Case Of Severe Aortic Stenosis Research Articles

Prognostic role of exercise stress echocardiography in asymptomatic severe aortic stenosis

Abstract Background Guidelines recognize the role of exercise stress testing in evaluating functional capacity in patients with asymptomatic severe aortic stenosis (AS). The study aimed to identify the prognostic role of exercise stress echocardiography (ESE) in asymptomatic severe AS. Methods We enrolled 153 asymptomatic patients (70±13 years; 88 male, 57%) with severe AS, aortic valve area (AVA) <1.0 cm2, mean aortic gradient ≥ 40 mmHg, ejection fraction (EF) ≥55%. All were referred for ESE in 7 quality-controlled centers from 5 countries. Rest and ESE assessment also included global longitudinal strain (GLS) and left atrial volume index (LAVI). B-lines were assessed by LUS with the 4-site simplified scan of the third intercostal space. A 4-point ESE score was based on 4 parameters (0 for normal, 1 for abnormal), with the following pre-determined cutoffs of abnormality: ∆-maximal aortic gradient (MAG) ≥20 mmHg; GLS at peak ≤ 19%, according to receiver operating characteristics curve analysis, stress B-lines ≥2; stress LAVI ≥ 34 mL/m2. Follow-up was completed in 142/153 patients (92%). Results At rest, AVA was 0.85±0.14 cm2, maximal aortic gradient: 79±14 mmHg, and peak aortic velocity: 4.42 ± 0.41 m/s. Mean EF at rest: 63.4±5.3% During a median follow-up of 1802 days (IQ range 651-2302), 41 events occurred in 39 patients: 15 all-cause deaths, 17 acute HF, 1 stroke, 1 myocardial infarction, and 7 coronary revascularization. Patients experiencing events displayed a greater increase in MAG during peak ESE, more B-lines with exercise, greater degree of LAVI dilation with exercise and slightly lower GLS compared to those without events (Table). Increase in ESE score was associated with a significant rise (p=0.001) in event incidence from score 0 (n=0/13, 0%) to score 1 (n=2/21, 9.5%), score 2 (n=10/42, 23.8%), and ≥3 (n=27/66, 40.9%), see figure. Conclusions In asymptomatic severe AS cases with preserved LV EF, comprehensive ESE provides early marker of potential cardiac decompensation at follow-up. The composite ESE index, including MAG, GLS, LAVI, and B-lines, holds promise as a prognostic predictor.TableFigure

Frailty assessment using photographs in patients undergoing transcatheter aortic valve replacement

BackgroundWhen frailty is considered in patient selection, better outcomes are achieved in transcatheter aortic valve replacement (TAVR) procedures. This study investigated whether patient photographs could be utilized to qualitatively assess patient frailty and independently predict poor outcomes following TAVR. MethodsThis study included 1345 patients with severe aortic stenosis who underwent TAVR at the Sakakibara Heart Institute, Japan, between 2013 and 2022. Patient photographs were taken prior to the initial outpatient clinic examination or at discharge in case the patient's first visit was unplanned admission. Frailty was assessed from patient photographs using a four-point photographic frailty scale; 1 (non-frail), 2 (vulnerable), 3 (mild frail), and 4 (frail). Photographic frailty scale of 3 and 4 were defined as high. The primary endpoint was all-cause mortality following TAVR. ResultsSeven hundred ninety-six patients who had their facial photographs taken within six months before the TAVR procedure were analyzed. Patients with a higher photographic frailty scale belonged to New York Heart Association classes III/IV, and had higher Society of Thoracic Surgeons scores, higher incidence of wheelchair usage, lower hemoglobin, and smaller aortic valve areas. According to the frailty assessment, patients with a higher photographic frailty scale exhibited slower performance in the 5-m walk test, reduced hand grip strength, more severe dementia, had a higher clinical frailty scale, and lower serum albumin level. Multivariable Cox regression analysis revealed that the high photographic frailty scale was independently associated with all-cause mortality (adjusted hazard ratio 1.62, 95 % confidence interval 1.12–2.33, p = 0.010). Kaplan–Meier analysis indicated that patients with high photographic frailty scale had higher all-cause mortality rates compared to those with low scale (log-rank p = 0.011). ConclusionsPatient registration photographs can be used to obtain qualitative assessments of frailty in severe aortic stenosis cases, and such assessments can independently predict poor outcomes following TAVR.

Enhanced detection of severe aortic stenosis via artificial intelligence: a clinical cohort study

ObjectiveWe developed an artificial intelligence decision support algorithm (AI-DSA) that uses routine echocardiographic measurements to identify severe aortic stenosis (AS) phenotypes associated with high mortality.Methods631 824 individuals with 1.08 million...

Prognostic Signals From Moderate Valve Disease in Big Data: An Artefact of Digital Imaging and Communications in Medicine Structured Reporting?

Recent studies have identified an association between moderate AS and outcome. We assessed whether DICOM structured reporting (SR), which captures and inserts echocardiographic measurements and text data directly into radiological reports, may lead to misclassifying patients with severe aortic stenosis (AS) as moderate. Moderate or severe AS cases were filtered from an echocardiography dataset based on aortic valve area (AVA) <1.5 cm2, indexed AVA (AVAi) <0.85 cm2/m2, mean pressure gradient (MPG) >25 mmHg, dimensionless severity index (DSI) <0.5, or peak velocity (Vmax) >3 m/s. Data validation was conducted by verification of each parameter. Each echocardiographic parameter and definitions of AS were compared pre- and post-validation by taking differences in measurements. Misclassification rates were assessed by determining percent of cases that changed AS severity classification and impact on outcomes. Patients were followed over 4.3±1.5 years. Of 2,595 validated echocardiograms with AS, up to 36% of the echocardiographic parameters for AS criteria had >10% difference between DICOM-SR and manual validation, highest with MPG (36%) and lowest with DSI (6.5%). The validation process changed the reported degree of AS in up to 20.6% of echocardiograms with resultant changes in AS severity and its association with mortality or heart failure-related hospitalizations. In contrast to multiple quantitative metrics in DICOM-SR after manual validation, clinicians' evaluation of AS severity was unable to distinguish composite outcomes over 3 years between moderate and severe AS. The risk of composite outcomes was significantly increased when severe AS was evidenced by at least 1 echocardiographic parameter of severe AS (hazard ratio (HR) =1.24 [95% CI: 1.12-1.37], p<0.001). The greatest hazard was based on DSI only (HR=1.26 [95% CI: 1.10-1.44, p<0.001), which was higher after manual validation compared to DICOM-SR. Averaging of repeated echo measures including invalid values contributed most to erroneous data. Non-peak data in DICOM-SR led to incorrect categorization of a high proportion of patients based on AS severity definitions. Standardization of data fields, and curation to ensure that only peak values are imported from DICOM-SR data are essential.

A Case of Severe Aortic Stenosis after Aortic Valve Neocuspidization Using Autologous Pericardium (Ozaki Procedure).

A 56-year-old man with a history of left nephrectomy for Wilms' tumor on chronic hemodialysis underwent aortic valve neocuspidization using autologous pericardium (Ozaki procedure) for aortic stenosis (AS) due to a bicuspid aortic valve 6 years ago. The AS gradually progressed and a decrease in the left ventricular ejection fraction was observed. Because of this, we decided to perform reoperative aortic valve replacement using a mechanical valve. Intraoperative findings showed severe calcification at the site where the autologous pericardium was sutured to the annulus. However, the degeneration of the valve leaflets themselves was mild. While excellent mid-term results have been reported for the Ozaki procedure, the long-term results are still unclear. In this case, the annulus was severely calcified, which reduced the mobility of the leaflet. We report the first case of AS progression requiring reoperation in the long-term period after the Ozaki procedure.

A Contrast Frugal Approach to Transcatheter Aortic Valve Replacement in Chronic Kidney Disease: A Pilot Study.

Transcatheter aortic valve replacement (TAVR) is now regarded as a viable treatment option for all cases of severe aortic stenosis (AS). Acute kidney injury (AKI) is common and lowers the survival of patients after TAVR and iodine-based contrast-induced nephropathy (CIN) plays a significant adverse role in AKI. Therefore, in chronic kidney disease (CKD) patients requiring pre-operative evaluation for TAVR, the risk of CIN is of particular concern. It was a single-center study including eight CKD patients who underwent pre-operative evaluation for TAVR with minimized contrast exposure by means of pre-operative contrast-sparing evaluation and intra-operative contrast minimization. All patients had glomerular filtration rate (eGFR) calculated before TAVR and on a follow-up about one month and one year post-operatively to document the impact of this TAVR protocol on prognosis of kidney function in patients with advanced CKD. New York Heart Association (NYHA) functional classification demonstrated significant improvement of symptomatology (p = 0.0001) by one-year post-TAVR. Patients' mean AS gradient was significantly improved (p = 0.00004) after the TAVR procedure. No significant post-operative paravalvular aortic regurgitation was noted on follow up echocardiogram. eGFR data showed mean eGFR for the group was slightly better (27.38 ml/min/per 1.73 m2 BSA vs. 30.38 ml/min/per 1.73 m2 BSA) after TAVR. "Contrast frugal" approach is feasible and safe for pre-TAVR evaluation and the procedure itself. Our pilot study showed no significant paravalvular leak of the prosthetic valve following this proposed protocol. No statistically significant decrease in eGFR was noted on a one-year follow-up.

486 A Novel Cardiac Ct-Based Left Ventricular Outflow Tract Diameter Measurement Improves Concordance Between Aortic Valve Area And Gradient In Severe Low-gradient Aortic Stenosis Compared To Echocardiography

Introduction: Accurate diagnosis of severe aortic stenosis (AS) as defined by an aortic valve area (AVA) <1.0 cm2, maximal aortic valve velocity (AVmax) ≥ 4.0 m/sec, and/or mean aortic valve gradient (AVG) ≥ 40 mm Hg is critical for timely aortic valve (AV) replacement. However, in 30% cases of severe AS by the AVA criteria, the mean AVG and AVmax are lower (non-severe AS range) leading to diagnostic difficulties in these patients with severe low-gradient AS (LG-AS). This discordance may be partly explained by erroneous measurement of the left ventricular outflow tract (LVOT) diameter at the aortic annulus by transthoracic echocardiography (TTE), an integral component of AVA calculation using the echo-based continuity equation (CE).

Uncovering the treatable burden of severe aortic stenosis in the UK

ObjectiveTo estimate the population prevalence and treatable burden of severe aortic stenosis (AS) in the UK.MethodsWe adapted a contemporary model of the population profile of symptomatic and asymptomatic severe AS...

Converging rapid deployment prostheses with minimal access surgery: analysis of early outcomes

BackgroundSutureless prostheses may have added benefit when combined with minimal access surgery, although this has not been fully assessed in the literature. This study aims to provide a comparative analysis of the Perceval valve comparing median sternotomy (MS) with mini-sternotomy (MIS).MethodsA retrospective analysis of prospectively collected data was conducted for all isolated aortic valve replacement (AVR), using the Perceval valve, for severe aortic stenosis cases in the period 2014 to 2019. Patients undergoing concomitant valve or revascularisation surgery were excluded.ResultsA total of 78 patients were included: MS group 41; MIS group 37. Operatively, bypass times were comparable between MS and MIS groups (mean 89.3 vs 83.4, p = 0.307), as were aortic cross clamp times (58.4 vs 55.9, p = 0.434). There were no operative deaths or new onset post-operative neurology. MIS was a predictor of reduced stay in the intensive care unit (coef − 3.25, 95% CI [− 4.93, − 0.59], p = 0.036) and hospital stay overall (p = 0.004). Blood transfusion units were comparable as were the incidence of heart block (n = 5 vs n = 3, p = 0.429) and new onset atrial fibrillation (n = 15 vs n = 9, p = 0.250). Follow-up echocardiography found a significant improvement in effective orifice area, left ventricular dimension and volume indices, and LVEF (p > 0.05) for all patients. Multivariate analysis found mini-sternotomy to be a predictor for reduced LV diastolic volume (coef − 0.35, 95% CI [− 1.02, − 0.05], p = 0.05).ConclusionsThe combination of minimal access surgery and sutureless AVR may enhance patient recovery and provide early LV remodelling.

TRANSCATHETER AORTIC VALVE IMPLANTATION AFTER CORONARY ARTERY BYPASS GRAFT

The perioperative risk of surgical aortic valve replacement in patients with severe aortic stenosis and previous coronary artery bypass grafting (CABG) is increased. Transcatheter aortic valve implantation (TAVI) represents an alternative. We report a case of severe aortic stenosis with an indication for native aortic valve replacement in a patient with prior quadruple bypass surgery. The patient underwent implantation of a 29-mm Corevalve Evolut R aortic valve by left femoral catheterization (TAVI), under general anesthesia with surgical approach to the left scarpa. The procedure went well and the evolution was simple. TAVI after coronary artery bypass grafting is an increasingly proposed alternative procedure with excellent results in high-risk surgical patients with severe calcified aortic stenosis.

Case report of Double Valve Replacement with Coronary Artery Bypass Grafting with Supracoronary Ascending Aortic Replacement in a Single Patient - A Chimera

Double valve replacement is now-a-days a common procedure to treat diseased cardiac valves and the primary aim of prophylactic aortic replacement during concomitant valve replacement is to prevent dreadful complication like dissection, aortic rupture and even death. Although aortic surgeries are complex and have high morbidity and mortality rates, additional double valve procedure with coronary surgery can make it even worse. But for these patients, surgery remains the one and only treatment option for symptom relieve and prolongation of life. We herein present a case of severe aortic stenosis (AS) with severe aortic regurgitation (AR) with severe mitral regurgitation (MR) with coronary artery disease (CAD) and aortic aneurysm treated successfully by us at Square Hospitals; and to our best knowledge and according to the published articles, this is probably the first time, this type of combined cardiac procedure has been accomplished along with aortic surgery, in our country. We recommend that surgeons should perform bypass grafting along with aortic replacement and valve replacement surgery when indicated, without worrying that adding such a procedure will escalate post-operative adverse effect. Cardiovasc j 2021; 14(1): 82-87

Three-D measurements of LVOT: impact on quantification of aortic stenosis (AS)

Abstract Background Discrepancies between aortic valve area (AVA) and gradients are recognized in patients with AS and normal LVEF and can impact on surgical referral decisions. Purpose Pilot study to determine whether using 3D rather than 2D LVOT dimensions leads to fewer discrepancies and less patients diagnosed with severe AS by continuity equation. Methods AS was quantified as per BSE guidelines in 55 consecutive patients (M: 32, age: 73±10) with LVEF&amp;gt;50% and at least moderate AS by AVA. LVOT was imaged with 3D zoom and its two orthogonal diameters were used to calculate the LVOT area for the continuity equation. Results Severe AS was diagnosed by AVA in 24/55 (44%) patients (Table 1). By 3D measurements the LVOT eccentricity index (D1/D2) was 0.8±0.1 and the LVOT area and SVi were larger than the ones calculated by 2D measurements:3.74±0.7 cm2 vs. 3.29±0.5 cm2 and 51.4±13 ml/BSA, vs. 45.3±9 ml/BSA, respectively, p&amp;lt;0.05. 3D measurements reduced the number of severe AS cases from 24 to 18 (AVA) and from 33 to 24 (AVAi) (25% and 27% respectively, p&amp;lt;0.05). AS severity agreement for all parameters slightly improved from 34/55 (62%) to 37/55/ (67%), p: ns Conclusions 1) In this pilot study, the use of 3D-derived LVOT measurements reduced by 25% the frequency of severe AS diagnosis. 2) If these results are confirmed in larger studies, use of 3D LVOT measurements may become standard of practice. Funding Acknowledgement Type of funding source: None

In the midst of a dangerous intersection with unclear therapeutic strategies: a challenging case of severe aortic stenosis

BackgroundOne out of seven patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR) may be affected by transthyretin cardiac amyloidosis (ATTR-CA), mostly presenting with low-flow low-gradient AS with mildly reduced ejection fraction. The complex interaction of these two pathologies poses specific diagnostic and management challenges. The prognostic implications of this clinical intersection are not defined yet. Moreover, whether TAVR may have a prognostic benefit in ATTR-CA patients with symptomatic severe AS remains unclear, posing doubts on the best management strategy in this increasingly recognized subset of patients.Clinical caseWe present a case of an 87-year old man with low-flow low-gradient severe AS, for whom a diagnosis of ATTR-CA was suspected based on clinical and echocardiographic criteria specific to coexisting AS and ATTR-CA. The diagnosis was eventually confirmed by positive bone tracer scintigraphy imaging. Following in-depth Heart team discussion, integrating frailty and prognostic information from combined cardiomyopathy states, a decision was made to manage the patient’s severe AS conservatively.ConclusionIn the presented case, we deemed the natural history of ATTR-CA amyloidosis to negatively affect both the patient’ prognosis and procedural risk, adversing TAVR indication despite symptomatic severe AS. No clear evidence is currently available to guide decision making in this setting, advocating for prospective studies to clarify if TAVR may have a prognostic benefit in ATTR-CA - and which ATTR-CA - patients.

From Rapid Recommendation to Online Preference-Sensitive Decision Support: The Case of Severe Aortic Stenosis.

The launch of ‘Rapid Recommendations’ by the Grading of Recommendations Assessment, Development and Evaluation (GRADE) group, in collaboration with Making GRADE the Irresistible Choice (MAGIC) and the British Medical Journal (BMJ), is a very interesting recent development in e-healthcare. Designed to respond quickly to developments that have created new decision situations, their first project resulted from the arrival of minimally invasive Transcatheter Aortic Valve Implantation (TAVI) as an alternative to Surgical Aortic Valve Replacement (SAVR), for patients with symptomatic severe aortic stenosis. The interactive MAGIC decision aid that accompanies a Rapid Recommendation and is the main route to its clinical implementation, represents a major advance in e-health, for a cardiovascular decision in this case. However, it needs to go further in order to facilitate fully person-centred care, where the weighted preferences of the individual person are elicited at the point of decision, and transparently integrated with the best (most personalised) estimates of option performances, to produce personalised, preference-sensitive option evaluations. This can be achieved by inputting the collated GRADE evidence on the criteria relevant in the TAVI/SAVR choice into a Multi-Criteria Decision Analysis-based decision support tool, generating a personalised, preference-sensitive opinion. A demonstration version of this add-on to the MAGIC aid, divested of recommendations, is available online as proof of method.

Abstract 16797: Long-Term Incidence of Clinically Important Aortic Stenosis Among Community-Dwelling Older Adults: The Cardiovascular Health Study

Background: Subclinical aortic valve calcification is common among older adults, but the incidence and prevalence of clinically significant aortic stenosis (AS) in the general population is not well characterized. We leveraged the Cardiovascular Health Study (CHS), a population-based investigation of older adults with up to 25 years of follow up, to study AS at an epidemiologic level. Methods: We used a case capture methodology involving ICD-9 diagnosis and procedure codes and CHS echo data to ascertain probable or definite cases of AS at baseline and during longitudinal follow up. Using targeted procedure- and diagnosis-code screening, review of CHF hospitalizations and CHS echo data, along with systematic review of longitudinal hospital records, we identified CHS subjects who developed at least moderate AS, had AS-related hospitalizations, or had AS-related valve interventions. Results: There were 5888 participants in CHS (mean age 72.9, 42% male). Of these, 958 were identified for review based on screening methods. Among those with an echo at baseline (1989-1990 for the first cohort and 1994-1995 for the second cohort) and without AS at that time, there were 275 (4.7%) incident probable or definite cases of moderate or greater AS and 169 (2.9%) incident probable or definite cases of severe AS. The median time to moderate or greater AS was 11.3 (range 0.3-24.9) years following baseline echo. Among these subjects, 248 (90%) had an AS-related hospitalization, while only 98 (36%) underwent an aortic valve procedure in this largely pre-TAVR era. Sensitivity analyses were performed, showing that clinically significant AS among the non-reviewed subjects was uncommon (&lt;1%). Conclusions: To our knowledge, this is the first study to evaluate the long-term incidence of clinical AS in the general elderly U.S. population. Starting at age 65, moderate to severe AS affects about 1 in 20 individuals late in life, and is associated with high rate of morbidity leading to hospitalization.

Sudden unexpected death with primary adrenal lymphoma

An 82-year-old man was found dead on the road near his home with unwitnessed interval of 3 h from final witness. He had been diagnosed with hypertension and mild aortic stenosis (AS) 13 years before death, and was continuously followed up with medication. Although a recent medical check-up related to cardiac function was stable and consistent with moderate AS, he sometimes complained of general fatigue, anorexia associated with intermittent mild fever and rare vomiting in the weeks before death. At autopsy, no lethal injury or drug intoxication was found, but congenital bicuspid aortic valve (BAV) with central rache was found. Although calcification was found in a restricted area of one cusp, valvular structural deformity was clearly milder than in typical severe AS cases. Moderate left ventricular hypertrophy without coronary disease was found. A brownish-red, soft nodular lesion was found in both adrenal glands, but no other tumorous focus was evident in any other organs. Immunohistochemical examination showed that B-lymphocyte-derived markers (CD20, melanoma associated antigen (mutated) 1, and CD79a) were exclusively positive. Therefore, we diagnosed primary adrenal lymphoma (PAL), diffuse large B-cell lymphoma phenotype. We concluded that the cause of sudden unexpected death (SUD) was adrenal insufficiency associated with PAL, with a background of moderate AS related to BAV.

TCTAP C-221 Management of Embolized Sapien XT During TAVR

### Patient Initials or Identifier Number B076473 ### Relevant Clinical History and Physical Exam 86-year-old man complained of chest distress and dyspnea with sub ordinary activity for one year. He was a case of severe aortic stenosis with heart failure functional class III for one year and CAD

Life-saving transcatheter aortic valve replacement for a case of severe aortic stenosis after resuscitation in a patient with cardiac arrest

Life-saving transcatheter aortic valve replacement for a case of severe aortic stenosis after resuscitation in a patient with cardiac arrest

Skuteczne usunięcie przemieszczonego prowadnika z końcówką w kształcie „J” za pomocą samodzielnie skonstruowanej pętli u 75-letniego pacjenta — bezpieczna i dostępna metoda

A 8-year-old boy was referred for evaluation of ejection systolic murmur. On examination multiple xanthomas and xanthelesmas were noted. Investigations confirmed familial hypercholesterolemia and severe aortic stenosis in background of tricuspid aortic valve. We report a case of severe aortic stenosis in background of morphologically normal valve, a rare complication of heterozygous familial hypercholesterolaemia.

Role of Transesophageal Echocardiography in the Diagnosis of Paradoxical Low Flow, Low Gradient Severe Aortic Stenosis.

Background and ObjectivesPrior studies indicate that up to 35% of cases of severe aortic stenosis (AS) have paradoxical low flow, low gradient despite preserved left ventricular ejection fraction (LVEF). However, error in left ventricular outflow tract (LVOT) diameter may lead to misclassification. Herein, we determined whether measurement of LVOT diameter by transesophageal echocardiography (TEE) results in reclassification of cases to non-severe AS.Subjects and MethodsPatients with severe AS with aortic valve area (AVA) <1 cm2 by transthoracic echocardiography (TTE) within 6 months were studied. Paradoxical low flow, low gradient was defined as mean Doppler gradient (MG) <40 mm Hg and stroke volume index (SVI) ≤35 mL/m2. Preserved LVEF was defined as ≥0.50.ResultsAmong 108 patients, 12 (15%) had paradoxical low flow, low gradient severe AS despite preserved LVEF based on TTE measurement. When LVOT diameter by TEE in 2D was used, only 5 (6.3%) patients had low flow, low gradient severe AS (p<0.001). Coefficients of variability for intraobserver and interobserver measurement of LVOT were <10%. However, the limits of agreement between TTE and TEE measurement of LVOT ranged from 0.43 cm (95% confidence interval [CI]: 0.36 to 0.5) to -0.31 cm (95% CI: -0.38 to -0.23).ConclusionTEE measured LVOT diameter may result in reclassification to moderate AS in some patients due to low prevalence of true paradoxical low flow, low gradient (PLFLG) severe AS.