Presence Of Aortic Stenosis Research Articles

Elasticity Properties of Pulmonary Artery in Patients with Bicuspid Aortic Valve

Although the vascular complications of bicuspid aortic valve (BAV) disease cause significant morbidity and mortality, the role of pulmonary artery in this pathogenesis is less understood. We aimed to assess the elastic properties of pulmonary artery with echocardiography in patients with BAV. Thirty patients with BAV (26 males) were enrolled in this study. The presence of aortic stenosis was accepted as exclusion criteria. Thirty-two healthy subjects (27 males) with no any history of cardiovascular disease comprised the control group. In all patients, maximal frequency shift (MFS) and acceleration time (AcT) of the pulmonary artery flow trace were measured echocardiographically in parasternal short-axis view. Subsequently, pulmonary artery stiffness (PAS) was calculated by using the following formula PAS (kHz/sec) = MFS/AcT. There were no significant differences in baseline demographic characteristics of the study population. Aortic strain and aortic distensibility index were lower, and aortic stiffness index (SI) higher, in patients with BAV. The PAS was significantly increased in patients with BAV compared with control subjects with tricuspid aortic valve (11.08 ± 2.27 vs. 7.11 ± 1.54, P < 0.001). There was a significant correlation between aortic diameters, aortic elasticity indexes, and PAS. Multivariate linear regression analysis, the only significant independent factor affecting the PAS was SI (β = 0.547, P < 0.001). We demonstrated that elastic properties of pulmonary artery tend to be impaired as in the aorta in patients with BAV disease.

Aortic Root Disease in Athletes: Aortic Root Dilation, Anomalous Coronary Artery, Bicuspid Aortic Valve, and Marfan’s Syndrome

Two professional athletes in the U.S. National Basketball Association required surgery for aortic root dilation in 2012. These cases have attracted attention in sports medicine to the importance of aortic root disease in athletes. In addition to aortic root dilation, other forms of aortic disease include anomalous coronary artery, bicuspid aortic valve, and Marfan's syndrome. In this review, electronic database literature searches were performed using the terms "aortic root" and "athletes." The literature search produced 122 manuscripts. Of these, 22 were on aortic root dilation, 21 on anomalous coronary arteries, 12 on bicuspid aortic valves, and 8 on Marfan's syndrome. Aortic root dilation is a condition involving pathologic dilation of the aortic root, which can lead to life-threatening sequelae. Prevalence of the condition among athletes and higher risk athletes in particular sports needs to be better delineated. Normative parameters for aortic root diameter in the general population are proportionate to anthropomorphic variables, but this has not been validated for athletes at the extremes of anthropomorphic indices. Although echocardiography is the favored screening modality, computed tomography (CT) and cardiac magnetic resonance imaging (MRI) are also used for diagnosis and surgical planning. Medical management has utilized beta-blockers, with more recent use of angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), and statins. Indications for surgery are based on comorbidities, degree of dilation, and rate of progression. Management decisions for aortic root dilation in athletes are nuanced and will benefit from the development of evidence-based guidelines. Anomalous coronary artery is another form of aortic disease with relevance in athletes. Diagnosis has traditionally been through cardiac catheterization, but more recently has included evaluation with echocardiography, multislice CT, and MRI. Athletes with this condition should be restricted from participation in competitive sports, but can be cleared for participation 6 months after surgical repair. Bicuspid aortic valve is another form of aortic root disease with significance in athletes. Although echocardiography has traditionally been used for diagnosis, CT and MRI have proven more sensitive and specific. Management of bicuspid aortic valve consists of surveillance through echocardiography, medical therapy with beta-blockers and ARBs, and surgery. Guidelines for sports participation are based on the presence of aortic stenosis, aortic regurgitation, and aortic root dilation. Marfan's syndrome is a genetic disorder with a number of cardiac manifestations including aortic root dilation, aneurysm, and dissection. Medical management involves beta-blockers and ARBs. Thresholds for surgical management differ from the general population. With regard to sports participation, the most important consideration is early detection. Athletes with the stigmata of Marfan's syndrome or with family history should be tested. Further research should determine whether more aggressive screening is warranted in sports with taller athletes. Athletes with Marfan's syndrome should be restricted from activities involving collision and heavy contact, avoid isometric exercise, and only participate in activities with low intensity, low dynamic, and low static components. In summary, many forms of aortic root disease afflict athletes and need to be appreciated by sports medicine practitioners because of their potential to lead to tragic but preventable deaths in an otherwise healthy population.

Aortic Valve Disease in Pulmonary Atresia and Major Aortopulmonary Collaterals

Aortic valve disease in association with pulmonary atresia, ventricular septal defect, and major aortopulmonary collaterals (PA/VSD/MAPCAs) is an extremely rare combination of congenital heart defects. The presence of aortic stenosis or insufficiency or both imposes an additional physiologic burden that complicates the management of PA/VSD/MAPCAs. This report summarizes our experience with 7 patients who underwent surgical repair of this rare combination of defects. This was a retrospective review of patients who had both aortic valve disease and PA/VSD/MAPCAs. Four patients had predominantly aortic stenosis, 2 patients had aortic insufficiency, and 1 had mixed stenosis and insufficiency. Anatomically, this corresponded to a dysplastic trileaflet valve in 4, bicuspid valve in 2, and quadricuspid valve in 1. Four of the 7 patients underwent aortic valve surgery at the time of their first operation for PA/VSD/MAPCAs. The remaining 3 patients had aortic valve surgery at subsequent operations. All 7 patients are alive, with a median duration of follow-up of 3 years. One patient has required aortic valve replacement 2 years after repair of an insufficient bicuspid valve. This manuscript summarizes our experience with 7 patients who had the rare combination of aortic valve disease and PA/VSD/MAPCAs. Although aortic valve disease has been reported for other conotruncal defects, we believe this is the first report of its presence in association with PA/VSD/MAPCAs.

Do Clinical Characteristics Predict the Presence of Small Bowel Angioectasias on Capsule Endoscopy?

Angioectasias (AVMs) are the most common vascular anomaly of the gastrointestinal (GI) tract, and these lesions are often associated with obscure gastrointestinal bleeding (OGIB). It is unknown if the presence of upper and/or lower gastrointestinal AVMs are predictive of small bowel AVMs. The aims of this study are to define the small bowel segmental distribution of AVMs and to identify the factors predicting the presence of small bowel AVMs among a cohort of patients with a known history of AVMs in the upper and/or lower GI tracts who are undergoing capsule endoscopy (CE) for OGIB. We performed a retrospective cohort analysis of 1,125 patients undergoing CE at our institution between 11/1/2001 and 8/31/2007. Inclusion criteria were: (1) complete esophagoduodenoscopy (EGD), CE, and colonoscopy, (2) OGIB indication for CE, and (3) history of ≥ 1 AVM on EGD and/or colonoscopy that was previously treated in the past or deemed not to be a clinically significant source of bleeding. Exclusion criteria were: (1) history of radiation therapy to the GI tract, and (2) presence of a congenital or systemic disease associated with GI AVMs. Data were extracted on: (1) age; (2) gender; (3) presence of diabetes, (4) presence of hypertension, (5) presence of aortic stenosis, (6) history of non-steroidal anti-inflammatory therapy, (7) history of anticoagulant therapy, (8) hemoglobin, platelet, and INR values prior to CE; (9) baseline serum creatinine; and (10) presence and GI tract segmental location of AVMs. Multivariate logistic regression was used to identify independent predictors of small bowel AVMs. 1,125 patients underwent EGD, CE, and colonoscopy. One hundred and fourteen patients had a history of ≥ 1 AVM on EGD and/or colonoscopy and met inclusion and exclusion criteria. The mean age was 69 years, and 63% of patients were women. 37% of patients were found to have ≥ 1 jejunal AVM and 15% were found to have ≥ 1 ileal AVM. In multivariate analysis, age ≥ 65 (OR 2.62, P = 0.05) and the presence of AVMs on EGD (OR 4.61, P = 0.02) were predictive of jejunal AVMs. AVMs on colonoscopy alone were not predictive of jejunal or ileal AVMs. No factors were found to predict the presence of ileal AVMs. Patients with AVMs on EGD have an increased risk of jejunal AVMs on CE, particularly if they are elderly. Future studies should validate these findings in a prospective cohort.

In Vitro Investigation of the Impact of Aortic Valve Stenosis Severity on Left Coronary Artery Flow

Patients with aortic valve stenosis (AS) may experience angina pectoris even if they have angiographically normal coronary arteries. Angina is associated with a marked increase in the risk of sudden death in AS patients. Only a few in vitro models describing the interaction between the left ventricular and aortic pressures, and the coronary circulation have been reported. These models were designed for specific research studies and they need to be improved or modified when other specific studies are required. Consequently, we have developed an in vitro model that is able to mimic the coronary circulation in presence of aortic stenosis. First, we have validated the model under physiological conditions. Then, we have examined and quantified the hemodynamic effects of different degrees of AS (from normal to severe AS) on the coronary flow using a model of the normal left coronary artery. In the coronary in vitro model without AS (normal valve), the amplitude and shape of coronary flow were similar to those observed in in vivo measurements obtained under physiological conditions, as described by Hozumi et al. (1998, "Noninvasive Assessment of Significant Left Anterior Descending Coronary Artery Stenosis by Coronary Flow Velocity Reserve With Transthoracic Color Doppler Echocardiography," Circulation, 97, pp. 1557-1562). The presence of an AS induced an increase in the maximum and mean coronary flow rates (97% and 73%, respectively, for a very severe AS). Furthermore, when AS was very severe, a retrograde flow occurred during systole. This study allowed us to validate our coronary in vitro model under physiological conditions, both in the absence and presence of AS. These changes could explain the fact that even if patients have angiographically normal epicardial coronary arteries, we can observe the occurrence of angina pectoris in these patients in the presence of an AS.

Hemodynamic Support Using the Impella 2.5 Catheter System during High‐Risk Percutaneous Coronary Intervention in a Patient with Severe Aortic Stenosis

The Impella 2.5 catheter is a percutaneously implanted left ventricular assist device cleared by the Food and Drug Administration to provide circulatory support for up to 6 hours. The presence of aortic stenosis is deemed to be a contraindication to its use, and ongoing clinical trials exclude patients with an aortic valve area of 1.5 cm(2) or less. We describe a case of severe aortic stenosis with an estimated valve area of 0.9 cm(2) and severe ischemic cardiomyopathy in whom the Impella catheter was successfully used for high-risk multivessel percutaneous coronary intervention.

Apicoaortic valved conduit with an apical connector for aortic stenosis with a calcified aorta

We report a case of apicoaortic bypass using an apical connector for severe aortic stenosis. A 74-year-old woman suffered from severe aortic stenosis, with a small aortic annulus and a severely calcified aorta. A valved conduit with an apical connector was placed between the left ventricular apex and the descending thoracic aorta because the risk of aortic valve replacement was high. Use of an apical connector facilitated a secure connection between the conduit and the left ventricular apex. The pressure gradient across the native aortic valve fell from 64 mm Hg before the operation to 19 mm Hg afterward. Apicoaortic bypass using the apical connector is a reliable option for relieving obstruction of the left ventricular outflow tract in the presence of aortic stenosis when aortic valve replacement is a high risk.

Correlation between plasma osteopontin levels and aortic valve calcification: Potential insights into the pathogenesis of aortic valve calcification and stenosis

The inflammatory process of aortic stenosis involves the differentiation of aortic valve myofibroblasts into osteoblasts. Osteopontin, a proinflammatory glycoprotein, both stimulates differentiation of myofibroblasts and regulates the deposition of calcium by osteoblasts. Osteopontin levels are increased in patients with such conditions as end-stage renal disease, ectopic calcification, and autoimmune disease. We hypothesized that increased plasma osteopontin levels might be associated with the presence of aortic valve calcification and stenosis. Venous blood from volunteers older than 65 years undergoing routine echocardiographic analysis or aortic valve surgery for aortic stenosis was collected. Plasma osteopontin levels were measured by means of enzyme-linked immunosorbent assay. The presence of aortic stenosis was defined as an aortic valve area of less than 2.0 cm(2). Aortic valve calcification was assessed by using a validated echocardiographic grading system (1, none; 2, mild; 3, moderate; 4, severe). Comparisons were performed with nonpaired t tests. Aortic stenosis was present in 23 patients (mean age, 78 years) and was absent in 7 patients (mean age, 72 years). Aortic valve calcification scores were 3.5 +/- 0.6 and 1.3 +/- 0.5 in patients with and without aortic stenosis, respectively (P < .001). Patients with no or mild aortic valve calcification had lower osteopontin levels compared with patients with moderate or severe aortic valve calcification (406.1 +/- 165.8 vs 629.5 +/- 227.5 ng/mL, P = .01). Similarly, patients with aortic stenosis had higher osteopontin levels compared with patients without aortic stenosis (652.2 +/- 218.7 vs 379.7 +/- 159.9 ng/mL, P < .01). Increased levels of plasma osteopontin are associated with the presence of aortic valve calcification and stenosis. These findings suggest that osteopontin might play a functional role in the pathogenesis of calcific aortic stenosis.

Aortic Valve Replacement and Concomitant Coronary Artery Bypass: Assessing the Impact of Multiple Grafts

The impact of multivessel coronary artery disease and multivessel coronary artery bypass grafting on outcomes after combined aortic valve replacement and coronary artery bypass grafting (AVR-CABG) has not been sufficiently evaluated. We retrospectively reviewed all patients who underwent AVR-CABG at our institution between January 2000 and December 2004. Patients with any previous or concomitant procedures were excluded. The Kaplan-Meier method was used to calculate survival and freedom from postoperative repeat revascularization. Predictors of mortality were determined by Cox regression analysis. The study cohort consisted of 233 AVR-CABG patients. Mean follow-up was 2.2 +/- 1.7 years with one patient lost to follow-up. Preoperative clinical characteristics were well-matched between patients who received one (n = 86), two (n = 81), or three or four (n = 66) bypass grafts. Operative mortality was 9.3%, 11.1%, and 7.6%, respectively (p = 0.76). Patients in all groups demonstrated significant improvement in New York Heart Association (NYHA) status (p < 0.01). Freedom from postoperative repeat revascularization for all patients after five years was 96.8% and did not differ among groups (p = 0.93). Five-year survival for each group was 63.6%, 72.4%, and 63.9%, respectively (p = 0.91). Emergent operation, ejection fraction less than 0.30, operative age greater than 65 years, NYHA class III/IV, and chronic obstructive pulmonary disease were significant predictors of mortality. The number of stenosed vessels, the number of bypass grafts, incomplete revascularization, and the presence of aortic stenosis or aortic insufficiency did not predict mortality. For patients undergoing AVR-CABG, the number of bypass grafts does not adversely affect survival. Rather, a patient's preoperative risk factors are a better predictor of outcome.

Aortic stenosis is associated with elevated plasma levels of asymmetric dimethylarginine (ADMA)

Objectives We tested the hypothesis that the presence of aortic stenosis (AS) is associated with elevation of plasma levels of asymmetric dimethylarginine (ADMA), a physiological inhibitor of nitric oxide synthase, a mediator and marker of endothelial dysfunction and an indicator of incremental cardiovascular risk. Background The presence of aortic sclerosis (ASC), the precursor of AS is independently associated both with endothelial dysfunction, and with incremental coronary event risk. It remains uncertain whether elevations of ADMA levels might mediate endothelial dysfunction in these conditions. Methods Forty two consecutive patients referred for echocardiography for evaluation of AS, who had calculated aortic valve areas of <1.4 cm 2 (AS group) were evaluated together with 42 consecutive age-matched referred patients (non-AS group). Plasma ADMA levels were measured by high-performance liquid chromatography (HPLC). Determinants of elevation of plasma ADMA levels were identified via stepwise multiple linear regression analysis. Results Plasma ADMA levels were not statistically different between the AS and non-AS group (median 0.59 vs 0.54 μmol/L, p = 0.13, Mann-Whitney test) on univariate analysis. However, in backward stepwise multiple linear regression, the presence of AS was a significant predictor of elevated ADMA levels ( p = 0.04, 95% CI = 0.001, 0.072). In addition, elevated plasma ADMA levels were also associated with history of atrial fibrillation ( p = 0.009, 95% CI = 0.015, 0.100), and negatively associated with creatinine clearance ( p = 0.01, 95% CI = −0.002, 0.000), and the use of statin therapy ( p = 0.01, 95% CI = −0.081, −0.011). Conclusions AS is independently associated with elevation of ADMA levels, beyond that implied by “conventional” risk factors for endothelial dysfunction. The clinical status of AS as an incremental marker of cardiovascular risk may reflect ADMA-mediated endothelial dysfunction.

Analytical modeling of the instantaneous maximal transvalvular pressure gradient in aortic stenosis

In presence of aortic stenosis, a jet is produced downstream of the aortic valve annulus during systole. The vena contracta corresponds to the location where the cross-sectional area of the flow jet is minimal. The maximal transvalvular pressure gradient (TPG max) is the difference between the static pressure in the left ventricle and that in the vena contracta. TPG max is highly time-dependent over systole and is known to depend upon the transvalvular flow rate, the effective orifice area (EOA) of the aortic valve and the cross-sectional area of the left ventricular outflow tract. However, it is still unclear how these parameters modify the TPG max waveform. We thus derived an explicit analytical model to describe the instantaneous TPG max across the aortic valve during systole. This theoretical model was validated with in vivo experiments obtained in 19 pigs with supravalvular aortic stenosis. Instantaneous TPG max was measured by catheter and its waveform was compared with the one determined from the derived equation. Our results showed a very good concordance between the measured and predicted instantaneous TPG max. Total relative error and mean absolute error were on average 9.4±4.9% and 2.1±1.1 mmHg, respectively. The analytical model proposed and validated in this study provides new insight into the behaviour of the TPG max and thus of the aortic pressure at the level of vena contracta. Because the static pressure at the coronary inlet is similar to that at the vena contracta, the proposed equation will permit to further examine the impact of aortic stenosis on coronary blood flow.

Mathematical modeling of coronary inflow in presence of aortic stenosis

Aortic stenosis (AS) is the most common heart valve disease. AS causes an obstruction to blood flow from the left ventricle (LV) to the aorta, resulting in a compensatory concentric hypertrophy of ...

Perioperative Risk of Noncardiac Surgery Associated With Aortic Stenosis

The perioperative risk of noncardiac surgery in patients with aortic stenosis (AS) remains ill-defined, and the few studies published have reported conflicting results. A sample of patients from the National Hospital Discharge Survey database diagnosed with AS who underwent any noncardiac surgical procedure was searched. Patients who underwent any cardiac surgery were excluded. Patients with AS were matched by decile of age and surgical risk for twice as many controls. A discharge diagnosis of acute myocardial infarction (AMI) and death was used as the end points for analysis. From 1996 to 2002, 5,149 patients with a diagnosis of AS had undergone noncardiac surgery and were matched with 10,284 controls. The incidence of AMI was greater in patients with AS than in controls (3.86% vs 2.03%, p <0.001). After correcting for gender and the presence of coronary artery disease, hypertension, and diabetes mellitus in a multivariate logistic regression model, the presence of AS was associated with an increased likelihood of AMI (odds ratio 1.55, 95% confidence interval 1.27 to 1.90, p <0.001). There was no significantly increased risk for death in patients with AS versus controls. In the era of more intense perioperative medical management of patients who undergo noncardiac surgery, the presence of AS increases the risk for perioperative AMI but not overall mortality. The impact of the actual severity of AS on outcomes with noncardiac surgery needs further study.

Plasma NT‐proBNP is a potential marker of disease severity and correlates with symptoms in patients with chronic rheumatic valve disease

A noninvasive marker of disease severity and presence of symptoms is required in patients with chronic rheumatic valve disease (RVD). We sought to test the utility of measuring of N-terminal pro-B type natriuretic peptide (NT-proBNP) in chronic phase RVD. We also evaluated whether echocardiographic measures are interrelated with NT-proBNP levels. The study comprised 92 patients with RVD (mean age of 40+/-14 years) and 50 age/gender-matched control subjects. Functional status was assessed. Detailed echocardiographic examination was performed and mitral valve score was estimated. Venous blood samples were taken for measuring the level of NT-proBNP. The plasma levels of NT-proBNP rose with increasing severity of mitral valve stenosis (p<0.001), increasing severity of mitral valve score (p<0.001), increasing severity of clinical symptom (p<0.001), increasing severity of mitral regurgitation (p<0.013), presence of mitral valve calcification (p<0.001), presence of tricuspid valve stenosis (p<0.001), increasing severity of tricuspid regurgitation (p<0.011), presence of aortic stenosis (p=0.043), decreasing left ventricular ejection fraction (p<0.001), presence of left atrial thrombus (p=0.0019), and with increasing left atrium dimensions (p=0.002). NT-proBNP levels in patients with chronic RVD are a potential marker of disease severity and correlates with symptoms.

A ventricular-vascular coupling model in presence of aortic stenosis

In patients with aortic stenosis, the left ventricular afterload is determined by the degree of valvular obstruction and the systemic arterial system. We developed an explicit mathematical model formulated with a limited number of independent parameters that describes the interaction among the left ventricle, an aortic stenosis, and the arterial system. This ventricular-valvular-vascular (V(3)) model consists of the combination of the time-varying elastance model for the left ventricle, the instantaneous transvalvular pressure-flow relationship for the aortic valve, and the three-element windkessel representation of the vascular system. The objective of this study was to validate the V(3) model by using pressure-volume loop data obtained in six patients with severe aortic stenosis before and after aortic valve replacement. There was very good agreement between the estimated and the measured left ventricular and aortic pressure waveforms. The total relative error between estimated and measured pressures was on average (standard deviation) 7.5% (SD 2.3) and the equation of the corresponding regression line was y = 0.99x - 2.36 with a coefficient of determination r(2) = 0.98. There was also very good agreement between estimated and measured stroke volumes (y = 1.03x + 2.2, r(2) = 0.96, SEE = 2.8 ml). Hence, this mathematical V(3) model can be used to describe the hemodynamic interaction among the left ventricle, the aortic valve, and the systemic arterial system.

Usefulness of aortic valve calcium scores by electron beam computed tomography as a marker for aortic stenosis

This study was undertaken to determine whether aortic valve calcium (AVC) scores measured by electron beam tomography can identify patients with echocardiographically defined aortic stenosis. Electron beam tomography is increasingly being used to detect coronary artery calcium. AVC can also be measured on electron beam tomographic (EBT) scans obtained to screen for coronary calcium. Whether EBT AVC scores correlate with the presence of aortic stenosis, as assessed by echocardiography, is unknown. Results of this study suggest that AVC scores should be calculated routinely for coronary calcium screening EBT scans, and that patients with Agatston AVC scores above a certain level (e.g., >150) should be referred for echocardiography.

Left ventricular aneurysm, aortic valve disease and coronary narrowing in a patient with Hunter's syndrome

Hunter's syndrome (mucopolysaccharidosis type 2, MPS 2) is an inherited disorder of glycosaminoglycan degradation commonly associated with cardiac disease. We present the case of a young man with unusual cardiac manifestations of this syndrome. When mixed aortic valve disease was noted in childhood, other classical features of the milder form of Hunter's syndrome were present. There was no symptomatic or echocardiographic cardiovascular deterioration until age 27 when the patient presented in severe biventricular failure. Investigations demonstrated cardiomegaly and a large apical left ventricular aneurysm. The patient died suddenly soon after this diagnosis. Post mortem examination demonstrated a hypertrophied left ventricle with a 6-cm apical aneurysm. Coronary arterial walls were diffusely thickened but with only mild lumenal stenosis. Mitral and aortic valve disease was also present. There is one previous report of ventricular aneurysm in Hunter's syndrome. Pathophysiological contributions to aneurysm formation may include abnormal coronary flow, the presence of aortic stenosis and abnormal myocardium. This patient's sudden deterioration after a long period of clinical stability reinforces the need for careful follow-up of patients with cardiac manifestations of Hunter's disease.

Smoking and Obesity Are Associated with the Progression of Aortic Stenosis

The purpose of the study was to identify clinical predictors of progression of aortic stenosis. The natural history of valvular aortic stenosis includes a latency period followed by an unpredictable progression. Recent investigations have shown an association between risk factors for atherosclerosis and the presence of aortic stenosis. The authors hypothesized that atherosclerosis risk factors are also associated with the progression of aortic stenosis. In a retrospective study, patients with a diagnosis of aortic stenosis were identified by continuous wave Doppler and a follow-up study of at least 6 months. Clinical data at the time of the index echocardiogram were obtained from review of patients' medical records. Independent risk factors for the progression of aortic stenosis were identified by stepwise logistic regression analysis. One hundred twenty-three patients were identified, and complete data were obtained for 87 patients (mean age, 70.7 +/- 10 years; men, 81%; mean follow-up, 2.54 +/- 1.6 years). The initial gradient was mild in 61% of patients and moderate in 31%. The mean rate of progression was 6.3 +/- 13 mm Hg/year. Mild aortic stenosis in 36% of patients at the time of the index echocardiogram progressed to moderate or severe over an average of 2.9 +/- 2.0 years. Independent clinical factors associated with a progression of 5 mm Hg/year or greater included a history of smoking (relative risk [RR] = 3.06; 95% confidence interval [CI] = 1.09-8.61; p = 0.034) and body mass index (RR = 1.16; 95% CI = 1.03-1.30; p = 0.013). Hypertension, diabetes, cholesterol, age, gender, and coronary artery disease were not independently associated with progression. Body mass index and a history of smoking are independent predictors of significant progression of aortic stenosis, defined as > 5 mm Hg/year. The rate of progression of aortic stenosis is variable. However, a substantial number of patients have progression of even initially mild aortic stenosis within a relatively short period of time. The effect of controlling atherosclerosis risk factors on the rate of progression of aortic stenosis remains to be determined.

Prospectively Randomized Comparison of Different Mechanical Aortic Valves

Background —The aim of this prospectively randomized study was to evaluate the hemodynamic and functional outcomes after aortic valve replacement with 3 different bileaflet mechanical valves. Methods and Results —Three hundred consecutive patients were randomly assigned to receive ATS (n=100), Carbomedics (n=100), or St Jude Medical Hemodynamic Plus (n=100) mechanical aortic valve replacement. There were no significant differences regarding patient age (average 61±8 years), body surface area (1.9±0.2 m 2 ), left ventricular function (ejection fraction 0.59±0.17), and presence of aortic stenosis (90%, 89%, and 91%), respectively. All patients had postoperative as well as 6-month and 1-year follow-ups that included transthoracic echocardiography. Multivariate statistical analysis was performed. Implanted valve sizes were comparable at 24±2 (ATS), 23.7±1.6 (CM), and 23.6±1.9 (SJM HP ) mm (NS). At 1-year follow-up, the following incidence of events was noted: death 3/1/1, all non–valve related; stroke 0/1/1; trivial transvalvular incompetence 3/3/2; paravalvular leak 2/3/2; and reoperation 0/1/1, respectively (NS). Transvalvular flow velocities were 2.5/2.6/2.4 m/s postoperatively ( P =0.03) and 2.4/2.4/2.3 m/s at 6-month follow-up, respectively (NS). There was a significant decrease in left ventricular mass for all patients but no significant differences among the groups. Conclusions —There are no clinically relevant differences among the tested bileaflet aortic valves. Regardless of valve type, there was a low complication rate. On the basis of these findings, all 3 bileaflet prostheses are well suited for aortic valve replacement.

Doppler Echocardiography as a Predictor of Pregnancy Outcome in the Presence of Aortic Stenosis: A Case Report

Aortic stenosis in pregnancy can be a life-threatening condition, but fortunately it is rare. In the modern era, careful obstetric and cardiologic monitoring, particularly through echocardiography, have improved fetal and maternal outcomes. However, a test that could predict outcome has not been available for patients with aortic stenosis who seek prepregnancy counseling. We report a case in which exercise Doppler echocardiography was used to predict cardiac function and maximal gradients in a woman with a bicuspid aortic valve who wished to become pregnant. (J Am Soc Echocardiogr 1999;12:324-5.)