Smaller Valve Area Research Articles

SEVERE SYMPTOMATIC MITRAL REGURGITATION AFTER ANNULOPLASTY FAILURE: SUCCESSFUL TRANSCATHETER EDGE TO EDGE REPAIR

Abstract Surgical mitral valve repair is the most common, feasible and preferred procedure to treat primary and secondary mitral regurgitation (MR). However, 30% of patients suffer from residue severe regurgitation 10 years after surgical intervention, resulting in a considerable number of Redo procedures. In elderly and high–risk patients with major comorbidities medical treatment is the only and often insufficient option for symptoms’ relief. Percutaneous Transcatheter Edge to Edge repair technique (TEER) with MitraClip system is emerging as an off–label valid alternative to successfully treat severe mitral regurgitation after surgical valvuloplasty failure. Transesophageal echocardiography (TEE) is essential in diagnosis, planning, intraprocedural device placement, and follow up. In the peculiar setting of failed annuloplasty, with small residual valve area, the main risk is the creation of a gradient across the mitral valve. We present two cases of severe mitral regurgitation after surgical annuloplasty with ring placement, carefully evaluated for TEER and successfully treated with this procedure: 1) a 79–year–old man presented with exertional dyspnea and orthopnea in the setting of previous surgical mitral Annuloplasty (2003) with a 32–mm Carpentier Ring. Transesophageal echocardiography demonstrated severe mitral regurgitation due to P2 prolapse and central V–shaped cut of the valve, mean diastolic gradient 1.8 mmHg. 2) a 83 year–old woman presented with dyspnea (NYHA functional class III) and severe mitral regurgitation after previous Annuloplasty with a 34–mm Edwards Ring and placement of Goretex artificial Chordae (2016). TEE showed prolapse of P2 and P3 leaflets, mean diastolic gradient 2.17 mmHg, valvular area 3.5 cmq. Both patients underwent transfemoral and transseptal implantation of one MitraClip device (XTw and XT, respectively) under Transesophageal echocardiography guidance with successful reduction of mitral regurgitation to mild level and symptoms relief. In the first case post procedural mean diastolic gradient was 3.7 mmHg, in the second case it was 3.16 mmHg.

Degenerative Mitral Stenosis-Diagnostic Challenges and Future Directions.

Determining the severity of stenosis in degenerative mitral stenosis (DMS) is fraught with challenges. Neither a high trans-mitral gradient nor a small valve area calculation is sufficiently diagnostic for DMS due to variable left atrial and left ventricular compliance in the setting of diastolic dysfunction, and the variable flow seen in patients with chronic kidney disease (i.e., high flow state) and elderly women (low flow state). Three-dimensional measurement of mitral valve area may be underestimated due to shadowing from basal calcium, and mitral valve annulus (MVA) by continuity equation (CEQ) or dimensionless mitral valve index can be erroneous in the presence of significant regurgitation of left-sided valves. The proposed dimensionless mitral stenosis index (DMSI) can be an easy echocardiographic tool to use in daily practice but needs further validation and is limited in the setting of significant regurgitation of left sided valves. Mean trans-mitral gradients 8 mmHg and pulmonary artery pressure 50 mmHg are independent predictors of mortality in those with MVA 1.5 derived by CEQ. In patients who have symptoms that are out of proportion to the degree of stenosis reported, exercise stress testing may help determine the physiologic effects of the stenotic valve. A combination of MVA by CEQ or DMSI and mean transmitral gradient at a given left ventricle stroke volume (flow) should be evaluated in larger studies.

599 Gender-based differences in TAVI outcomes: report from a large contemporary real-world population of self-expandable valves

Abstract Aims Small sub-study data derived from randomized clinical trials suggest a gender-based disparity in TAVI outcomes. However, large real-world contemporary data is missing. The aim of this study is to compare the risk factors, procedural characteristics and clinical outcomes of male and female patients who underwent transcatheter aortic valve implantation (TAVI) using two next-generation self-expandable bioprostheses (ACURATE neo and Evolut R/Pro valves). Methods We performed a first unmatched comparison and a propensity score-matched analysis (PSM) to assess the outcomes derived by the sex difference beyond the impact of pre-procedural risk factors in a large, contemporary, real-world, multicentre, international, retrospective registry of 3862 consecutive patients. The primary endpoint was a composite of all-cause death or any stroke (disabling and non-disabling) at 1 year. Results Sixty-four per cent (2162/3353 patients) of the study cohort was female and was older (mean age 82.3 years vs. 81.1 years for men (P<0.001)) had a higher BMI (27.7±5.7 for women vs. 27.2±4.5 for men), and lower prevalence of dyslipidaemia (50.2% vs. 54.7, P=0.037), diabetes (26.8% vs. 33.7, P<0.001), smoking (10.0% vs. 24.3%, P<0.001), COPD (17.4% vs. 21.9%, P=0.002), pacemaker/ICD (9.6% vs. 14.0%, P<0.001), previous cardiac surgery (8.6% vs. 18.8%, P<0.001), previous PCI (23.0% vs. 36.8%, P<0.001). Mean STS score for women was higher 5.2±3.9% vs. 4.5±3.4% (P<0.001). Women had higher mean valve gradients (45.4±17.1 vs. 42.7±14.7 mmHg; P<0.001), smaller valve areas (mean 0.7 cm2 vs. 0.9 cm2, P=0.037) and smaller annular perimeters (56.8±23.0 vs. 62.0±23.8, P<0.001). The primary endpoint was resulted in a rate of 7.9% vs. 6.9% (P=0.337) in the unmatched population and 9.4% vs. 6.0% (P=0.014) after the PSM, respectively for women and for men. Independently, there was no difference in mortality (5.9% vs. 5.6%; P=0.786) and stroke (2.5% vs. 1.8%; P=0.243) rates between women and men in the un-matched groups. Rates of cardiac tamponade (1.5% vs. 0.4%, P=0.008), major vascular complications (7.7% vs. 4.1%, P<0.001), life-threatening bleeding (2.8% vs. 1.4%, P=0.016), major bleeding (5.1% vs. 2.9%, P=0.004), need of transfusion (8.9% vs. 4.6%, P<0.001) and acute kidney injury (8.5% vs. 5.7%, P=0.009), were all significantly higher in women. After PSM, mortality was similar between the two groups (11.3% for women vs. 9.5% for men, P=0.264) but strokes were more prevalent in women (2.8% vs. 1.2%, P<0.024). Furthermore, in the matched population, major vascular complications (6.8% vs. 4.1%, P=0.024), need of transfusion (9.1% vs. 4.6%, P<0.001) and acute kidney injury (8.7% vs. 5.6%, P=0.009) remained significantly different between women and men, respectively. Conclusions In this large real-world contemporary TAVI registry, female gender was associated with higher rates of stroke, vascular complications, major bleeding, and acute kidney injury. Further studies are required to explore the underlying pathophysiological mechanisms for these observations.

The use of MRI in quantification of the atrial fibrosis in patients with rheumatic mitral disease

BackgroundAtrial fibrillation (AF) is a common type of arrhythmia with higher incidence in countries with increased prevalence of rheumatic heart disease (RHD), where AF contributes to significant morbidity and mortality in young population. Atrial fibrosis is a common feature of AF. Delayed enhancement MRI (DE-MRI) is a well-established method for characterizing fibrosis in ventricles. The use of DE-MRI to detect left atrial fibrosis helps to evaluate the extent of atrial structural remodeling non-invasively. The aim of this study is to evaluate the atrial fibrosis in patients with mitral valve disease, using the DE MRI, regarding its amount, distribution, and relation to AF.ResultsPatients with AF were older and have longer duration of symptoms, smaller valve area, larger LA size, and more fibrosis at the left atrium (with the posterior wall most frequently involved) in comparison to those with sinus rhythm. Patients with atrial fibrosis were older and have longer duration of symptoms, smaller valve area, and larger LA, and most of them had AF compared to those without fibrosis. The comparison between types of AF showed a significant difference in the amount of atrial fibrosis that increases across the spectrum of AF.ConclusionIn patients with rheumatic mitral valve diseases, AF is associated with more atrial fibrosis as assessed by DE-MRI. Atrial fibrosis is the best independent predictor of AF.

NEW METHOD OF ESTIMATION OF THE RELATIVE AREA OF PERFORATIONS ON VALVES OF CENTRIC DIATOMS USING SEM IMAGES ON THE EXAMPLE OF MINIDISUS VODYANITSKIYI LYAKH ET BEDOSHVILI

The diatoms interact with the environment through the siliceous frustule. The total area of frustule perforations determines the ability of diatom to exchange nutrients, gases and other matters. The aim of the present study was to estimate the area of perforations on the valve surface of a centric diatom. In the paper we describe a method for the estimation of the area of perforations on a diatom valve using SEM images. The method is tested on valves of centric diatom Minidiscus vodyanitskiyi Lyakh et Bedoshvili. The results show that the total area of cribral pores is less than 5% of the total valve area. This value is consistent with the relative perforation of land plants leaves, which is less than 3%. We hypothesize that such small valve area occupied by perforations is usual for many other centric diatom species. To verify this hypothesis additional researches are necessary.

MitraClip After Disinsertion of a Prosthetic Mitral Ring

summary We report the case of a MitraClip procedure for recurrent mitral regurgitation after prior mitral valve repair. The unique feature of our case is the partial disinsertion of the Physio-ring’s posterior portion, which caused shadowing, but grasping visualization was sufficient to proceed. It also illustrates a successful MitraClip procedure after surgical valve repair with a relatively small valve area.

Predicting outcome after percutaneous balloon mitral commissurotomy : Role of neutrophil-lymphocyte ratio.

The value of the neutrophil-lymphocyte ratio (NLR) along with the severity of mitral stenosis (MS) in predicting the outcome of percutaneous balloon mitral commissurotomy (PBMC) has not been studied. Patients with severe MS undergoing PBMC between 2013 and 2014 in auniversity hospital were prospectively enrolled. Complete blood cell count was obtained upon admission and NLRs were calculated. The correlations between NLR with immediate PBMC success and restenosis in 1 year were evaluated. In all, 102 patients (80women) with amean age of 44.5± 13.1years were enrolled in the study. NLR on admission was 2.6± 0.8 and mitral valve area (MVA) was 0.89± 0.18cm2. Patients with a lower MVA at baseline had a higher NLR (p= 0.016). The rate of immediate success was 63 % for PBMC. There was no difference in NLR between patients with regard to early and late failures, as well as those who developed restenosis of the valve. Smaller valve area and the rate of valvular dilatation during PBMC were the only independent factors that predicted early and late failure, respectively. NLR at the time of treatment was not useful in predicting procedural outcome or restenosis during follow-up of patients undergoing PBMC.

Medium‐term CT evaluation of stent geometry, integrity, and valve function of the Edwards SAPIEN transcatheter heart valve in the pulmonary position

Distortion of transcatheter heart valve (THV) stent shape and morphology has been shown to impact on THV function. This study sought to evaluate the relationship between geometrical CT follow-up data and consequent valve function in patients undergoing transcatheter pulmonary valve replacement with the Edwards SAPIEN THV. All patients were enrolled in the COMPASSION trial. Multidetector computed tomography (MDCT) was performed as part of the study protocol at 6 months and yearly thereafter following valve implantation. Prosthesis eccentricity indices, circularity ratios, and expansion ratios (ER) were calculated. Valve function and reintervention rates were correlated with MDCT findings. Twenty consecutive patients undergoing 58 CT scans were included. Maximum Doppler gradients across the right ventricular outflow tract (RVOT) were significantly reduced following valve implantation (P < 0.001). Geometrical indices and maximum RVOT gradients were compared between the reintervention group (n = 4) and the nonreintervention group (n = 16). Although there was no difference in eccentricity index between the groups, ER [6 months: 90 +/- 12% vs. 69 ± 9%; P = 0.014; at 12 months: 89 ± 14 vs. 69 ± 10%; P = 0.018; at 24 months: 87 ± 14% vs. 70 ± 11%; P = 0.056] and valve area [6 months: 3.98 ± 0.54 vs. 2.86 ± 0.38 P = 0.005; at 12 months: 3.93 ± 0.56 vs. 2.86 ± 0.39 P = 0.006; 24 months: 3.78 ± 0.50 vs. 2.90 ± 0.45 P = 0.019] were lower in the reintervention group compared with the nonreintervention group at all time periods. Geometrical THV measurements as assessed by CT may predict the need for reintervention in patients undergoing transcatheter pulmonary valve replacement with the SAPIEN valve. Valve symmetry is maintained, however under-expansion and smaller valve area are strongly associated with the need for reintervention.

Impact of B-type natriuretic peptide on short-term clinical outcomes following transcatheter aortic valve implantation

We aimed to assess the impact of B-type natriuretic peptide (BNP) on short-term outcomes in patients undergoing transcatheter aortic valve implantation (TAVI). Of 500 consecutive patients with severe aortic stenosis undergoing TAVI at our institution, we studied 340 patients who had a BNP assessment prior to TAVI. Patients were divided into tertiles - low: BNP ≤201 pg/mL (n=114), mid: BNP 202-595 pg/mL (n=113) and high: BNP ≥596 pg/mL (n=113). The primary endpoint was all-cause mortality, cardiac death and major adverse cardiac and cerebrovascular events (MACCE; death, major stroke and myocardial infarction) at 30 days. Compared with low tertile, high tertile patients were at higher baseline surgical risk (STS score 5.5±3.0 vs. 7.4±4.1, p=0.002). On echocardiography, high tertile patients had smaller valve areas (0.74±0.21 vs. 0.66±0.23 cm², p=0.008), higher left ventricular (LV) mass indices (123.40±33.66 vs. 168.22±47.96 g/m², p<0.001) and lower LV ejection fractions (61.59±7.18 vs. 42.65±15.41%, p<0.001) as compared with low tertile patients. At 30 days, a significantly higher incidence of death (hazard ratio [HR] 7.41, p=0.001) cardiac death (HR 5.82, p=0.006) and MACCE (HR 9.04, p<0.001) was observed among high as compared to low tertile patients. In TAVI patients, higher BNP values at baseline are associated with an increased risk for an adverse event periprocedurally and after 30 days, respectively.

Low-gradient, low-flow severe aortic stenosis with preserved left ventricular ejection fraction: characteristics, outcome, and implications for surgery.

Severe low-gradient, low-flow (LG/LF) aortic stenosis with preserved left ventricular ejection fraction (EF) has been described as a more advanced form of aortic stenosis. However, the natural history and need for surgery in patients with LG/LF aortic stenosis remain subjects of intense debate. We sought to investigate the outcome of LG/LF aortic stenosis in comparison with moderate aortic stenosis and with high-gradient (HG) aortic stenosis in a real-world study, in the context of routine practice. This analysis included 809 patients (ages 75 ± 12 years) diagnosed with aortic stenosis and preserved EF (≥50%). Patients were divided into 4 groups: mild-to-moderate aortic stenosis; HG aortic stenosis; LG/LF aortic stenosis; and low-gradient, normal-flow (LG/NF) aortic stenosis. Compared with mild-to-moderate aortic stenosis patients, LG/LF aortic stenosis patients had smaller valve areas and stroke volumes, higher mean gradients, and comparable degrees of ventricular hypertrophy. Under medical management (22.8 months; range 7 to 53 months), compared with mild-to-moderate aortic stenosis patients, HG aortic stenosis patients were at higher risk of death (adjusted hazard ratio [HR]: 1.47; 95% confidence interval [CI]: 1.03 to 2.07), whereas LG/LF aortic stenosis patients did not have an excess mortality risk (adjusted HR: 0.88; 95% CI: 0.53 to 1.48). During the entire (39.0 months; range 11 to 69 months) follow-up (with medical and surgical management), the mortality risk associated with LG/LF aortic stenosis was close to that of mild-to-moderate aortic stenosis (adjusted HR: 0.96; 95% CI: 0.58 to 1.53), whereas the excess risk of death associated with HG aortic stenosis was confirmed (adjusted HR: 1.74; 95% CI: 1.27 to 2.39). The benefit associated with aortic valve replacement was confined to the HG aortic stenosis group (adjusted HR: 0.29; 95% CI: 0.18 to 0.46) and was not observed for LG/LF aortic stenosis (adjusted HR: 0.75; 95% CI: 0.14 to 4.05). In this study, the outcome of severe LG/LF aortic stenosis with preserved EF was similar to that of mild-to-moderate aortic stenosis and was not favorably influenced by aortic surgery. Further research is needed to better understand the natural history and the progression of LG/LF aortic stenosis.

Aortic Valve Calcification Helps Distinguish Severity in Discordant Aortic Stenosis

Severe aortic stenosis (AS) is typically characterized by small valve area and high gradient (≥40 mm Hg or peak aortic jet velocity of ≥4 m/sec). However, some patients with severe AS based on valve area have low (discordant) gradients, despite normal left ventricular ejection fraction (LVEF) and flow, confounding diagnosis and treatment. In this multicenter study, investigators reviewed echocardiographic and computed tomographic (CT) scans …

Low flow, low gradient severe aortic stenosis: diagnosis, treatment and prognosis

Low flow, low gradient aortic stenosis is a highly challenging condition in terms of diagnosis and therapeutic management. With regard to prognosis and to management decisions, it is essential to distinguish those patients with preserved systolic left ventricular ejection fraction from patients with impaired systolic left ventricular ejection fraction, and in particular those with true severe aortic stenosis from patients who have non-significant aortic stenosis associated with reduced transvalvular flow for other reasons and who present with a functionally small valve area. In addition, measurement errors deserve particular consideration in order to avoid a misdiagnosis. Echocardiography, including low dose dobutamine stress studies, is the key diagnostic tool. Magnetic resonance imaging, invasive assessment of haemodynamics by catheterisation and quantification of valve calcification by computed tomography calcium scoring can provide additional information that helps to assess aortic stenosis severity accurately, predict outcome and guide treatment decisions. Percutaneous aortic valve implantation may provide an intervention with lower periprocedural risk in this challenging patient subset; however, further studies are required to define its exact role in this setting.

Outcome of Patients With Aortic Stenosis, Small Valve Area, and Low-Flow, Low-Gradient Despite Preserved Left Ventricular Ejection Fraction

The aim of this case match study was to compare the outcome of patients with paradoxical low-flow (left ventricular ejection fraction [LVEF] ≥50% but stroke volume index <35 ml/m(2)), low-gradient (mean gradient [MG] <40 mm Hg), a priori severe (aortic valve area [AVA] ≤1.0 cm(2)) aortic stenosis (AS) (PLG-SAS group) with that of patients with a severe AS (AVA ≤1.0 cm(2)) and consistent high-gradient (MG ≥40 mm Hg) (HG-SAS group) and with that of patients with a moderate AS (AVA >1.0 cm(2) and MG <40 mm Hg) (MAS group). In patients with preserved LVEF, a discordance between the AVA (in the severe range) and the gradient (in the moderate range) raises uncertainty with regard to the actual severity of the stenosis and thus the therapeutic management of the patient. In a prospective cohort of AS patients with LVEF ≥50%, we identified 187 patients in the PLG-SAS group. These patients were retrospectively matched: 1) according to the gradient, with 187 patients with MAS; and 2) according to the AVA, with 187 patients with HG-SAS. Patients with PLG-SAS had reduced overall survival (1-year: 89 ± 2%; 5-year: 64 ± 4%) compared with patients with HG-SAS (1-year: 96 ± 1%; 5-year: 82 ± 3%) or MAS (1-year: 96 ± 1%; 5-year: 81 ± 3%). After adjustment for other risk factors, patients with PLG-SAS had a 1.71-fold increase in overall mortality and a 2.09-fold increase in cardiovascular mortality compared with the 2 other groups. Aortic valve replacement was significantly associated with improved survival in the HG-SAS group (hazard ratio: 0.18; p = 0.001) and in the PLG-SAS group (hazard ratio: 0.50; p = 0.04) but not in the MAS group. Prognosis of patients with paradoxical low-flow, low-gradient severe AS was definitely worse than those with high-gradient severe AS or those with moderate AS. The finding of a low gradient cannot exclude the presence of a severe stenosis in a patient with a small AVA and preserved LVEF and should mandatorily prompt further investigation.

Hemodynamics in the Cardiac Catheterization Laboratory of the 21st Century

There has been a striking evolution in the role of the cardiac catheterization laboratory over the past decades.1 In the 1950s and 1960s, hemodynamic assessment in the cardiac catheterization laboratory was essential for understanding the physiology and pathophysiology of patients with cardiovascular diseases. With the development of surgical interventions to treat patients with valvular and congenital heart disease, it became necessary for the cardiac catheterization laboratory to provide an accurate hemodynamic assessment, laying out a therapeutic road map. Nearly all patients who had open heart surgery underwent a complete hemodynamic catheterization before surgery. In the 1980s and 1990s, the evolution of 2-dimensional echocardiography and Doppler echocardiography provided an alternative noninvasive approach for the assessment of both cardiac anatomy and hemodynamics in patients with structural heart disease.2 By measuring blood flow velocities noninvasively, Doppler echocardiography was able to provide information on volumetric flow, intracardiac pressures, pressure gradients, and valve areas, as well as diastolic filling of the heart. Furthermore, noninvasive studies could be repeated easily, allowing the practitioner to follow the progress of his/her patient's condition longitudinally. At the same time, there was growing emphasis on coronary angiography for defining epicardial coronary disease with the subsequent development of interventional approaches for coronary disease with catheter-based therapies. As the major focus in the catheterization laboratory shifted to the diagnosis and treatment of the patient with acute and chronic coronary artery disease, the hemodynamic assessment of patients with structural heart disease was left to the noninvasive echocardiographic laboratory. As a consequence, many cardiac catheterization laboratories provided neither the training nor the expertise to assess hemodynamics properly. However, the advent of procedures such as balloon valvotomy, percutaneous valve implantation, and septal ablation has revived interest in structural heart disease and provided the invasive cardiologist with an armamentarium to treat patients who previously …

Gender differences in clinical presentation and surgical outcome of aortic stenosis

BackgroundLittle is known about the gender differences of patients undergoing aortic valve replacement (AVR) for isolated severe aortic stenosis.Methods and Results408 consecutive patients (215 women and 193 men; p=0.9) were...

An Echocardiographic Study of the Limitations of the Tei Index in Aortic Stenosis

The omnibus Tei index, the sum of isovolumic contraction and relaxation times divided by the ejection time, is a good indicator of global cardiac function. However, these time intervals can be influenced by valvular heart disease and the role of the Tei index among patients with aortic stenosis (AS) and left ventricular systolic dysfunction remains incompletely defined. Doppler time intervals were measured retrospectively by two observers, and the Tei index were calculated on 80 patients with various degrees of left ventricular systolic dysfunction and severity of AS. Differences between observers were resolved by consensus. Ejection fraction (EF) was visually estimated, and the aortic valve area (AVA) was calculated using the continuity equation. The mean AVA was 1.1+/-0.5 cm(2) and the mean EF was 0.39+/-0.15. Although correlation (r = 0.61, P < 0.001) and agreement (intraclass correlation coefficient=0.55) for the Tei index were satisfactory, there were significant differences between observers (P < 0.001). Using consensus data, the mean Tei index was 0.32+/-0.20 and significantly lower among patients with severe compared with less severe AS (P=0.01). The index varied inversely with left ventricular function (P=0.003). However, receiver operating characteristic analysis shows that the Tei index lacks discrimination in accurately identifying poor left ventricular function or severe AS or both. The Tei index varies inversely with systolic ventricular function (low index with good EF) and positively with severity of AS (low index with smaller valve area). As such, it may have limited utility among individual patients with AS.

Comparison of Heavier Versus Lighter Operatively Excised Stenotic Aortic Valves in Adults With Aortic Stenosis and Implications for Percutaneous Aortic Valve Implantation Without Replacement

To better understand aortic valves amenable to percutaneous aortic valve implantation, operatively excised stenotic aortic valves were examined and divided into 2 groups: heavier and lighter valves. Among 2,247 operatively excised stenotic aortic valves in adults aged >20 years without associated mitral stenosis or mitral valve replacement, 1,608 valves were weighed; 1,241 (77%) weighed <4 g, and 367 (23%) weighed > or =4 g. Of the valves from 1,038 men, 717 (69%) weighed <4 g, and 321 (31%) weighed > or =4 g; of the valves from 570 women, 524 (92%) weighed <4 g, and 46 (8%) weighed > or =4 g. The patients with heavier (> or =4 g) valves had higher transvalvular peak gradients (78 +/- 28 vs 55 +/- 27 mm Hg, p <0.0001), smaller valve areas (0.69 +/- 0.30 vs 0.75 +/- 0.27 cm(2), p <0.0001), and more often congenitally malformed valves (327 of 367 [89%] vs 638 of 1,241 [51%], p <0.0001). In patients aged 81 to 90 years, 44 of the 195 valves (23%) were congenitally unicuspid or bicuspid; in those aged 41 to 50 years, 112 of 128 valves (88%) were congenitally malformed. In conclusion, compared with patients whose stenotic aortic valves weighed <4 g, those with valves weighing > or =4 g were younger, had higher transvalvular peak systolic pressure gradients, had smaller valve areas, and usually (about 90%) had congenitally unicuspid or bicuspid valves. It seems reasonable to avoid percutaneous aortic valve implantation in patients with heavily calcified stenotic aortic valves, most of which are either congenitally unicuspid or bicuspid.

Approach to the patient with aortic stenosis and low ejection fraction

Aortic stenosis is the most common valvular abnormality in the United States today. It has been well established that most patients with severe symptomatic aortic stenosis should undergo operation with aortic valve replacement. This is particularly true when ventricular function is maintained, as the operative risk is low and the long-term outcome is excellent. In most patients with a reduced ejection fraction, there is an increased risk of operation and poorer long-term outcome. However, operation is still of benefit in most patients, as relief of an afterload mismatch will improve ventricular function and provide symptom relief. There is a subset of patients with left ventricular dysfunction at even higher risk who have a low aortic valve gradient and small valve area, some of whom may not have severe obstruction. Pharmacologic challenge may be necessary to identify those patients with true aortic stenosis and further helps determine those who would benefit from surgical intervention.

Small valve area index: its influence on early mortality after mitral valve replacement.

To test the hypothesis that mitral valve prosthesis-patient mismatch increases postoperative mortality. The effect of mitral valve prosthesis-patient mismatch on survival in a cohort of consecutive patients after mitral valve replacement with a mechanical prosthesis was measured, focusing on the lower tail of the normal distribution curve of the prosthetic valve area index. For the calculation of the geometric valve area index (cm(2)/m(2) body surface area), we used specifications for the geometric valve area supplied by the manufacturer. The cut-off value of the 10th percentile of the valve area index was 1.919 cm(2)/m(2). The study population consisted of 428 adult patients who underwent mitral valve replacement by a Medtronic Hall (n=270, 63%) or a St. Jude Medical prosthesis (n=158, 37%). The size of the valves implanted ranged from 25 mm to 31 mm. The valve area index showed a normal distribution curve ranging from 1.43 to 2.98 cm(2)/m(2) with a mean of 2.2 cm(2)/m(2). Group 1 (n=33) had a valve area index <1.9 cm(2)/m(2) and group 2 (n=395), > or =1.9 cm(2)/m(2). The 30-day mortality was higher in group 1 than in group 2 (18.2 vs. 4.1%, P=0.005). Multivariate logistic regression analysis of the determinants of the 30-day mortality rendered a small valve area index (<1.9 cm(2)/m(2)) as an independent risk indicator: relative risk 4.3 (95% CI 1.6-9.5; P=0. 0043). The difference in overall survival between the two groups was entirely due to the high 30-day mortality in the patients with small valve area indices, congestive heart failure being the main cause of death. By concentrating on the extreme lower tail of the normal distribution of the valve area index, a strong and independent relation was found between relatively small valves (valve area index <1.9 cm(2)/m(2)) and 30-day mortality. We found no influence of valve size on late mortality beyond the first 30 days.

Prominent Large V Wave in Mitral Stenosis and It's Clinical Significance

Background and Objectives:Although a prominent large V wave in left atrial pressure tracing (PVLAP has been reported to be associated with significant mitral regurgitation (MR or decreased left atrial compliance (LAC, it is sometimes observed in patients with tight mitral stenosis (MS. The purpose of this study was to determine the prevalence and the hemodynamic significance of PVLAP in tight MS. Materials and Methods:Catheterization data before percutaneous mitral balloon valvuloplasty (PMV were analyzed in 84 consecutive patients and PVLAP was defined as V wave 10 mm Hg higher than mean left atrial pressure (MLAP. Results:PVLAP was observed in 45% (38/84 and factors associated with PVLAP were younger age (p=0.02, higher MLAP (p<0.01, higher mitral gradient (p=0.04, smaller valve area (p=0.01 and low echo score (p=0.02; among them MLAP was the only independent factor in multivariate analysis. The presence of PVLAP had no effect on the result of PMV and successful PMV abolished PVLAP. Conclusion: PVLAP was observed not infrequently in these selected patients with MS referred for PMV. The presence of PVLAP was not associated with MR and had good correlation with MLAP, which suggest that PVLAP be determined by decreased LAC. ( ( ( (Korean Circulation J 2000;30( ( ( (2 :147-152