86%, 71%, and 46%, respectively, compared with 100%, 94%, and 94%, respectively, for patients who underwent AVR (p = 0.004). Aortic valve replacement remained an independent predictor of increased survival after adjusting for group differences and univariate predictors of mortality. The benefit of AVR was further supported by propensity score analysis. Despite serving as a class III indication, AVR is independently associated with increased survival among patients with severe asymptomatic AR, LVEF greater than 50%, LV end-diastolic dimension less than 70 mm, and LV end-systolic dimension less than 50 mm.

Treatment of Systolic Hypertension and Severe Asymptomatic Aortic Regurgitation

Treatment of Systolic Hypertension and Severe Asymptomatic Aortic Regurgitation

Ventricular Long-Axis Contraction as an Earlier Predictor of Outcome in Asymptomatic Aortic Regurgitation

The long-term prognostic significance of left ventricular (LV) long-axis contraction was investigated prospectively in 65 consecutive patients aged 58+/-15 years with asymptomatic aortic regurgitation, normal LV ejection fraction at rest, and no coronary artery or aortic root disease. A complete transthoracic echocardiographic study was performed at baseline and 12 months later. In 24 of 65 patients with peak systolic wave velocity at the lateral mitral annulus (LatS)<9 cm/s, LV diameter (p<0.01), volume (p<or=0.01), mass (p<0.001), and end-systolic wall stress (p<0.001) significantly increased after 12 months, whereas LV shortening and ejection fraction (p=0.001) and tissue Doppler right ventricular peak systolic wave velocity (p<0.05) decreased significantly. In patients with peak systolic wave velocity at the lateral mitral annulus>or=9 cm/s, none of these parameters was significantly affected during follow-up. Aortic valve replacement was performed in 6 of 24 patients (25%) with peak systolic wave velocity at the lateral mitral annulus<9 cm/s and none with peak systolic wave velocity at the lateral mitral annulus>or=9 cm/s. In patients with peak systolic wave velocity at the lateral mitral annulus<9 cm/s, a cut-off value of 6.25 cm/s predicted aortic valve replacement within the next year with 97% sensitivity and 83% specificity. In conclusion, ventricular long-axis contraction seems to be a reliable indicator for outcome prediction in patients with asymptomatic aortic regurgitation.

1037 Evaluation of ventricular long axis contraction for outcome prediction in asymptomatic aortic regurgitation. A prospective 12-month follow-up study

1037 Evaluation of ventricular long axis contraction for outcome prediction in asymptomatic aortic regurgitation. A prospective 12-month follow-up study

Kontrastní zátěžová echokardiografie u asymptomatické chronické významné aortální regurgitace

Kontrastní zátěžová echokardiografie u asymptomatické chronické významné aortální regurgitace

The Role of Left Ventricular Long-axis Contraction in Patients with Asymptomatic Aortic Regurgitation

We aimed to investigate the role of long axis contraction in patients with asymptomatic chronic aorta regurgitation (AR). In 84 consecutive patients (48 men, mean age 55.5 +/- 13.5 years) tissue Doppler imaging was performed. During catheterization, left ventricular end-diastolic pressure (LVEDP) and end-diastolic wall stress (EDWS) were calculated. The best predictor for group membership (exercise ejection fraction increase > or < of 5%) is the systolic wave maximal velocity (Sv) at the lateral mitral annulus (9 cm/s). Patients with Sv > 9 cm/s (45 patients) formed group I, while 39 patients with Sv < 9 cm/s formed group II. LVEDP and EDWS were higher in group II (15.5 +/- 1.9 mm Hg and 214.8 +/- 233.3 g/cm2) than in group I (10.3 +/- 1.7 mmHg and 111.8 +/- 40.8 g/cm2), P = .0001 and P = .01, respectively. In patients with asymptomatic AR, the estimation of left ventricular long axis contraction at rest, can unmask a subnormal left ventricular functional status.

509 The role of left ventricular long axis contraction in patients with asymptomatic aortic regurgitation

509 The role of left ventricular long axis contraction in patients with asymptomatic aortic regurgitation

International Society for Heart and Lung Transplantation: Practice guidelines for management of heart failure in children

Heart failure (HF) in the United States is well recognized as a major public health problem, with over 900,000 hospital admissions annually in the United States, and greater than 250,000 deaths per year. The great majority of heart failure occurs in adults. In children, the scope of the problem is less well defined, but recent data from the Pediatric Cardiomyopathy Registry suggest an annual incidence of 1.13 cases of cardiomyopathy per 100,000 children. 1 While some of this represents asymptomatic disease, the burden of disease overall is nonetheless quite high. In the Pediatric Cardiomyopathy Registry, the majority of children with cardiomyopathy also had HF, with mortality rates of 13.6% at 2 years in dilated forms of cardiomyopathy. The etiology of heart failure differs greatly between children and adults. Children in the Pediatric Cardiomyopathy Registry had a recognizable syndrome or genetic diagnosis in 27% of cases, with an additional 5% of cases due to myocarditis. Furthermore, a large percentage of children with end-stage HF (between 25% and 75%, depending upon the age group) have an underlying diagnosis of congenital heart disease. 2 In contrast to adult patients, ischemic heart disease is rare in children. There is a large, and rapidly growing literature addressing HF treatment for adult patients, with a much smaller literature concerning HF therapy in children. Excellent guidelines for adult patients have recently been published, but given the significant differences between adult and pediatric patients with HF, there is little reason to believe that these guidelines are directly applicable to children. 3 Accordingly, in this document we have attempted to summarize the relevant literature and synthesize management guidelines for children with HF. The document that follows has been prepared in a consensus fashion, with input from pediatric cardiologists at multiple sites throughout the United States and Canada.

Elevated B-type natriuretic peptide in asymptomatic men with chronic aortic regurgitation and preserved left ventricular systolic function

Serum B-type natriuretic peptide (BNP) levels reflect myocardial strain and are known to be elevated in patients with heart failure. To determine if BNP levels are elevated in patients with aortic regurgitation, we measured BNP levels in patients with chronic asymptomatic aortic regurgitation and normal left ventricular systolic function.

Vasodilation with felodipine in chronic asymptomatic aortic regurgitation

Background Afterload reduction decreases volume overload on the left ventricle and may thereby delay the need for valve replacement in chronic asymptomatic aortic regurgitation. The aims of this randomized double-blind, placebo-controlled trial to were examine short- and long-term hemodynamic effects of felodipine in chronic asymptomatic aortic regurgitation. Methods Sixteen patients were randomly assigned to an intravenous infusion of either felodipine 0.3 mg or placebo followed by 3 months' treatment with felodipine 10 mg or placebo orally once daily. Magnetic resonance imaging was performed at baseline, immediately after intravenous treatment, and after 3 months of oral treatment. Results Intravenous felodipine caused a statistically significant reduction in the systemic vascular resistance from (mean ± SD) 1160 ± 400 to 970 ± 320 dynes · s · cm −5 ( P < .05), in the regurgitant volume index from 1.5 ± 0.8 to 1.3 ± 0.8 L · min −1. m −2 ( P < .05) and in the regurgitant fraction from 0.31 ± 0.15 to 0.26 ± 0.14 ( P < .05). The forward cardiac output index increased significant from 3.2 ± 0.9 to 3.5 ± 0.7 L · min −1 ·m −2 ( P < .05). Three months of oral treatment with felodipine caused a corresponding but more pronounced decrease in systemic vascular resistance of 880 ± 330 dynes · s · cm −5 ( P < .05), regurgitant volume index of 1.2 ± 0.7 L · min −1 · m −2 ( P < .05), and regurgitant fraction 0.25 ± 0.11 ( P < .05), whereas the forward cardiac output index increased to 3.6 ± 0.7 l · min −1 · m −2 ( P < .05). No significant changes were found in the placebo group. Left ventricular volumes and ejection fraction remained unaffected by treatment, but compared with the placebo group left ventricular myocardial mass decreased significantly from 137 ± 24 to 132 ± 21 g · m −2 ( P < .01). Conclusion In chronic asymptomatic aortic regurgitation, felodipine causes beneficial hemodynamic effects that may postpone the need for valve replacement.

Beneficial effects of 1-year captopril therapy in children with chronic aortic regurgitation who have no symptoms

Objective This prospective study was performed to assess the effects of 1 year of angiotensin-converting enzyme inhibition with captopril in 20 children (mean age 14.3 ± 2.3 years) with asymptomatic chronic aortic regurgitation. Methods and Results At 12 months patients receiving captopril had a significant reduction in left ventricular end-diastolic and end-systolic dimensions (57 ± 9.3 vs 51 ± 9.5 mm, p < 0.001; 35.4 ± 6.1 vs 32 ± 6.8 mm, p < 0.001), end-diastolic and end-systolic volume indexes (111 ± 36 vs 94 ± 29 ml/m 2, p < 0.001; 35 ± 13 vs 30 ± 12 ml/m 2, p < 0.001, respectively), and mass index (138 ± 37 vs 109 ± 32 gm/m 2, p < 0.0001) determined by two-dimensional echocardiography. Meridian ( p < 0.01) and circumferential ( p < 0.0001) wall stresses also decreased significantly with therapy. Significant reduction (27.8%, p < 0.0001) was achieved in regurgitant fraction with captopril. Conclusions These data show that the long-term therapy with angiotensin-converting enzyme inhibitors is able to reverse left ventricular dilation and hypertrophy and suggest that such therapy has the potential to favorably influence the natural history of the disease in children. (Am Heart J 1998;135:598-603.)

Combined rest and exercise electrocardiographic repolarization findings in relation to structural and functional abnormalities in asymptomatic aortic regurgitation

The relationship of combined rest and exercise electrocardiographic (ECG) repolarization abnormalities to left ventricular geometry and function was examined in 48 patients with asymptomatic chronic pure aortic regurgitation and no recent use of digitalis. Echocardiographic and radionuclide cineangiographic findings were compared in groups defined by the presence or absence of the “strain” pattern of repolarization abnormality on the resting ECG and also by the presence or absence of standard positive repolarization changes during upright treadmill exercise (>0.1 mV additional horizontal or downsloping ST depression). These hierarchic groups demonstrated trends toward progressively abnormal left ventricular dimensions, mass, wall stress, and change in ejection fraction with exercise. Although the presence of the strain pattern on the resting ECG alone was most strongly correlated with underlying functional and geometric abnormalities, an abnormal exercise test response was independently associated with abnormal left ventricular systolic dimension. The large group of patients with no symptomes and normal resting repolarization had only 0% to 4% prevalences of markedly increased systolic dimension (>55 mm), reduced ejection fraction at rest (<45%), or reduced ejection fraction during exercise (<40%), whereas the small group of patients with abnormal resting repolarization and a positive exercise test response had 50% to 83% prevalences of these findings. These data suggest a possible role for rest and exercise ECG in the serial evaluation of patients with aortic regurgitation.

Clinical outcome of severe asymptomatic chronic aortic regurgitation: A long-term prospective follow-up study

One hundred one patients with asymptomatic chronic severe aortic regurgitation and normal ejection fraction were monitored for up to 10 years (mean 55.4 ± 33.5 months). Predefined surgical indications were the development of cardiac symptoms or the documentation of impaired basal left ventricular function. During the follow-up period there were no cardiac deaths; 14 patients needed surgery, 8 because of development of symptoms and 6 because of left ventricular impairment. The risk of surgery was 12% at 5 years and 24% at 10 years. Baseline end-systolic diameter >50 mm and radionuclide ejection fraction <60% were independent predictors or either cardiac symptoms or left ventricular dysfunction. In patients needing surgery, a pattern of progressive left ventricular dilatation was demonstrated. There were no deaths during surgery, and echocardiographic and radionuclide parameters normalized in the first year of follow-up. Our data confirm that the prognosis of severe aortic regurgitation in patients with no symptoms is good and that the occurrence of asymptomatic left ventricular dysfunction is an uncommon event. Surgery can be safely postponed until the appearance of cardiac symptoms or the documentation of left ventricular dysfunction at rest.

Asymptomatic Aortic Regurgitation: Indications for Operation

Left ventricular (LV) systolic function is an important determinant of long-term prognosis in patients with chronic aortic regurgitation. In patients undergoing aortic valve replacement (AVR), those with preoperative LV dysfunction have a greater risk of postoperative congestive heart failure and death than do those in whom preoperative LV systolic function is normal. Patients with preoperative LV dysfunction are not a homogeneous group, however, but may be further stratified according to risk on the basis of the severity of symptoms, exercise intolerance, and temporal duration of LV dysfunction. Hence, asymptomatic patients with reproducible and definite evidence of impaired LV function should undergo operation without waiting for the development of symptoms or more severe LV dysfunction. Among asymptomatic patients with normal LV systolic function (normal ejection fraction and fractional shortening), the prognosis is excellent with only a gradual rate of deterioration during conservative, nonoperative management. The long-term follow-up experience of such patients indicates that the annual mortality rate is less than 0.5% and that less than 4% per year require AVR because symptoms or LV dysfunction at rest develop. Patients likely to require operation over a 10-year period because symptoms or LV dysfunction develop can be identified on the basis of age, severity of LV dilatation by echocardiography, and progressive change in LV dimensions or resting ejection fraction during the course of serial follow-up studies. Patients at risk of sudden death before surgery is performed may be identified by extreme LV dilatation (diastolic dimension > 80 mm, systolic dimension > 55 mm).(ABSTRACT TRUNCATED AT 250 WORDS)

Usefulness of left ventricular wall stress at rest and after exercise for outcome prediction in asymptomatic aortic regurgitation

Sensitive indexes for detection of left ventricular (LV) systolic performance are necessary for optimal clinical management of asymptomatic patients with aortic regurgitation (AR). To investigate the prognostic value of noninvasively determined baseline LV wall stress, we studied 10 asymptomatic patients with AR who had normal LV systolic function on two-dimensional directed M-mode echocardiography at rest and after maximal treadmill exercise. At follow-up (mean 3.6 years) three patients (group A) had progressed to decompensated LV volume overload or death related to aortic valve disease (one cardiac death and two aortic valve replacements), and seven patients (group B) remained unchanged clinically and on serial echocardiographic study. Although baseline LV chamber dimensions and systolic performance at rest were similar in the two groups of patients, LV fractional shortening after exercise and LV wall stress at rest and after exercise were significantly different ( p = 0.02). Noninvasively determined baseline LV wall stress at rest and after exercise may be useful indexes for determining prognosis in asymptomatic AR.

Relation of left ventricular shape to volume and mass in patients with minimally symptomatic chronic aortic regurgitation

In 19 male patients with significant but minimally symptomatic or asymptomatic chronic aortic regurgitation, measurements of left ventricular shape, volume, and mass were assessed by cross-sectional echocardiography. End-diastolic volume and mass were significantly larger than normal values. There was a significant negative correlation between the volume-to-mass ratio ( V M ) and both the end-diastolic ( r = −0.70, p < 0.01) and end-systolic ( r = −0.73, p < 0.001) long axis-to-minor diameter ratios ( L D ), suggesting that maintenance of the normal geometry of the left ventricle is in part dependent on the adequacy of hypertrophy, as expressed by a normal V M . Since preoperative volume-to-mass indices have been shown to be important predictors of postoperative course, the L D ratio should be a useful and simple parameter to follow in asymptomatic patients.

Left ventricular response to submaximal and maximal exercise in asymptomatic aortic regurgitation

In patients with chronic aortic regurgitation the quantitative changes in loading conditions and left ventricular performance from rest to submaximal exercise have not been related to the magnitude of change observed from rest to maximal exercise. Changes in end-diastolic volume index, as a measure of preload, and measures of contractile performance (ejection fraction and the systolic blood pressure/end-systolic volume index ratio) were assessed at rest, submaximal and maximal supine bicycle exercise using radionuclide angiography in 74 patients with chronic moderate to severe aortic regurgitation. With exercise, end-diastolic volume index decreased in a stepwise manner from 166 ± 47 to 152 ± 41 to 143 ± 41 ml/m 2 at rest, submaximal and maximal exercise, respectively. For the entire group, these changes were not associated with a significant change in ejection fraction but were associated with stepwise increases in systolic blood pressure to end-systolic volume index ratio. However, when patients were divided into 3 subgroups based on an increase (group I), minimal change (group II) or a decrease (group III) in ejection fraction from rest to maximal exercise, stepwise increases in systolic blood pressure to endsystolic volume index were again observed in groups I and II but not in group III. These changes were significantly greater in group I than in group II at submaximal and maximal exercise levels. Differences in ejection fraction response and end-diastolic and end-systolic volumes with exercise in the 3 groups were evident at the submaximal exercise level. These data suggest that the stepwise changes in left ventricular volumes and performance that occur during submaximal exertion are smaller but directionally similar to changes at maximal exertion. Conversely, the findings at maximal exertion may be used to infer the response of the left ventricle at submaximal exertion during activities of daily living.

Echocardiographic analysis of left ventricular filling in isolated pure chronic aortic regurgitation

Left ventricular (LV) diastolic filling was assessed using digitized M-mode echocardiography in 12 patients with aortic regurgitation (AR) and in 12 normal subjects. Ten patients with AR were asymptomatic and 2 patients had congestive heart failure. LV chamber dimensions, fractional shortening and the rate of change of LV dimensions during systole and diastole were determined. In addition, the timing of the rate of change of LV dimensions in diastole (peak dD dt , 50% peak dD dt and 20% peak dD dt ) was also measured. Patients with AR had a significant reduction in dD dt (12.2 ± 3.5 cm/s in patients with AR vs 15.9 ± 1.9 cm/s in normal subjects, p < 0.01) and a delay in the timing of peak dD dt (160 ± 35.2 ms in patients with AR vs 86 ± 17.6 ms in normal subjects, p < 0.01) from the minimum LV dimension. These diastolic abnormalities were present in patients with symptomatic as well as those with asymptomatic AR, occurred even when the fractional shortening and peak systolic emptying rate (peak dD dt ) were normal, and showed no correlation with the calculated LV mass (r = 0.14). The delay in the diastolic filling velocities (peak dD dt , 50% and 20% peak dD dt ) was associated with a decreased rate of change of LV dimension in diastole, suggesting delayed early LV filling. These findings indicate an abnormality of LV diastolic filling in patients with symptomatic as well as asymptomatic AR and suggest that diastolic abnormalities may precede echocardiographic indexes of systolic LV dysfunction.