Valvular Heart Disease In Patients Research Articles

A clinical study of Rheumatic Valvular Heart Disease in patients above forty years of age admitted in Assam Medical College and Hospital, Dibrugarh

BackgroundIt is thought uncommon for Rheumatic Heart Disease (RHD) to present in the 5th decade or later with their first symptom. Only few studies are available on RHD in elderly. AimTo study the clinical profile of RHD in patients above 40 years of age presenting for the first time. Methods and materialAll patients aged 40 years and above, presenting for the first time with clinical features of RHD during a period of one year from May 2011 to April 2012, were studied. Other valvular heart diseases of non-rheumatic origin and congenital valvular heart diseases were excluded from the study. Patients were then evaluated with detailed history, clinical examination, electrocardiography, chest x-ray and echocardiography and relevant blood investigations. ResultsA total of 42 cases were enrolled in the present study. Most of patients presented with exertional dyspnea (38.1%), orthopnea (19.05%) and palpitation (35.71%). Atrial fibrillation (AF) was found in 64.29%, cerebrovascular accident (CVA) in 26.19%, congestive cardiac failure (CCF) in 16.67% and infective endocarditis (IE) in 9.52%. Isolated Mitral Stenosis (MS) was the most common valvular lesion, observed in 47.62% cases. Surprisingly, all the female patients did not have any cardiovascular symptoms during their pregnancies. ConclusionThis study revealed that a large number of patients of RHD presenting for the first time are elderly. Even the female patients were asymptomatic during their previous pregnancies. Complications were fairly common at presentation. The factors which could be responsible for these need evaluation. Burden of RHD in elderly also need estimation.

Valvular Heart Disease in Patients Supported With Left Ventricular Assist Devices

Patients with advanced HF and coexisting VHD who undergo LVAD implantation constitute a growing population and pose unique challenges in clinical and surgical management. Contemporary continuous-flow LVADs alter blood flow dynamics and cardiovascular physiology and can induce progression of preexisting VHD or lead to de novo VHD. Although we have defined our recommendations for treatment options (Table 2), continued changes to device technology, patient selection, and surgical techniques will undoubtedly lead to further changes in practice. Finally, the rapid growth in the field of mechanical circulatory support necessitates collaborative multicenter approaches to study the impact of these practice changes in the form of prospective randomized trials.

Drug-induced valve disease and considerations of benefit versus risk

This editorial refers to ‘Frequency of drug-induced valvular heart disease in patients previously exposed to benfluorex: a multicentre prospective study’[†][1], by C. Tribouilloy et al. , on page 3580 Data from epidemiological studies, and a single randomized trial, have plausibly suggested that a variety of amphetamine-related molecules can cause valvular morphological lesions and variable degrees of valvular dysfunction.1–10 Though a causal relationship has not been unequivocally proven, cellular mechanisms have been defined that may account for such a relationship.11,12 However, early in the experience with the phentermine–fenfluoramine combination that sensitized the medical community to such problems,1 the frequency of valve involvement probably was markedly overstated. Indeed, at the height of the concern, when several very small series suggested that the majority of exposed patients developed valve disease, five patients (as large as some of the published series) were referred to me after moderately long exposure to seek evidence of valve disease; none was apparent in any. Importantly, the involved drugs all were approved for specific benefits, e.g. weight reduction for morbidly obese persons who might suffer from orthopaedic, psychological, cardiovascular, and other debilities in part because of their body weight, and diabetes control for patients in whom glucose metabolic abnormalities could have several unwanted and potentially preventable consequences. In all such situations, the appropriateness of the therapies must be determined on the basis of a judgement of putative benefits vs. putative risks. Since the benefits and the risks of the amphetamine-related therapies are intrinsically different, the relationship between benefit and risk is impossible to quantify rigorously and must be based on the judgement of experienced observers. Therefore, it is essential to quantify, as precisely as possible, the benefits and the risks. Benefits often are reasonably quantified by randomized, appropriately controlled trials enabling comparison of … [1]: #fn-2

Frequency of drug-induced valvular heart disease in patients previously exposd to benfluorex: a multicentre prospective study

The epidemiologic link between benfluorex use and an increased global frequency of left heart valve regurgitation has been well documented. However, no data linking previous drug exposure to the frequency of diagnosis of drug-induced valvular heart disease (DI-VHD) are available. The present study was conducted to address this issue. This echocardiography reader-blinded, controlled study conducted in 10 centres between February 2010 and February 2012 prospectively included 835 subjects previously exposed to benfluorex referred by primary care physicians for echocardiography. Based on blinded off-line analysis, echocardiography findings were classified as: (i) DI-VHD⁺ for patients with an echocardiographic diagnosis of DI-VHD, (ii) inconclusive, and (iii) DI-VHD⁻ for patients without signs of DI-VHD. Fifty-seven (6.8%) patients exposed to benfluorex were classified as DI-VHD⁺, 733 (87.8%) patients were classified as DI-VHD⁻, and 45 (5.4%) were classified as inconclusive. Mitral and aortic DI-VHD were reported in 43 patients (5.1%) and 30 (3.6%) patients, respectively. Longer duration of exposure, female gender, smoking, and lower BMI were independently associated with a diagnosis of DI-VHD. Good inter-observer reproducibility was observed for the echocardiography classification (Kappa = 0.83, P < 0.00001). About 7% of patients without a history of heart valve disease previously exposed to benfluorex present echocardiography features of DI-VHD. Further studies are needed to study the natural history of DI-VHD and to identify risk factors for the development of drug-induced valve lesions.

SAT0234 Valvular heart disease in antiphospholipid syndrome

BackgroundAntiphospholipid syndrome (APS) is defined by the presence of venous or arterial thrombosis, recurrent pregnancy loss and anti-phospholipid antibodies (aPLs). Echocardiographic studies have disclosed heart valve abnormalities in about a...

Valvular heart disease in patients undergoing chronic hemodialysis

Valvular heart disease in patients undergoing chronic hemodialysis

Valvular heart disease in patients exposed to pergolide: insights from the clinical presentation

The aim of this study was to determine whether the presence of symptoms would aid in the detection of valvular heart disease (VHD) in those exposed to pergolide. Utilizing a prospective, cross-sectional study design, patients with an exposure to pergolide were asked regarding the presence or absence of chest pain, shortness of breath or lower extremity edema through a questionnaire. Echocardiograms were obtained on the same day as the questionnaire and were blinded to all staff involved in the study. The sensitivity, specificity, positive and negative predictive value of the reported symptoms towards the outcome moderate or severe valvular regurgitation were obtained. Using the area under the receiver-operating characteristic curve, we also ascertained whether a relationship existed between symptoms, pergolide dose and presence of VHD. To understand the associations between symptoms and echocardiographic covariates, a logistic regression analysis was performed adjusted for age and gender. The sensitivity, specificity, positive and negative predictive value of symptom presentation and total dose was sufficiently low that it did not aid in the determination whether significant valvular regurgitation was present. Multivariable analysis noted a significant association with indexed left atrial volume (p = 0.011), estimated pulmonary artery pressure (p = 0.047) and shortness of breath. The presence or absence of symptoms does not help guide whether valvular regurgitation is present or absent in individuals exposed to pergolide. Therefore, echocardiography is needed to confirm or refute pergolide-associated VHD.

Retrospective investigation of in-hospital patients diagnosed with chronic heart failure in Hubei province

ObjectiveTo evaluate the current status of chronic heart failure (CHF) in Hubei province and analyse the epidemiology of CHF including the general condition, aetiology and pharmacological therapy.MethodsData of in-hospital patients...

A comparison of cabergoline and bromocriptine on the risk of valvular heart disease in patients with prolactinomas

Therapy with dopamine agonists has been associated with valvular heart disease (VHD) in Parkinson's disease, raising concern about the safety of these drugs. In hyperprolactinemic patients, the studies have mainly focused on the cardiac effects of cabergoline (CBG), with little information on bromocriptine (BRC). The aim of the present study was to evaluate the prevalence of VHD in patients with prolactinomas treated with CBG and BRC. The CBG group consisted of 51 patients (37 female; age 42.3 ± 13.5 years) who had been taking CBG for at least 1 year (mean 37.8 ± 21.3 months; cumulative doses 16-1,286.8 mg). The BRC group consisted of 19 patients (14 female; age 41.8 ± 11.5 years) who were on BRC for at least 1 year (mean 54.8 ± 30.2 months; cumulative doses 4,687.5-23,478.8 mg). The controls (CTR) were 59 healthy subjects matched for age, sex, and prevalence of arterial hypertension. Participants were subjected to transthoracic echocardiography and the valvular regurgitation was graduated as absent (grade 0), trace (1), mild (2), moderate (3) or severe (4). Compared to CTR, trace mitral (Mi) regurgitation (49% vs. 27.1%; P = 0.02), trace tricuspid (Tri) regurgitation (45.1% vs. 20.3%; P = 0.0003) and mild Tri regurgitation (7.8% vs. 0%; P = 0.0003) were more prevalent with CBG, while trace Tri regurgitation (73.7% vs. 20.3%; P = 0.0004) were more prevalent with BRC. Mitral tenting area was significantly higher in CBG than in BRC and CTR. None of the valvar abnormalities was associated with symptoms. In conclusion, patients with prolactinomas treated with either CBG or BRC showed higher prevalence of trace and mild Tri or Mi regurgitation, but these findings were not clinically significant.

Risk Factors for the Development and Progression of Carcinoid Heart Disease

The development of valvular heart disease in patients with carcinoid syndrome is thought to be related to the secretion of vasoactive substances by a tumor. We sought to identify modifiable risk factors for the development of carcinoid heart disease because this may help define strategies to attenuate the disease process. Two hundred fifty-two patients with carcinoid syndrome were prospectively followed with serial echocardiograms at 6-month intervals. Clinical characteristics, biochemical markers, and radiologic markers were measured at set intervals. An echocardiographic scoring system was applied. Patients were defined as having progression of carcinoid heart disease if the echocardiographic score increased by ≥25%. After a median follow-up of 29 months, 44 patients developed carcinoid heart disease or had progression of existing valvular dysfunction. At time of progression of carcinoid heart disease compared to the previous 6 months, there was a significant increase in median levels of 5-hydroxyindoleacetic acid (5-HIAA; 791 vs 460.5 μmol/24 hours) and flushing episodes (4.5 vs 2 episodes per day). Independent predictors of the development or progression of carcinoid heart disease were a 5-HIAA level ≥ 300 μmol/24 hours and ≥ 3 episodes of flushing per day. 5-HIAA levels of ≥ 300 to 599, 600 to 899, and > 900 μmol/24 hours conferred 2.74, 3.16, and 3.40 times the risk of progression of carcinoid heart disease, respectively. In conclusion, a 5-HIAA level ≥ 300 μmol/24 hours and ≥ 3 flushing episodes per day are predictors of the development or progression of carcinoid heart disease.

Valve replacement in haemodialysis: bleeding risk in mechanical vs bioprosthetic valves

Valve replacement in haemodialysis: bleeding risk in mechanical vs bioprosthetic valves

ORIGINAL ARTICLE: Assessment of cardiac valve dysfunction in patients receiving cabergoline treatment for hyperprolactinaemia

SummaryObjective Cabergoline is a highly effective medical treatment for patients with hyperprolactinaemia. There is an increased risk of valvular heart disease in patients receiving cabergoline for Parkinson’s disease. This study examined whether cabergoline treatment of hyperprolactinaemia is associated with a greater prevalence of valvulopathy.Design Cross‐sectional, two‐dimensional echocardiographic study performed by a single echocardiographer.Patients Seventy‐two patients (median age 36 years, 19 men) receiving cabergoline for hyperprolactinaemia, and 72 controls prospectively matched for age, sex and cardiovascular risk factors.Measurements Assessment of valvular mobility, regurgitation and morphology.Results Median cumulative dose exposure for cabergoline was 126 (58–258) mg, and patients had received cabergoline for 53 (26–96) months. The frequency of mild mitral regurgitation was identical (5/72, 7%) in patient and control groups. Mild aortic regurgitation was not significantly different between groups (4/72 [controls] vs 2/72 [patients], P = 0·681). There was only one case of tricuspid regurgitation, which was mild and observed in a cabergoline‐treated patient. Nodular thickening of the right coronary cusp, noncoronary cusp or left coronary cusp of the aortic valve was observed at a similar frequency in both groups. There were no cases of extensive thickening of any valvular leaflet.Conclusion Our data demonstrates that there is no association between cabergoline treatment for hyperprolactinaemia and valvulopathy. This study therefore supports continued use of low‐dose cabergoline for patients with hyperprolactinaemia.

Acrocomia Aculeata as an Unreported Cause of Tricuspid Regurgitation

Penetrating chest trauma can produce a wide range of lesions to cardiac structures. Some patients develop signs and symptoms of residual sequelae. We describe the case of an 11-year-old boy with severe tricuspid regurgitation caused by the thorn of a palm tree. A De Vega annuloplasty of the tricuspid valve and a bidirectional Glenn procedure were successfully performed 7 years after the episode. This case illustrates the importance of a thorough investigation of possible valvular heart disease in patients who suffered from chest trauma.

Analysis of association between carcinoid heart disease and mesenteric fibrosis in patients with midgut carcinoid tumour

e15650 Background: Valvular heart disease in patients with carcinoid syndrome is due to development of fibrosis and endocardial thickening in the heart. The most accepted theory relating to development of heart disease is secretion of serotonin (5- hydroxy tryptamine) by the tumour or metastases. Mesenteric fibrosis develops as a result of peptides e.g.TGF beta released by local metastases. Both complications cause significant morbidity and mortality in patients with carcinoid syndrome. Aim: to evaluate the relationship of carcinoid heart disease and mesenteric fibrosis. Methods: We analysed retrospectively all patients (n=200) who had metastatic (liver metatstasis) neuroendocrine tumour and carcinoid syndrome with the primary clearly identified within the small bowel or caecum. We aimed to evaluate clinically symptoms of mesenteric ischemia and small bowel obstruction and also radiological presence of desmoplasia and small bowel dilatation. All patients underwent clinical and echocardiographic cardiovascular assessment to determine the presence of carcinoid heart disease. Results: Of 200 patients 42 had echocardiographic evidence of carcinoid heart disease. 4 patients had evidence of both mesenteric desmoplasia and carcinoid heart disease. 38 patients had carcinoid heart disease alone. Of the remaining 158 patients who had no evidence of carcinoid heart disease, 24 of them had evidence of desmoplasia and/or clinical evidence of sub-acute bowel obstruction where no other cause could be found. The remaining 134 patients had none of these complications. Comparing the relationship of Carcinoid heart disease and mesenteric fibrosis using two tailed exact Fisher's test, p value is 0.45, demonstrating they are statistically independent. We are currently assessing the effect on mortality. Conclusions: Carcinoid heart disease and mesenteric fibrosis (and its effects) are important determinants in morbidity and mortality of patients with midgut neuroendocrine tumour. Although carcinoid heart disease and mesenteric fibrosis are part of the same patho-physiologic process affecting patients with midgut neuroendocrine tumour, the results suggest that progression of these complications is independent of each other. No significant financial relationships to disclose.

Long-term cabergoline therapy is not associated with valvular heart disease in patients with prolactinomas

Long-term cabergoline therapy is not associated with valvular heart disease in patients with prolactinomas

Valvular heart disease in patients with Parkinson’s disease treated with pergolide, levodopa or both

Cardiac valvulopathy has been reported in patients with Parkinson’s disease treated with pergolide. The aim of this study was to clarify the frequency and severity of valvular heart disease (VHD) in patients treated with pergolide, levodopa or both. We evaluated VHD by transthoracic echocardiography in 25 patients who were taking pergolide, 29 patients taking levodopa and 20 patients taking both levodopa and pergolide. All groups were compared with two separate age-matched control groups. There was no increase in the frequency of any type of echocardiographically-significant valvulopathy in the pergolide groups. Echocardiographically significant aortic regurgitation was found in 8% of the patients in the pergolide group and in 37.9% of the patients in the levodopa group. There was no correlation between VHD and pergolide dose, cumulative dose or duration of therapy. The mean pergolide dose was 2.6 ± 1.4 mg/day in the pergolide monotherapy group. We did not find any unequivocal evidence that pergolide causes significant valvular regurgitation. However, the mean pergolide dosage in our study was lower than in previous studies.

Long-term cabergoline therapy is not associated with valvular heart disease in patients with prolactinomas

Ergot-derived dopamine receptor agonists, especially pergolide and cabergoline, have been associated with an increased risk of valvular heart disease in patients treated for Parkinson's disease. Cabergoline at lower doses than those employed in Parkinson's disease is widely used in patients with prolactinomas, because of its high efficacy and tolerability; however, its safety with regard to cardiac valve disease is unknown. In order to assess the prevalence of cardiac valve regurgitation in patients with prolactinomas treated with long-term cabergoline, we performed a prospective and multicentric study including four university centers in the province of Quebec. A transthoracic echocardiogram was performed in 70 patients with prolactinomas treated with cabergoline for at least 1 year (duration of treatment, 55 +/- 22 months; cumulative dose 282 +/- 271 mg, mean +/- SD) and 70 control subjects matched for age and sex. Valvular regurgitation was graded according to the American Society of Echocardiography recommendations as mild, moderate, or severe. Moderate valvular regurgitation was found in four patients (5.7%) and five control subjects (7.1%) (P = 0.73). No patient had severe valvular regurgitation. There was no correlation between the presence of significant heart-valve regurgitation and cabergoline cumulative dose, duration of cabergoline treatment, prior use of bromocriptine, age, adenoma size, or prolactin levels. Our results show that low doses of cabergoline seem to be a safe treatment of hyperprolactinemic patients. However, in patients with prolonged cabergoline treatment, we suggest that echocardiographic surveillance may be warranted.

Aortic Valve Calcification and Mild Tricuspid Regurgitation But No Clinical Heart Disease after 8 Years of Dopamine Agonist Therapy for Prolactinoma

Treatment with ergot-derived dopamine agonists, pergolide, and cabergoline has been associated with an increased frequency of valvular heart disease in Parkinson's disease. The aim of the present study was to assess the prevalence of valvular heart disease in patients treated with dopamine agonists for prolactinomas. This was a cross-sectional study. We performed two-dimensional and Doppler echocardiography in 78 consecutive patients with prolactinoma (mean age 47 +/- 1.4 yr, 26% male, 31% macroprolactinoma) treated with dopamine agonists for at least 1 yr (mean 8 +/- 0.6 yr) and 78 control subjects. Patients were classified according to treatment: patients treated with cabergoline (group 1: n = 47) and patients not treated with cabergoline (group 2: n = 31). Clinically relevant valvular heart disease was present in 12% of patients (nine of 78) vs. 17% of controls (13 of 78) (P = 0.141) and 17% (eight of 47) of patients treated with cabergoline vs. 3% (one of 31) of patients not treated with cabergoline (P = 0.062). Mild tricuspid regurgitation was present in 41% of patients vs. 26% of controls (P = 0.042), and aortic valve calcification was present in 40% of patients, compared with 18% of controls (P = 0.003). There was no relation between the cumulative dose of cabergoline and the presence of mild, moderate, or severe valve regurgitation. Several years of dopamine agonist treatment in patients with prolactinomas is associated with increased prevalence of aortic valve calcification and mild tricuspid regurgitation but not with clinically relevant valvular heart disease. Therefore, additional studies on the adverse cardiac effects of dopaminergic drugs in prolactinoma are warranted, especially in patients with much longer use of these drugs.

Valvular heart disease in patients with Parkinson’s disease treated with pergolide. Course following treatment modifications

Valvular heart abnormalities have been reported in patients with Parkinson's disease (PD) treated with pergolide. However, the incidence and severity of these abnormalities vary from study to study and their course after drug withdrawal has not been systematically assessed. To estimate the frequency and severity of valvular heart abnormality and its possible reversibility after drug withdrawal in a case-control study. All PD patients in the Amiens area treated with pergolide were invited to attend a cardiologic assessment including transthoracic echocardiography. Thirty PD patients participated in the study. A second echocardiography was performed (median interval: 13 months) after pergolide withdrawal (n=10 patients). Controls were age- and sex-matched non-PD patients referred to the cardiology department. Compared to controls, aortic regurgitation (OR: 3.1; 95% IC: 1.1-8.8) and mitral regurgitation (OR: 10.7; 95% IC: 2.1-53) were more frequent in PD patients (tricuspid: NS). The number of affected valves (n=2.4+/-0.7) and the sum of regurgitation grades (n=2.8+/-1.09) were higher (p=0.008 and p=0.006, respectively) in the pergolide group. Severity of regurgitation was not correlated with pergolide cumulative dose. A restrictive pattern of valvular regurgitation, suggestive of the role of pergolide, was observed in 12/30 (40%) patients including two with heart failure. Pergolide was discontinued in 10 patients with valvular heart disease, resulting in a lower regurgitation grade (p=0.01) at the second transthoracic echocardiography and the two patients with heart failure returned to nearly normal clinical examination. This study supports the high frequency of restrictive valve regurgitation in PD patients treated with pergolide and reveals that a significant improvement is usual when the treatment is converted to non-ergot dopamine agonists.

Is a minithoracotomy approach justified for heart valve surgery in high risk patients?

We report our experience with a minimal invasive approach for valvular heart disease in patients at high risk. From February 2002 to June 2007, 97 (age 62,5 years) patients underwent heart valve surgery through a right anterolateral minithoracotomy at the fourth intercostal space. 24 of them (24.7%) were classified as at high risk (HR group): redo (58%), euroscore >10 (54%) and associated procedures (cryo-maze ablation, pulmonary lobectomy, coronary artery bypass graft, multiple valve surgery). The remaining patients were considered at lower risk (LR group) and otherwise comparable to the HR group. HTEA was applied to 67% and 50% of the LR and HR group (p 0.06). One patient died for cerebral ischemia (HR group) and one for the detatchment of a mitral prosthese (LR group). A short circulatory arrest was required to repair a posterior aortic lesion in two redo cases. Early extubation was achived in 51% and 66.6% of the LR and HR group respectively. There was no difference between operative time and aortic cross-clamping time (217±45 vs 276±80min and 70±16 vs 64±37min in the LR and HR group) whereas perfusion time was significantly longer in the MR group (p 0.0001) as well as hospital stay (p 0.006). The need of transfusion (12/24) and cerebral events (3/24) rates were higher in the HR group (p 0.03 and 0.006). At a mean follow-up of 28.6±13.9 months the 95 survived patients are alive and well. Right anterolateral minithoracotomy approach is a valuable option for heart valve surgery with acceptable perioperative morbidity and mortality even in high risk patients.