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Novo Matos J, Payne JR, Mullins J, Luis Fuentes V. Isolated discrete upper septal thickening in a non-referral cat population of senior and young cats. J Vet Cardiol 2023; 50:39-50. [PMID: 37924557 DOI: 10.1016/j.jvc.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 09/27/2023] [Accepted: 09/29/2023] [Indexed: 11/06/2023]
Abstract
INTRODUCTION/OBJECTIVES Discrete upper septal thickening (DUST) is a phenotype of elderly people. The cardiac phenotype in senior cats has been incompletely described. We aimed to characterize the echocardiographic phenotype of senior cats, specifically to determine prevalence of DUST and hypertrophic cardiomyopathy (HCM). ANIMALS One hundred and forty-nine healthy, normotensive cats. MATERIALS AND METHODS Prospective cross-sectional study. Senior (≥9 years) and young (<6 years) cats were recruited from non-referral population. We defined DUST as an isolated basilar septal bulge, and HCM as left ventricular wall thickness ≥6 mm. An interventricular septum ratio (basal-to-mid septal thickness ratio) was calculated. We assessed for associations between clinical and echocardiographic variables and DUST. Data are presented as mean (±SD), median (range), or frequency (percentage). RESULTS One-hundred and two senior and 47 young cats were enrolled. Aortoseptal angle (AoSA) was steeper in senior cats (137° (±14.5) vs. 145° (±12.3) in young cats, P=0.002). Eighteen cats had DUST (18/149, 12%), fourteen senior, and four young cats (P=0.4). Cats with DUST had steeper AoSA (125° (±8.3) vs. 142° (±13.7), P<0.0001) and higher interventricular septum ratio (1.4 (1.2-2.0) vs. 1.0 (0.7-1.8)). Univariable analysis showed decreased odds of DUST with greater AoSA (OR 0.9, P<0.0001), age was not associated with DUST. Twenty-nine senior cats had HCM (28.4%). DISCUSSION/CONCLUSIONS Prevalence of DUST was 12%. There was no association between age and DUST. Smaller/steeper AoSA was the main factor associated with DUST. There was a high prevalence of HCM in this senior population.
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Affiliation(s)
- J Novo Matos
- Clinical Science and Services, Royal Veterinary College, Hawkshead Lane, North Mymms, AL9 7TA, UK.
| | - J R Payne
- Langford Vets Small Animal Referral Hospital, University of Bristol, Langford House, BS40 5DU, Langford, UK
| | - J Mullins
- Clinical Science and Services, Royal Veterinary College, Hawkshead Lane, North Mymms, AL9 7TA, UK
| | - V Luis Fuentes
- Clinical Science and Services, Royal Veterinary College, Hawkshead Lane, North Mymms, AL9 7TA, UK
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Crofton AE, Kovacs SL, Stern JA. Subvalvular Aortic Stenosis: Learning From Human and Canine Clinical Research. Cardiol Res 2023; 14:319-333. [PMID: 37936623 PMCID: PMC10627371 DOI: 10.14740/cr1547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 10/03/2023] [Indexed: 11/09/2023] Open
Abstract
Subvalvular aortic stenosis (SAS) is the most common congenital heart disease (CHD) in dogs and is also prevalent in human children. A fibrous ridge below the aortic valve narrows the left ventricular outflow tract (LVOT) and increases blood flow velocity, leading to devastating side effects in diseased patients. Due to the similarities in presentation, anatomy, pathophysiology, cardiac development, genomics, and environment between humans and dogs, canine SAS patients represent a critical translational model of human SAS. Potential adverse outcomes of SAS include arrhythmias, left-sided congestive heart failure, endocarditis, exercise intolerance, syncope, and sudden cardiac death. The greatest divergence between canine and human SAS clinical research has been the standard of care regarding treatment of these outcomes, with pharmacological intervention dominating best practices in veterinary medicine and surgical intervention comprising the standard practice for human SAS patients. Regardless of the species, the field has yet to identify a treatment option to prevent disease progression or permanently remove the fibrous ridge, but historical leaps in SAS research support a continued translational approach as the most promising method for achieving this goal.
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Affiliation(s)
- Amanda E. Crofton
- Department of Medicine and Epidemiology, School of Veterinary Medicine, University of California Davis, Davis, CA 95616, USA
| | - Samantha L. Kovacs
- Veterinary Medical Teaching Hospital, School of Veterinary Medicine, University of California Davis, Davis, CA 95616, USA
| | - Joshua A. Stern
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC 27607, USA
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Perez Y, Dearani JA, Miranda WR, Stephens EH. Subaortic Stenosis in Adult Patients With Atrioventricular Septal Defect. Ann Thorac Surg 2023; 115:479-484. [PMID: 35987344 DOI: 10.1016/j.athoracsur.2022.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 07/11/2022] [Accepted: 08/01/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Patients with atrioventricular septal defects (AVSD) are at risk for development of subaortic stenosis throughout their lifetime. The early and midterm outcomes of adults with AVSD undergoing primary operation or reoperation for subaortic stenosis remain unknown. METHODS All patients aged 18 years or more with partial or complete AVSD who underwent operation for subaortic stenosis at our institution from 1992 to 2020 were retrospectively reviewed. RESULTS Nineteen patients were identified: 15 patients with partial AVSD (79%); 3 (16%) with complete AVSD; and 1 (5%) with transitional AVSD. Fifteen patients (79%) had previously corrected AVSD (median 8 years; interquartile range, 3.6-23.1) and 7 (37%) had previous repair of subaortic stenosis. The mechanism for obstruction included subaortic membrane (n = 19, 100%); septal hypertrophy (n = 11, 58%); anomalous papillary muscle, chordae, or left atrioventricular valve tissue (n = 9, 47%); and tunnel obstruction (n = 5, 26%). All patients underwent transaortic membrane resection, and septal myectomy was done in 18 patients (95%). There was no early mortality. During follow-up (median 8.3 years, maximum 28), survival was 100% at 5 years and 95% at 10 years. One patient required reintervention for subaortic stenosis 15 years after the operation at our institution. CONCLUSIONS Surgical correction of subaortic obstruction in adult patients with AVSD can be accomplished with low morbidity and mortality. Subaortic stenosis can appear late after the initial repair of AVSD, and these patients remain at risk for recurrence after resection.
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Affiliation(s)
- Yalile Perez
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
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Schlein J, Wollmann F, Kaider A, Wiedemann D, Gabriel H, Hornykewycz S, Base E, Michel-Behnke I, Laufer G, Zimpfer D. Long-term outcomes after surgical repair of subvalvular aortic stenosis in pediatric patients. Front Cardiovasc Med 2022; 9:1033312. [DOI: 10.3389/fcvm.2022.1033312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 11/11/2022] [Indexed: 12/03/2022] Open
Abstract
ObjectivesSubvalvular aortic stenosis (SAS) can occur as discrete or tunnel-like obstruction of the left ventricular outflow tract and as progressive disease often leads to aortic valve regurgitation. We report our 30-year single-center experience after surgical repair of SAS.MethodsA retrospective chart review of all patients aged < 18 years, who underwent surgical repair of SAS from May 1985 to April 2020, was conducted. Mortality was cross-checked with the national health insurance database (93.8% complete mortality follow-up in April 2020). Survival and competing risks analysis were used to analyze the primary endpoints survival and incidence of reoperations.ResultsFrom May 1985 until April 2020 103 patients (median age 5.5 years) underwent surgical repair of SAS. Survival was 90.8% at 10 years and 88.7% at 20 and 30 years. Age < 1 year at time of surgery, Shone’s complex, mitral stenosis and concomitant mitral valve surgery were associated with mortality. The cumulative incidence of reoperation for SAS was 21.6% at 10 years, 28.2% at 20 and 30 years. The incidence of reoperation for SAS did not differ between the myectomy, membrane resection and combined myectomy and membrane resection groups. The cumulative incidence of reoperation on the aortic valve was 13.5% at 20 years.ConclusionRecurrence rate of SAS is not to be neglected, though surgical repair of subaortic stenosis has good long-term results. Patients who needed a combined membrane resection and septal myectomy are not more prone to recurrence than patients who underwent solitaire myectomy or membrane resection.
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Shar JA, Keswani SG, Grande-Allen KJ, Sucosky P. Significance of aortoseptal angle anomalies to left ventricular hemodynamics and subaortic stenosis: A numerical study. Comput Biol Med 2022; 146:105613. [PMID: 35751200 PMCID: PMC10570849 DOI: 10.1016/j.compbiomed.2022.105613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 05/02/2022] [Accepted: 05/10/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Discrete subaortic stenosis (DSS) is an obstructive cardiac disease caused by a membranous lesion in the left ventricular (LV) outflow tract (LVOT). Although its etiology is unknown, the higher prevalence of DSS in LVOT anatomies featuring a steep aortoseptal angle (AoSA) suggests a potential role for hemodynamics. Therefore, the objective of this study was to quantify the impact of AoSA steepening on the LV three-dimensional (3D) hemodynamic stress environment. METHODS A 3D LV model reconstructed from cardiac cine-magnetic resonance imaging was connected to four LVOT geometrical variations spanning the clinical AoSA range (115°-160°). LV hemodynamic stresses were characterized in terms of cycle-averaged pressure, temporal shear magnitude (TSM), and oscillatory shear index. The wall shear stress (WSS) topological skeleton was further analyzed by computing the scaled divergence of the WSS vector field. RESULTS AoSA steepening caused an increasingly perturbed subaortic flow marked by LVOT flow skewness and complex 3D secondary flow patterns. These disturbances generated WSS overloads (>45% increase in TSM vs. 160° model) on the inferior LVOT wall, and increased WSS contraction (>66% decrease in WSS divergence vs. 160° model) in regions prone to DSS membrane formation. CONCLUSIONS AoSA steepening generated substantial hemodynamic stress abnormalities in LVOT regions prone to DSS formation. Further studies are needed to assess the possible impact of such mechanical abnormalities on the tissue and cellular responses.
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Affiliation(s)
- Jason A Shar
- Department of Mechanical Engineering, Kennesaw State University, 840 Polytechnic Lane, Marietta, GA, 30060, USA.
| | - Sundeep G Keswani
- Division of Pediatric Surgery, Texas Children's Hospital, Department of Surgery, Baylor College of Medicine, USA.
| | | | - Philippe Sucosky
- Department of Mechanical Engineering, Kennesaw State University, 840 Polytechnic Lane, Marietta, GA, 30060, USA.
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Papakonstantinou NA, Kanakis MA, Bobos D, Giannopoulos NM. Congenital, acquired, or both? The only two congenitally based, acquired heart diseases. J Card Surg 2021; 36:2850-2856. [PMID: 33908651 DOI: 10.1111/jocs.15588] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 04/14/2021] [Accepted: 04/16/2021] [Indexed: 11/28/2022]
Abstract
Discrete subaortic stenosis (DSS) is a type of left ventricular outflow tract obstruction whereas double-chambered right ventricle is a form of right ventricular outflow tract obstruction. Both of these cardiac malformations share lots of similar characteristics which classify them as acquired developmental heart diseases despite their congenital anatomical substrate. Both of them are frequently associated to ventricular septal defects. The initial stimulus in their pathogenetic process is anatomical abnormalities or variations. Subsequently, a hemodynamic process is triggered finally leading to an abnormal subaortic fibroproliferative process with regard to DSS or to hypertrophy of ectopic muscles as far as double-chambered right ventricle is concerned. In many cases, these pathologies are developed secondarily to surgical management of other congenital or acquired heart defects. Moreover, high recurrence rates after initial successful surgical therapy, particularly regarding DSS, have been described. Finally, an interesting coexistence of DSS and double-chambered aortic ventricle has also been reported in some cases.
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Affiliation(s)
| | - Meletios A Kanakis
- Department of Pediatric and Congenital Heart Surgery, Onassis Cardiac Surgery Center, Athens, Greece
| | - Dimitrios Bobos
- Department of Pediatric and Congenital Heart Surgery, Onassis Cardiac Surgery Center, Athens, Greece
| | - Nicholas M Giannopoulos
- Department of Pediatric and Congenital Heart Surgery, Onassis Cardiac Surgery Center, Athens, Greece
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Sinha M, Pandey NN, Sharma A, Parashar N, Kumar S, Sharma G. Aneurysmal and obstructive lesions of the left ventricular outflow: evaluation on multidetector computed tomography angiography. Pol J Radiol 2021; 86:e195-e203. [PMID: 34093915 PMCID: PMC8147719 DOI: 10.5114/pjr.2021.105588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 08/06/2020] [Indexed: 11/30/2022] Open
Abstract
The left ventricular outflow is an anatomically complex region situated between the anterior leaflet of the mitral valve and the left ventricular aspect of the muscular and membranous interventricular septum. It gives rise to the aorta, provides support to the aortic valvular cusps, and houses important components of the conduction system. The left ventricular outflow handles high pressures and pressure variations and is subsequently affected by a variety of aetio-pathological conditions. Diseases involving the left ventricular outflow can be intraluminal, mural, or extramural, and the consequent complications of the lesions can be local, loco-regional, or even systemic. Appropriate evaluation requires comprehensive multimodality imaging with each modality contributing to assessment of different aspects of diagnosis, lesion characterization, local extension, prognostication for systemic complications and mortality, and the decision for the approach and type of intervention and aggressive follow-up in case non-interventional management is decided. In this review, we briefly describe the relevant anatomy and the gamut of structural abnormalities pertaining to the left ventricular outflow on multidetector computed tomography angiography.
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Affiliation(s)
| | | | - Arun Sharma
- Correspondence address: Dr. Arun Sharma, 148, The Foothills, New Chandigarh (Pb), India, e-mail:
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Assessment of the conjunctival microcirculation in adult patients with cyanotic congenital heart disease compared to healthy controls. Microvasc Res 2021; 136:104167. [PMID: 33838207 DOI: 10.1016/j.mvr.2021.104167] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 03/30/2021] [Accepted: 03/30/2021] [Indexed: 11/23/2022]
Abstract
PURPOSE Congenital heart disease (CHD) is the most common live birth defect and a proportion of these patients have chronic hypoxia. Chronic hypoxia leads to secondary erythrocytosis resulting in microvascular dysfunction and increased thrombosis risk. The conjunctival microcirculation is easily accessible for imaging and quantitative assessment. It has not previously been studied in adult CHD patients with cyanosis (CCHD). METHODS We assessed the conjunctival microcirculation and compared CCHD patients and matched healthy controls to determine if there were differences in measured microcirculatory parameters. We acquired images using an iPhone 6s and slit-lamp biomicroscope. Parameters measured included diameter, axial velocity, wall shear rate and blood volume flow. The axial velocity was estimated by applying the 1D + T continuous wavelet transform (CWT). Results are for all vessels as they were not sub-classified into arterioles or venules. RESULTS 11 CCHD patients and 14 healthy controls were recruited to the study. CCHD patients were markedly more hypoxic compared to the healthy controls (84% vs 98%, p = 0.001). A total of 736 vessels (292 vs 444) were suitable for analysis. Mean microvessel diameter (D) did not significantly differ between the CCHD patients and controls (20.4 ± 2.7 μm vs 20.2 ± 2.6 μm, p = 0.86). Axial velocity (Va) was lower in the CCHD patients (0.47 ± 0.06 mm/s vs 0.53 ± 0.05 mm/s, p = 0.03). Blood volume flow (Q) was lower for CCHD patients (121 ± 30pl/s vs 145 ± 50pl/s, p = 0.65) with the greatest differences observed in vessels >22 μm diameter (216 ± 121pl/s vs 258 ± 154pl/s, p = 0.001). Wall shear rate (WSR) was significantly lower for the CCHD group (153 ± 27 s-1 vs 174 ± 22 s-1, p = 0.04). CONCLUSIONS This iPhone and slit-lamp combination assessment of conjunctival vessels found lower axial velocity, wall shear rate and in the largest vessel group, lower blood volume flow in chronically hypoxic patients with congenital heart disease. With further study this assessment method may have utility in the evaluation of patients with chronic hypoxia.
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Shar JA, Keswani SG, Grande-Allen KJ, Sucosky P. Computational Assessment of Valvular Dysfunction in Discrete Subaortic Stenosis: A Parametric Study. Cardiovasc Eng Technol 2021; 12:559-575. [PMID: 33432514 DOI: 10.1007/s13239-020-00513-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 12/22/2020] [Indexed: 01/16/2023]
Abstract
PURPOSE Discrete subaortic stenosis (DSS) is a left-ventricular outflow tract (LVOT) obstruction caused by a membranous lesion. DSS is associated with steep aortoseptal angles (AoSAs) and is a risk factor for aortic regurgitation (AR). However, the etiology of AR secondary to DSS remains unknown. This study aimed at quantifying computationally the impact of AoSA steepening and DSS on aortic valve (AV) hemodynamics and AR. METHODS An LV geometry reconstructed from cine-MRI data was connected to an AV geometry to generate a unified 2D LV-AV model. Six geometrical variants were considered: unobstructed (CTRL) and DSS-obstructed LVOT (DSS), each reflecting three AoSA variations (110°, 120°, 130°). Fluid-structure interaction simulations were run to compute LVOT flow, AV leaflet dynamics, and regurgitant fraction (RF). RESULTS AoSA steepening and DSS generated vortex dynamics alterations and stenotic flow conditions. While the CTRL-110° model generated the highest degree of leaflet opening asymmetry, DSS preferentially altered superior leaflet kinematics, and caused leaflet-dependent alterations in systolic fluttering. LVOT steepening and DSS subjected the leaflets to increasing WSS overloads (up to 94% increase in temporal shear magnitude), while DSS also increased WSS bidirectionality on the inferior leaflet belly (+ 0.30-point in oscillatory shear index). Although AoSA steepening and DSS increased diastolic transvalvular backflow, regurgitant fractions (RF < 7%) remained below the threshold defining clinical mild AR. CONCLUSIONS The mechanical interactions between AV leaflets and LVOT steepening/DSS hemodynamic derangements do not cause AR. However, the leaflet WSS abnormalities predicted in those anatomies provide new support to a mechanobiological etiology of AR secondary to DSS.
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Affiliation(s)
- Jason A Shar
- Department of Mechanical and Materials Engineering, Wright State University, Dayton, USA
| | - Sundeep G Keswani
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, USA
| | | | - Philippe Sucosky
- Department of Mechanical Engineering, Kennesaw State University, 840 Polytechnic Lane, Marietta, GA, 30060, USA.
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Kim AS, Henderson KJ, Pawar S, Kim MJ, Punjani S, Pollak JS, Fahey JT, Garcia‐Tsao G, Sugeng L, Young LH. Subaortic Membranes in Patients With Hereditary Hemorrhagic Telangiectasia and Liver Vascular Malformations. J Am Heart Assoc 2020; 9:e016197. [PMID: 33054561 PMCID: PMC7763373 DOI: 10.1161/jaha.120.016197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background Patients with hereditary hemorrhagic telangiectasia have liver vascular malformations that can cause high‐output cardiac failure (HOCF). Known sequelae include pulmonary hypertension, tricuspid regurgitation, and atrial fibrillation. Methods and Results The objectives of this study were to describe the clinical, echocardiographic, and hemodynamic characteristics and prognosis of hereditary hemorrhagic telangiectasia patients with HOCF who were found to have a subaortic membrane (SAoM). A retrospective observational analysis comparing patients with and without SAoM was performed. Among a cohort of patients with HOCF, 9 were found to have a SAoM in the left ventricular outflow tract by echocardiography (all female, mean age 64.8±4.0 years). The SAoM was discrete and located in the left ventricular outflow tract 1.1±0.1 cm below the aortic annular plane. It caused turbulent flow, mild obstruction (peak velocity 2.8±0.2 m/s, peak gradient 32±4 mm Hg), and no more than mild aortic insufficiency. Patients with SAoM (n=9) had higher cardiac output (12.1±1.3 versus 9.3±0.7 L/min, P=0.04) and mean pulmonary artery pressures (36±3 versus 28±2 mm Hg, P=0.03) compared with those without SAoM (n=19) during right heart catheterization. Genetic analysis revealed activin receptor‐like kinase 1 mutations in each of the 8 patients with SAoM who had available test results. The presence of a SAoM was associated with a trend towards higher 5‐year mortality during follow‐up. Conclusions SAoM with mild obstruction occurs in patients with hereditary hemorrhagic telangiectasia and HOCF. SAoM was associated with features of more advanced HOCF and poor outcomes.
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Affiliation(s)
- Agnes S. Kim
- Department of Internal Medicine Calhoun Cardiology Center University of Connecticut School of Medicine Farmington CT
| | - Katharine J. Henderson
- Section of Vascular and Interventional Radiology Department of Radiology and Biomedical Imaging Yale University School of Medicine New Haven CT
| | - Sumeet Pawar
- Section of Cardiovascular Medicine Department of Internal Medicine Yale University School of Medicine New Haven CT
| | - Min Jung Kim
- Department of Internal Medicine Calhoun Cardiology Center University of Connecticut School of Medicine Farmington CT
| | - Shahnaz Punjani
- Section of Cardiovascular Medicine Department of Internal Medicine Yale University School of Medicine New Haven CT
| | - Jeffrey S. Pollak
- Section of Vascular and Interventional Radiology Department of Radiology and Biomedical Imaging Yale University School of Medicine New Haven CT
| | - John T. Fahey
- Section of Cardiology Department of Pediatrics Yale University School of Medicine New Haven CT
| | - Guadalupe Garcia‐Tsao
- Section of Digestive Disease Department of Internal Medicine Yale University School of Medicine New Haven CT
| | - Lissa Sugeng
- Section of Cardiovascular Medicine Department of Internal Medicine Yale University School of Medicine New Haven CT
| | - Lawrence H. Young
- Section of Cardiovascular Medicine Department of Internal Medicine Yale University School of Medicine New Haven CT
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Demșa I, Crișu D, Haba CMȘ, Ursaru AM, Afrăsânie VA, Costache II, Petriș AO, Tesloianu DN. Persistent Left Superior Vena Cava with Absent Right Superior Vena Cava and Discrete Subaortic Stenosis Diagnosed in a Patient with Sick Sinus Syndrome: A Case Report and Brief Review of the Literature. Diagnostics (Basel) 2020; 10:diagnostics10100847. [PMID: 33086768 PMCID: PMC7589949 DOI: 10.3390/diagnostics10100847] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 10/17/2020] [Accepted: 10/18/2020] [Indexed: 01/20/2023] Open
Abstract
A persistent left superior vena cava (PLSVC) is the most frequent anomaly of the venous drainage system. While both a right and left superior vena cava (SVC) are usually present, a unique, left-sided SVC, also known as an isolated PLSVC, accounts for only 10–20% of cases. It is frequently associated with arrhythmias and other congenital cardiac anomalies. Though it is usually an asymptomatic condition, it may pose significant problems whenever central venous access is needed. We report a case of an isolated PLSVC that was diagnosed incidentally during pacemaker implantation for sinus node dysfunction. The venous anomaly was associated with subvalvular aortic stenosis determined by a subaortic membrane; this particular association of congenital cardiovascular anomalies is a rare finding, with only a few cases reported in the literature. We aim to highlight the clinical and practical implications of this condition, as well as to discuss the embryonic development and diagnostic methods of this congenital defect.
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Affiliation(s)
- Irina Demșa
- Department of Cardiology, Emergency Clinical Hospital “Sf. Spiridon”, Bd. Independenței nr. 1, 700111 Iași, Romania; (I.D.); (C.M.Ș.H.); (A.M.U.); (I.I.C.); (A.O.P.); (D.N.T.)
| | - Daniela Crișu
- Department of Cardiology, Emergency Clinical Hospital “Sf. Spiridon”, Bd. Independenței nr. 1, 700111 Iași, Romania; (I.D.); (C.M.Ș.H.); (A.M.U.); (I.I.C.); (A.O.P.); (D.N.T.)
- Correspondence: ; Tel.: +40-745-264-550
| | - Cristian Mihai Ștefan Haba
- Department of Cardiology, Emergency Clinical Hospital “Sf. Spiridon”, Bd. Independenței nr. 1, 700111 Iași, Romania; (I.D.); (C.M.Ș.H.); (A.M.U.); (I.I.C.); (A.O.P.); (D.N.T.)
- Department of Internal Medicine, “Grigore.T. Popa” University of Medicine and Pharmacy, str. Universitatii nr. 16, 700083 Iași, Romania
| | - Andreea Maria Ursaru
- Department of Cardiology, Emergency Clinical Hospital “Sf. Spiridon”, Bd. Independenței nr. 1, 700111 Iași, Romania; (I.D.); (C.M.Ș.H.); (A.M.U.); (I.I.C.); (A.O.P.); (D.N.T.)
| | - Vlad-Adrian Afrăsânie
- Department of Medical Oncology, “Grigore.T. Popa” University of Medicine and Pharmacy, str. Universitatii nr. 16, 700083 Iași, Romania;
| | - Irina Iuliana Costache
- Department of Cardiology, Emergency Clinical Hospital “Sf. Spiridon”, Bd. Independenței nr. 1, 700111 Iași, Romania; (I.D.); (C.M.Ș.H.); (A.M.U.); (I.I.C.); (A.O.P.); (D.N.T.)
- Department of Internal Medicine, “Grigore.T. Popa” University of Medicine and Pharmacy, str. Universitatii nr. 16, 700083 Iași, Romania
| | - Antoniu Octavian Petriș
- Department of Cardiology, Emergency Clinical Hospital “Sf. Spiridon”, Bd. Independenței nr. 1, 700111 Iași, Romania; (I.D.); (C.M.Ș.H.); (A.M.U.); (I.I.C.); (A.O.P.); (D.N.T.)
- Department of Internal Medicine, “Grigore.T. Popa” University of Medicine and Pharmacy, str. Universitatii nr. 16, 700083 Iași, Romania
| | - Dan Nicolae Tesloianu
- Department of Cardiology, Emergency Clinical Hospital “Sf. Spiridon”, Bd. Independenței nr. 1, 700111 Iași, Romania; (I.D.); (C.M.Ș.H.); (A.M.U.); (I.I.C.); (A.O.P.); (D.N.T.)
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Shar JA, Brown KN, Keswani SG, Grande-Allen J, Sucosky P. Impact of Aortoseptal Angle Abnormalities and Discrete Subaortic Stenosis on Left-Ventricular Outflow Tract Hemodynamics: Preliminary Computational Assessment. Front Bioeng Biotechnol 2020; 8:114. [PMID: 32175314 PMCID: PMC7056880 DOI: 10.3389/fbioe.2020.00114] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 02/04/2020] [Indexed: 12/27/2022] Open
Abstract
Discrete subaortic stenosis (DSS) is an obstruction of the left ventricular outflow tract (LVOT) due to the formation of a fibromuscular membrane upstream of the aortic valve. DSS is a major risk factor for aortic regurgitation (AR), which often persists after surgical resection of the membrane. While the etiology of DSS and secondary AR is largely unknown, the frequent association between DSS and aortoseptal angle (AoSA) abnormalities has supported the emergence of a mechanobiological pathway by which hemodynamic stress alterations on the septal wall could trigger a biological cascade leading to fibrosis and membrane formation. The resulting LVOT flow disturbances could activate the valve endothelium and contribute to AR. In an effort to assess this hypothetical mechano-etiology, this study aimed at isolating computationally the effects of AoSA abnormalities on septal wall shear stress (WSS), and the impact of DSS on LVOT hemodynamics. Two-dimensional computational fluid dynamics models featuring a normal AoSA (N-LV), a steep AoSA (S-LV), and a steep AoSA with a DSS lesion (DSS-LV) were designed to compute the flow in patient-specific left ventricles (LVs). Boundary conditions consisted of transient velocity profiles at the mitral inlet and LVOT outlet, and patient-specific LV wall motion. The deformation of the DSS lesion was computed using a two-way fluid-structure interaction modeling strategy. Turbulence was accounted for via implementation of the k-ω turbulence model. While the N-LV and S-LV models generated similar LVOT flow characteristics, the DSS-LV model resulted in an asymmetric LVOT jet-like structure, subaortic stenotic conditions (up to 2.4-fold increase in peak velocity, 45% reduction in effective jet diameter vs. N-LV/S-LV), increased vorticity (2.8-fold increase) and turbulence (5- and 3-order-of-magnitude increase in turbulent kinetic energy and Reynolds shear stress, respectively). The steep AoSA subjected the septal wall to a 23% and 69% overload in temporal shear magnitude and gradient, respectively, without any substantial change in oscillatory shear index. This study reveals the existence of WSS overloads on septal wall regions prone to DSS lesion formation in steep LVOTs, and the development of highly turbulent, stenotic and asymmetric flow in DSS LVOTs, which support a possible mechano etiology for DSS and secondary AR.
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Affiliation(s)
- Jason A. Shar
- Department of Mechanical and Materials Engineering, Wright State University, Dayton, OH, United States
| | - Kathleen N. Brown
- Department of Bioengineering, Rice University, Houston, TX, United States
| | - Sundeep G. Keswani
- Division of Pediatric Surgery, Texas Children’s Hospital, Houston, TX, United States
- Department of Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Jane Grande-Allen
- Department of Bioengineering, Rice University, Houston, TX, United States
| | - Philippe Sucosky
- Department of Mechanical and Materials Engineering, Wright State University, Dayton, OH, United States
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13
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Zhang X, Wang W, Yan J, Wang Q. Surgical treatment results of secondary tunnel‐like subaortic stenosis after congenital heart disease operations: A 7‐year, single‐center experience in 25 patients. J Card Surg 2019; 35:335-340. [PMID: 31765039 DOI: 10.1111/jocs.14369] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Xing Zhang
- Fuwai Hospital, National Center for Cardiovascular DiseaseChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijing China
| | - Wei Wang
- Fuwai Hospital, National Center for Cardiovascular DiseaseChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijing China
| | - Jun Yan
- Fuwai Hospital, National Center for Cardiovascular DiseaseChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijing China
| | - Qiang Wang
- Fuwai Hospital, National Center for Cardiovascular DiseaseChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijing China
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14
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Silbiger JJ, Lee S, Christia P, Perk G. Mechanisms, pathophysiology, and diagnostic imaging of left ventricular outflow tract obstruction following mitral valve surgery and transcatheter mitral valve replacement. Echocardiography 2019; 36:1165-1172. [DOI: 10.1111/echo.14370] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 04/06/2019] [Accepted: 05/07/2019] [Indexed: 11/29/2022] Open
Affiliation(s)
| | - Samantha Lee
- Icahn School of Medicine at Mount Sinai New York New York
| | | | - Gila Perk
- Icahn School of Medicine at Mount Sinai New York New York
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15
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McGregor PC, Manning P, Raj V, Pipilas A, Zhang Y, Rasalingam R, Aragam J. Does Presence of Discrete Subaortic Stenosis Alter Diagnosis and Management of Concomitant Valvular Aortic Stenosis? CASE 2019; 3:77-84. [PMID: 31049485 PMCID: PMC6479215 DOI: 10.1016/j.case.2018.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Adults with SM have slower hemodynamic progression and more rapid AS progression. Changes in LVOT velocities are minimal over time. Presence of SM with AS poses challenges in determining hemodynamic significance. In general, surgery should be recommended when AS is severe and symptoms develop.
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16
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Massé DD, Shar JA, Brown KN, Keswani SG, Grande-Allen KJ, Sucosky P. Discrete Subaortic Stenosis: Perspective Roadmap to a Complex Disease. Front Cardiovasc Med 2018; 5:122. [PMID: 30320123 PMCID: PMC6166095 DOI: 10.3389/fcvm.2018.00122] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 08/17/2018] [Indexed: 12/13/2022] Open
Abstract
Discrete subaortic stenosis (DSS) is a congenital heart disease that results in the formation of a fibro-membranous tissue, causing an increased pressure gradient in the left ventricular outflow tract (LVOT). While surgical resection of the membrane has shown some success in eliminating the obstruction, it poses significant risks associated with anesthesia, sternotomy, and heart bypass, and it remains associated with a high rate of recurrence. Although a genetic etiology had been initially proposed, the association between DSS and left ventricle (LV) geometrical abnormalities has provided more support to a hemodynamic etiology by which congenital or post-surgical LVOT geometric derangements could generate abnormal shear forces on the septal wall, triggering in turn a fibrotic response. Validating this hypothetical etiology and understanding the mechanobiological processes by which altered shear forces induce fibrosis in the LVOT are major knowledge gaps. This perspective paper describes the current state of knowledge of DSS, articulates the research needs to yield mechanistic insights into a significant pathologic process that is poorly understood, and proposes several strategies aimed at elucidating the potential mechanobiological synergies responsible for DSS pathogenesis. The proposed roadmap has the potential to improve DSS management by identifying early targets for prevention of the fibrotic lesion, and may also prove beneficial in other fibrotic cardiovascular diseases associated with altered flow.
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Affiliation(s)
- Danielle D Massé
- Department of Mechanical and Materials Engineering, Wright State University, Dayton, OH, United States
| | - Jason A Shar
- Department of Mechanical and Materials Engineering, Wright State University, Dayton, OH, United States
| | - Kathleen N Brown
- Department of Bioengineering, Rice University, Houston, TX, United States
| | - Sundeep G Keswani
- Division of Pediatric Surgery, Texas Children's Hospital, Houston, TX, United States.,Department of Surgery, Baylor College of Medicine, Houston, TX, United States
| | | | - Philippe Sucosky
- Department of Mechanical and Materials Engineering, Wright State University, Dayton, OH, United States
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17
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Mukadam S, Gordon BM, Olson JT, Newcombe JB, Hasaniya NW, Razzouk AJ, Bailey LL. Subaortic Stenosis Resection in Children: Emphasis on Recurrence and the Fate of the Aortic Valve. World J Pediatr Congenit Heart Surg 2018; 9:522-528. [DOI: 10.1177/2150135118776931] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Recurrence after surgical resection of discrete subvalvar aortic stenosis in children often requires repeat operation. Risk factors for recurrence are poorly understood. We sought to determine potential risk factors for recurrence and postoperative comorbidities in the long term. Methods: Retrospective chart review was performed on all pediatric patients who underwent surgical resection of discrete subaortic stenosis at our institution. Demographics, perioperative findings, and clinical data were analyzed for predisposing factors. Results: From 1991 to 2015, a total of 104 patients underwent primary surgical resection of discrete subaortic stenosis. There were no postoperative deaths. Three (2.9%) patients required pacemaker implantation. Nine (8.4%) patients required repeat resection for recurrence of subaortic membrane over a median follow-up of 8.5 years (interquartile range: 5.9-13.5 years). Actuarial freedom from repeat resection was 100%, 94%, and 82% at one, five, and ten years, respectively. Repeat resection occurred more frequently in patients with genetic disease (37.5% vs 10.7%; P = .033) and preoperative mitral regurgitation (MR; 25% vs 1.2%; P < .001). Postoperative aortic insufficiency (AI) that was moderate or worse was associated with older age at the time of first resection (relative risk [RR]: 1.54, P < .05), moderate or severe preoperative AI (RR: 1.84, P = .002), and repeat resection of subaortic stenosis (RR: 1.90, P < .001). Conclusion: The majority of children who undergo surgical resection of subaortic stenosis will not experience recurrence in childhood and those who do require repeat resection may have a higher incidence of genetic disease and preoperative MR. Postoperative AI is associated with repeat resection, older age at the time of surgery, and degree of preoperative AI.
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Affiliation(s)
- Shireen Mukadam
- Division of General Pediatrics, Department of Pediatrics, Loma Linda University Hospital, Loma Linda, CA, USA
| | - Brent M. Gordon
- Division of Pediatric Cardiology, Department of Pediatrics, Loma Linda University Hospital, Loma Linda, CA, USA
| | - Jeffrey T. Olson
- Division of General Pediatrics, Department of Pediatrics, Loma Linda University Hospital, Loma Linda, CA, USA
- Department of Medicine, Loma Linda University Hospital, Loma Linda, CA, USA
| | - Jennifer B. Newcombe
- Department of Cardiovascular and Thoracic Surgery, Loma Linda University Hospital, Loma Linda, CA, USA
| | - Nahidh W. Hasaniya
- Department of Cardiovascular and Thoracic Surgery, Loma Linda University Hospital, Loma Linda, CA, USA
| | - Anees J. Razzouk
- Department of Cardiovascular and Thoracic Surgery, Loma Linda University Hospital, Loma Linda, CA, USA
| | - Leonard L. Bailey
- Department of Cardiovascular and Thoracic Surgery, Loma Linda University Hospital, Loma Linda, CA, USA
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Abstract
PURPOSE OF REVIEW Distinction between discrete subvalvar aortic stenosis and other causes of left ventricular outflow obstruction has important implications for predicting natural history and guiding the timing and type of intervention. Imaging, primarily transthoracic echocardiography (TTE), plays a pivotal role in the diagnosis and management of adults with subvalvar aortic stenosis. RECENT FINDINGS Most systematic research on imaging of subvalvar aortic stenosis has focused on echocardiography. TTE, especially two-dimensional imaging with color and spectral Doppler, remains the main modality for delineation of the anatomic and hemodynamic features of subvalvar stenosis, associated anomalies and involvement of accessory mitral valve attachments to the subaortic septum or abnormally placed papillary muscles. Transesophageal echocardiography may provide more detailed definition of left ventricular outflow tract anatomy, including the presence and extension of the obstructive subaortic fibroelastic tissue onto the aortic or mitral valve, especially in patients with poor transthoracic windows. The clinical role for advanced imaging technologies, including three-dimensional echocardiography, cardiac magnetic resonance and computed tomography, is evolving but, largely because of the adequacy of established imaging with TTE, remains relatively limited. SUMMARY In the absence of other congenital heart defects or alternative indications (e.g. coronary angiography), TTE is usually adequate for the assessment of discrete subvalvar aortic stenosis in the adult. In specific clinical situations, supplemental imaging modalities can play an integral role in clinical decision making.
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Nawaytou HM, Mercer-Rosa L, Channing A, Cohen MS. Intraoperative transesophageal echocardiographic predictors of recurrent left ventricular outflow tract obstruction in children undergoing subaortic stenosis resection. Echocardiography 2018; 35:678-684. [PMID: 29437237 DOI: 10.1111/echo.13827] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Intraoperative transesophageal echocardiography (iTEE) is used to assess for residual left ventricular outflow tract obstruction (LVOTO) after surgical resection of subaortic membrane causing subaortic stenosis (sub-AS). We aimed to identify the iTEE features associated with recurrence of LVOTO. METHODS We conducted a retrospective study of children undergoing sub-AS resection from June 2006 to June 2014. Doppler assessment of the flow velocity and the anatomical features of the left ventricular outflow tract were analyzed from stored echocardiograms. Recurrent LVOTO was defined as an increase in the mean pressure gradient across the left ventricular outflow tract of > 15 mm Hg on the most recent follow-up echocardiogram from the mean pressure gradient on the predischarge echocardiogram or as doubling of the mean pressure gradient to a value ≥20 mm Hg. RESULTS Thirty-five patients were included, with median age at surgery was 8.1 years (range: 0.7-29 years) and median follow-up was 47 months (2-91 months). Ten patients (29%) had recurrent LVOTO, which was associated with a shorter distance between the narrowest diameter of the outflow tract and the aortic valve on iTEE [median 0.59 cm (range 0.39-0.74) vs 0.98 cm (0.75-1.5), P = .03]. No patients with more than mild residual LVOTO on iTEE regressed to mild or no LVOTO on follow-up echocardiograms. CONCLUSIONS LVOTO recurrence after sub-AS resection is common, and residual LVOTO remains the same or increases over time. Proximity of the LVOTO to the aortic valve is a risk factor for recurrent LVOTO. These findings may be useful in counseling patients and to guide the frequency of postoperative follow-up.
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Affiliation(s)
- Hythem M Nawaytou
- Department of Pediatrics, Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Laura Mercer-Rosa
- Department of Pediatrics, Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Alexandra Channing
- Department of Pediatrics, Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Meryl S Cohen
- Department of Pediatrics, Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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20
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Devabhaktuni SR, Chakfeh E, Malik AO, Pengson JA, Rana J, Ahsan CH. Subvalvular aortic stenosis: a review of current literature. Clin Cardiol 2018; 41:131-136. [PMID: 29377232 DOI: 10.1002/clc.22775] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2017] [Revised: 07/09/2017] [Accepted: 07/15/2017] [Indexed: 12/15/2022] Open
Abstract
Subvalvular aortic stenosis (SAS) is one of the common adult congenital heart diseases, with a prevalence of 6.5%. It is usually diagnosed in the first decade of life. Echocardiography is the test of choice to diagnose SAS. Surgical correction is the best treatment modality, and the prognosis is usually excellent. In this review, we describe the pathophysiology, diagnosis, prognosis, and management of SAS with a focus on different pathophysiologic mechanisms, diagnostic approach, and prognosis of the disease by reviewing the current literature.
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Affiliation(s)
| | - Eyas Chakfeh
- Department of Internal Medicine, University of Nevada School of Medicine, Las Vegas
| | - Ali O Malik
- Department of Internal Medicine, University of Nevada School of Medicine, Las Vegas
| | - Joshua A Pengson
- Department of Internal Medicine, University of Nevada School of Medicine, Las Vegas
| | - Jibran Rana
- Department of Internal Medicine, University of Nevada School of Medicine, Las Vegas
| | - Chowdhury H Ahsan
- Division of Cardiology, University of Nevada School of Medicine, Las Vegas
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21
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Hirano Y, Inamura N, Kawazu Y, Aoki H, Kayatani F, Iwai S, Kawata H. Evaluation of Factors Associated With Achievement of Biventricular Repair After Bilateral Pulmonary Artery Banding in Patients With Interrupted Aortic Arch. World J Pediatr Congenit Heart Surg 2018; 9:54-59. [PMID: 29310563 DOI: 10.1177/2150135117737685] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND At our institution, we perform bilateral pulmonary artery banding (BPAB) as the first-stage palliation for interrupted aortic arch (IAA) with low birth weight or severe subaortic stenosis (SAS). The present study aimed to identify factors that may influence the decision regarding the type of second-stage operation, that is, univentricular palliation or biventricular repair, in these patients. METHODS Cardiac catheterization and angiographic data of nine patients with IAA who underwent initial BPAB and subsequent univentricular or biventricular repair were retrospectively analyzed. RESULTS Between 2004 and 2014, of nine patients with IAA who underwent initial BPAB, biventricular repair was subsequently performed in six patients (group B) and univentricular repair in three patients (group U). All patients survived. There was no significant intergroup difference in IAA classification, location of ventricular septal defect, presence of 22q11.2 deletion, presence of aberrant right subclavian artery, band diameter, or post-BPAB pulmonary artery pressure and index. Timing of BPAB and the body weight at the time of BPAB, however, differed significantly between the groups ( P = .02). Catheter data before BPAB were not significantly different between the groups, with the exception of the degree of subaortic stenosis (or hypoplasia of the left ventricular outflow tract) expressed as percentage of the normal end-systolic aortic valve annular diameter for patient body surface area. This metric (%SAS before BPAB) was significantly higher in group B (60%-68%) than in group U (47%-60%; P = .04). Among patients for whom baseline %SAS was < 60%, the %SAS did not increase after BPAB. CONCLUSION The most important factor that allowed biventricular repair was not the pulmonary artery pressure or diameter but the degree of SAS. Patients who initially had more severe SAS ultimately underwent univentricular repair due to lack of substantial improvement in dimensions of the left ventricular outflow tract after BPAB.
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Affiliation(s)
- Yasuhiro Hirano
- 1 Department of Pediatric Cardiology, Osaka Medical Center and Research Institute for Maternal and Child Health, Izumi, Osaka, Japan
| | - Noboru Inamura
- 1 Department of Pediatric Cardiology, Osaka Medical Center and Research Institute for Maternal and Child Health, Izumi, Osaka, Japan.,2 Department of Pediatrics, Kinki University Faculty of Medicine, Osakasayama, Osaka, Japan
| | - Yukiko Kawazu
- 1 Department of Pediatric Cardiology, Osaka Medical Center and Research Institute for Maternal and Child Health, Izumi, Osaka, Japan
| | - Hisaaki Aoki
- 1 Department of Pediatric Cardiology, Osaka Medical Center and Research Institute for Maternal and Child Health, Izumi, Osaka, Japan
| | - Futoshi Kayatani
- 1 Department of Pediatric Cardiology, Osaka Medical Center and Research Institute for Maternal and Child Health, Izumi, Osaka, Japan
| | - Shigemitsu Iwai
- 3 Department of Cardiovascular Surgery, Osaka Medical Center and Research Institute for Maternal and Child Health, Izumi, Osaka, Japan
| | - Hiroaki Kawata
- 3 Department of Cardiovascular Surgery, Osaka Medical Center and Research Institute for Maternal and Child Health, Izumi, Osaka, Japan
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Anderson BR, Tingo JE, Glickstein JS, Chai PJ, Bacha EA, Torres AJ. When Is It Better to Wait? Surgical Timing and Recurrence Risk for Children Undergoing Repair of Subaortic Stenosis. Pediatr Cardiol 2017; 38:1106-1114. [PMID: 28508142 PMCID: PMC5987763 DOI: 10.1007/s00246-017-1622-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 05/09/2017] [Indexed: 10/19/2022]
Abstract
Recurrence of subaortic stenosis (SAS) after surgery is common in children. The effects of patient characteristics and surgical timing on disease recurrence are largely unknown. We performed a retrospective study, assessing the relative effects of patient age and left ventricular outflow tract (LVOT) gradient on the need for reoperation for recurrent SAS. We included all children <20 years of age who underwent initial surgical resection of SAS at our center, January 2003-December 2013. Stratified logistic regression was performed, considering the effects of patient demographics, clinical characteristics, echocardiographic parameters, and operative technique, and clustering standard errors by surgeon. The multivariable model was used to simulate predicted probabilities of recurrent SAS for children at varying ages and baseline LVOT gradients. Sixty-three patients (38 males) underwent initial operation for SAS. Patients were followed for a median of 3.7 years (IQR 1.2-7.1). Twenty-one percent of patients (n = 13) underwent reoperation for SAS. Twelve were male. For every 10 mmHg increase in preoperative peak gradient in boys, the odds of reoperation for SAS doubled (OR 2.01, CI 1.5-2.72, p < 0.001), and for every additional 6 months of age, the odds of reoperation decreased by 14% (OR 0.86, CI 0.84-0.88, p < 0.001). Both younger age and higher preoperative outflow tract gradient are independently associated with risk of reoperation. Clinicians should consider the age and rate of LVOT gradient change-and not just the absolute gradient-in determining initial surgical timing.
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Affiliation(s)
- Brett R Anderson
- Division of Pediatric Cardiology, NewYork-Presbyterian/Morgan Stanley Children's Hospital, Columbia University Medical Center, 3959 Broadway, CH-2N, New York, NY, 10032-3784, USA.
| | - Jennifer E Tingo
- Division of Pediatric Cardiology, NewYork-Presbyterian/Morgan Stanley Children's Hospital, Columbia University Medical Center, 3959 Broadway, CH-2N, New York, NY, 10032-3784, USA
| | - Julie S Glickstein
- Division of Pediatric Cardiology, NewYork-Presbyterian/Morgan Stanley Children's Hospital, Columbia University Medical Center, 3959 Broadway, CH-2N, New York, NY, 10032-3784, USA
| | - Paul J Chai
- Division of Cardiothoracic Surgery, Columbia University College of Physicians and Surgeons, New York, USA
| | - Emile A Bacha
- Division of Cardiothoracic Surgery, Columbia University College of Physicians and Surgeons, New York, USA
| | - Alejandro J Torres
- Division of Pediatric Cardiology, NewYork-Presbyterian/Morgan Stanley Children's Hospital, Columbia University Medical Center, 3959 Broadway, CH-2N, New York, NY, 10032-3784, USA
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Gerrah R, Haller SJ, George I. Mechanical Concepts Applied in Congenital Heart Disease and Cardiac Surgery. Ann Thorac Surg 2017; 103:2005-2014. [DOI: 10.1016/j.athoracsur.2017.01.068] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Revised: 01/04/2017] [Accepted: 01/16/2017] [Indexed: 11/30/2022]
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24
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Boettcher BT, Mungara C, Manupipatpong KK, Freed JK, Kaiser M, Pagel PS. An Unexpected Finding During Repair of An Ascending Aortic Aneurysm. J Cardiothorac Vasc Anesth 2017; 32:600-602. [PMID: 28552298 DOI: 10.1053/j.jvca.2017.02.054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Brent T Boettcher
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI.
| | - Charan Mungara
- Department of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, WI
| | | | - Julie K Freed
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI
| | - Markus Kaiser
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI
| | - Paul S Pagel
- Anesthesia Service, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI
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25
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Outcomes of Subaortic Obstruction Resection in Children. Heart Lung Circ 2017; 26:179-186. [DOI: 10.1016/j.hlc.2016.05.120] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Revised: 04/12/2016] [Accepted: 05/25/2016] [Indexed: 11/18/2022]
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26
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Gabriels C, De Backer J, Pasquet A, Paelinck BP, Morissens M, Helsen F, Van De Bruaene A, Budts W. Long-Term Outcome of Patients with Perimembranous Ventricular Septal Defect: Results from the Belgian Registry on Adult Congenital Heart Disease. Cardiology 2016; 136:147-155. [PMID: 27648950 DOI: 10.1159/000448513] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Accepted: 07/13/2016] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Studies evaluating the long-term outcome of adults with ventricular septal defect (VSD) are important to inform patients about prognosis. This study investigated the long-term outcome of patients with perimembranous VSD (pmVSD) followed in the Belgian Registry on Adult Congenital Heart Disease. METHODS All pmVSD patients in the registry were analyzed. RESULTS Two hundred and sixty-six patients were studied. Fifteen patients had Eisenmenger syndrome. One hundred and seventy-three had isolated pmVSD and 78 had pmVSD with concomitant lesions. Of the patients with isolated pmVSD, 52% were male, median age was 29 years (IQR 24-35 years) and median follow-up duration was 18 years (IQR 10-25 years). Fifty-three (31%) patients underwent VSD closure and 10 (19%) had a residual shunt. Most (93%) patients were in NYHA class I. No patients died. Two (4%) patients developed atrial arrhythmia and 2 (4%) required pacemaker implantation. Seven (14%) developed left ventricular outflow tract obstruction (LVOTO). In the unrepaired pmVSD group, 4 developed endocarditis. In the entire group, moderate or severe aortic regurgitation (AR) occurred in 9 (5%) patients. CONCLUSIONS Long-term survival in patients with isolated pmVSD was not uneventful. Moderate or severe AR might develop and endocarditis occurred in patients without VSD repair. Complications after VSD closure included atrial arrhythmia, pacemaker implantation and LVOTO.
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Cho EJ, Kim SM, Park SJ, Lee SC, Park SW. Identification of Factors that Predict whether the Right Parasternal View Is Required for Accurate Evaluation of Aortic Stenosis Severity. Echocardiography 2016; 33:830-7. [DOI: 10.1111/echo.13181] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- Eun Jeong Cho
- Cardiology Clinic; National Cancer Center; Gyeonggi-do Korea
| | - Sung-Mok Kim
- Cardiovascular Imaging Center; Heart Vascular Stroke Institute; Samsung Medical Center; Sungkyunkwan University School of Medicine; Seoul Korea
| | - Sung-Ji Park
- Cardiovascular Imaging Center; Heart Vascular Stroke Institute; Samsung Medical Center; Sungkyunkwan University School of Medicine; Seoul Korea
| | - Sang-Chol Lee
- Cardiovascular Imaging Center; Heart Vascular Stroke Institute; Samsung Medical Center; Sungkyunkwan University School of Medicine; Seoul Korea
| | - Seung Woo Park
- Cardiovascular Imaging Center; Heart Vascular Stroke Institute; Samsung Medical Center; Sungkyunkwan University School of Medicine; Seoul Korea
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Bhatia A, Mehta TH, Manning P, Kuvin JT. Adults With Left-Sided Pressure Loading Lesions. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2015; 17:55. [DOI: 10.1007/s11936-015-0416-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Qureshi A, Awuor S, Martinez M. Adult Presentation of Subaortic Stenosis: Another Great Hypertrophic Cardiomyopathy Mimic. Heart Lung Circ 2015; 24:e7-e10. [DOI: 10.1016/j.hlc.2014.08.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Accepted: 08/08/2014] [Indexed: 10/24/2022]
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Barboza LA, Garcia FDM, Barnoya J, Leon-Wyss JR, Castañeda AR. Subaortic membrane and aorto-septal angle: an echocardiographic assessment and surgical outcome. World J Pediatr Congenit Heart Surg 2014; 4:253-61. [PMID: 24327492 DOI: 10.1177/2150135113485760] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Development of a subaortic membrane is not fully understood. Recurrence after surgical removal continues to be high. We sought to assess the differences in aorto-septal angles (AoSA) to possibly explain alterations within the left ventricular outflow tract, hence in subaortic membrane formation. METHODS A total of 113 patients who underwent subaortic membrane resection were matched by age and sex with 113 controls. The subaortic membrane resection group included isolated subaortic membranes (n = 34, group I), associated with ventricular septal defect (n = 29, group II), or patent ductus arteriosus (n = 50, group III). RESULTS Mean (± standard deviation) AoSA (in degrees) were not different between subaortic membrane groups I, II, and III but were steeper than their control groups (126.2 ± 9.2 vs 138.6 ± 7.0, 129.2 ± 9.9 vs 137.7 ± 10.0, and 126.2 ± 8.1 vs 135 ± 8.5, respectively; all Ps < .05). Additionally, group II had lower preoperative gradients (28.8 ± 20.7 mm Hg) compared to groups I and III (67.0 ± 32.9 and 66.2 ± 33.1 mm Hg, respectively, P < .001). Follow-up ranged from 3 to 132 months. In 22 (32%) patients, a subaortic membrane recurred. Early postoperative residual gradients and development of aortic regurgutation were associated with the need for reoperation (P < .05). CONCLUSIONS These findings suggest a contributing role of the AoSA in the development of subaortic membrane. Further rheological experiments are warranted. Whether the steeper the angle the higher the risk of recurrence may be revealed by longer follow-up periods.
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Affiliation(s)
- Laura A Barboza
- Department of Pediatric Cardiac Surgery, Unidad de Cirugía Cardiovascular de Guatemala-UNICAR, Guatemala City, Guatemala
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Tsuda T, Dunn S, Radtke W. Acquired discrete subaortic stenosis in solid organ transplant recipients. Pediatr Transplant 2014; 18:E161-4. [PMID: 24814282 DOI: 10.1111/petr.12270] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/07/2014] [Indexed: 11/30/2022]
Abstract
DSS is a rare acquired abnormality of the LV outflow tract in children and adults. DSS can be seen with or without associated congenital heart disease, but the mechanism of its emergence has been poorly understood. Here, we report two cases of DSS that developed after solid organ transplant in childhood. One patient underwent liver and kidney transplant at three yr of age for hereditary polycystic disease, and the other had liver transplant at three months of age due to uncontrollable high-output failure secondary to a large hepatic hemangioma. Both patients developed mild dynamic LV outflow tract obstruction and systemic hypertension soon after transplant, both of which resolved by the time of discharge. Transient LV hypertrophy was observed in both cases. Corticosteroids, cyclosporine A, and tacrolimus were used as initial immunosuppressants. Both patients developed DSS long after the regression of the initial dynamic LV outflow tract obstruction. Herein, we report DSS as an atypical late cardiovascular complication after solid organ transplant and postulate that transient post-transplant hyperdynamic LV outflow tract obstruction and chronic immunosuppressive treatment may lead to subendocardial remodeling resulting in a fibromuscular membranous ridge in susceptible subjects.
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Affiliation(s)
- Takeshi Tsuda
- Nemours Cardiac Center, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
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Belanger MC, Côté E, Beauchamp G. Association between aortoseptal angle in Golden Retriever puppies and subaortic stenosis in adulthood. J Vet Intern Med 2014; 28:1498-503. [PMID: 24965966 PMCID: PMC4895594 DOI: 10.1111/jvim.12390] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2013] [Revised: 04/02/2014] [Accepted: 05/07/2014] [Indexed: 11/29/2022] Open
Abstract
Background Predicting subaortic stenosis (SAS) in adult Golden Retriever dogs (GRs) by evaluating them as puppies is hampered by the progressive expression of the SAS phenotype in youth. In some children who develop SAS as adults, an abnormal aortoseptal angle (AoSA) precedes development of stenosis. Objectives To determine the normal AoSA in young adult GRs using echocardiography; to assess the value of AoSA in GR puppies for predicting development of the SAS phenotype. Animals Forty‐eight 2‐ to 6‐month‐old GR puppies. Methods Prospective study. Puppies were recruited from clients and breeders. Puppies were evaluated with a physical examination and an echocardiogram, and this evaluation was repeated when they were 12–18‐month‐old adults. Puppies were classified as unaffected (WNL) or affected (SAS) retroactively, based on their results as adults. Results In WNL young adult GRs, mean ± SD AoSA was 152.3 ± 6.5°. Mean ± SD AoSA in SAS puppies (144.9 ± 8.6°) was significantly different from mean AoSA in WNL puppies (155.7 ± 8.8°, P < .01). No puppy with AoSA >160° had the SAS phenotype as a young adult; 93% (75.7–99.1%) of puppies with AoSA <145° had the SAS phenotype as young adults. Peak LVOT velocity increased significantly between evaluations (P < .0001) whereas AoSA did not (P = .45). Conclusion and Clinical Significance A steep AoSA in GR puppies is associated with the SAS phenotype in young adulthood. Some GR puppies have an abnormal AoSA that persists in young adulthood and is detectable before peak LVOT velocity reaches levels consistent with SAS.
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Affiliation(s)
- M C Belanger
- Department of Clinical Sciences, School of Veterinary Medicine, University of Montreal, Saint-Hyacinthe, QC, Canada
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Intervention and Management of Congenital Left Heart Obstructive Lesions. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2013; 15:632-45. [DOI: 10.1007/s11936-013-0260-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Ezon DS. Fixed subaortic stenosis: a clinical dilemma for clinicians and patients. CONGENIT HEART DIS 2013; 8:450-6. [PMID: 23947905 DOI: 10.1111/chd.12127] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/04/2013] [Indexed: 11/29/2022]
Abstract
Subaortic stenosis carries considerable morbidity and mortality. In most cases, patients have an underlying left ventricular outflow tract morphology that promotes turbulence at the outflow tract, which induces the development of subaortic fibromuscular tissue. A subset of patients will progress to develop severe stenosis and aortic regurgitation, but it has been difficult to determine which patients are at risk. While resection of the subaortic tissue improves immediate outcome, many patients have recurrence of both stenosis and regurgitation, questioning the efficacy of surgical intervention in asymptomatic patients. This review article describes the current understanding of the etiology, treatment, and prognosis of subaortic stenosis.
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Affiliation(s)
- David S Ezon
- Section of Pediatric Cardiology, Baylor College of Medicine, Texas Children's Hospital, Houston, Tex, USA
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Uysal F, Bostan OM, Signak IS, Semizel E, Cil E. Evaluation of subvalvular aortic stenosis in children: a 16-year single-center experience. Pediatr Cardiol 2013; 34:1409-14. [PMID: 23456292 DOI: 10.1007/s00246-013-0664-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2012] [Accepted: 02/09/2013] [Indexed: 11/29/2022]
Abstract
Subvalvular aortic stenosis accounts for 1-2 % of all congenital heart disease and for 8-20 % of cases of left-ventricular outflow tract (LVOT) obstruction in children. Recurrence of subaortic stenosis (SAS) is not uncommon after surgical management. This study was performed to investigate the clinical and surgical outcomes and to estimate the predictability of recurrences of SAS. Seventy-nine patients age 3-21 years with SAS between 1994 and 2010 were reviewed. Fifty-one patients had discrete SAS, whereas the remaining 15 patients had fibromuscular ridge-type SAS. Mean follow-up time without surgery was 22 months (range of 1-94). Forty-one patients with a diagnosis of SAS underwent surgery. Recurrence rates were 22.7 % (15 patients), and these patients developed SAS at a mean of 4.7 years follow-up. We performed second surgical membrane resection in only 1 patient. The risk of recurrence of SAS was only linked to higher preoperative LVOT gradient. Twenty-three patients had no aortic regurgitation (AR) at preoperative echocardiography. Of these, 39.1 % had trivial, 8.7 % had mild, and 8.7 % had moderate AR after surgery; there was no significant AR. We conclude that surgical intervention was required most of the time in patients with SAS, and surgical outcomes was excellent even if there were associated cardiac defects. The risk of recurrences was higher, especially in patients with higher initial LVOT gradients, although a second surgery was rarely necessary in these patients.
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Affiliation(s)
- Fahrettin Uysal
- Department of Pediatric Cardiology, University of Uludag, Bursa, Turkey.
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Silbiger JJ. Left ventricular false tendons: anatomic, echocardiographic, and pathophysiologic insights. J Am Soc Echocardiogr 2013; 26:582-8. [PMID: 23602169 DOI: 10.1016/j.echo.2013.03.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2012] [Indexed: 01/12/2023]
Abstract
Left ventricular (LV) false tendons are chordlike structures that traverse the LV cavity. They attach to the septum, to the papillary muscles, or to the free wall of the ventricle but not to the mitral valve. They are found in approximately half of human hearts examined at autopsy. Although it has been more than 100 years since their initial description, the functional significance of these structures remains largely unexplored. It has been suggested that they retard LV remodeling by tethering the walls to which they are attached, but there are few data to substantiate this. Some studies have suggested that false tendons reduce the severity of functional mitral regurgitation by stabilizing the position of the papillary muscles as the left ventricle enlarges. LV false tendons may also have deleterious effects and have been implicated in promoting membrane formation in discrete subaortic stenosis. This article reviews current understanding of the anatomy, echocardiographic characteristics, and pathophysiology of these structures.
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van der Linde D, Takkenberg JJM, Rizopoulos D, Heuvelman HJ, Budts W, van Dijk APJ, Witsenburg M, Yap SC, Bogers AJJC, Silversides CK, Oechslin EN, Roos-Hesselink JW. Natural history of discrete subaortic stenosisin adults: a multicentre study. Eur Heart J 2012; 34:1548-56. [DOI: 10.1093/eurheartj/ehs421] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Weymann A, Schmack B, Rosendal C, Karck M, Szabó G. Surgical management of subaortic stenosis. Ann Thorac Cardiovasc Surg 2012. [PMID: 23196660 DOI: 10.5761/atcs.cr.12.01966] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
A 63-year-old male patient with subaortic stenosis (Pmax 105 mmHg, Pmean 55 mmHg) and an aneurysm of the ascending aorta was referred to our hospital due to progressive angina pectoris. Transesophageal echocardiography demonstrated high and turbulent subaortic flow velocities. A calcified subaortic membrane was identified. The membrane was removed and the aneurysm was treated with a Bentall procedure. The patient recovered smoothly from surgery and was doing well 6 months after discharge.
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Affiliation(s)
- Alexander Weymann
- Department of Cardiac Surgery, Heart Center-University of Heidelberg, Heidelberg, Germany
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Reist-Marti SB, Dolf G, Leeb T, Kottmann S, Kietzmann S, Butenhoff K, Rieder S. Genetic evidence of subaortic stenosis in the Newfoundland dog. Vet Rec 2012; 170:597. [PMID: 22645160 DOI: 10.1136/vr.100019] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Subaortic stenosis (SAS) is a cardiac disorder with a narrowing of the descending aorta below the left ventricular outflow tract of the heart. It occurs in several species and breeds. The Newfoundland is one of the dog breeds where it is more common and usually leads to death at early adulthood. It is still discussed to which extent SAS has a genetic background and what its mode of inheritance could be. Extensive pedigree data comprising more than 230,000 Newfoundland dogs from the European and North American population reaching back to the 19th century including 6023 dogs with a SAS diagnosis were analysed for genetic factors influencing SAS affection. The incidence and prevalence of SAS in the analysed Newfoundland population sample were much higher than those reported in previous studies on smaller population samples. Assuming that some SAS-affected dogs remained undiscovered or were not reported, these figures may even be underestimated. SAS-affected Newfoundland dogs were more often inbred and closer related to each other than unaffected dogs, which is an indicator for a genetic background of SAS. The sex had no significant impact on SAS affectedness, pointing at an autosomal inheritance. The only simple mode of inheritance that fitted the data well was autosomal codominant with lethal homozygosity and a penetrance of 1/3 in the heterozygotes.
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Affiliation(s)
- S B Reist-Marti
- Swiss College of Agriculture, Bern University of Applied Sciences, Laengasse 85, Zollikofen, Switzerland.
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Kanemitsu S, Yamamoto K, Shimono T, Shimpo H. Discrete subaortic stenosis 37 years after repair of a ventricular septal defect. Interact Cardiovasc Thorac Surg 2012; 14:683-5. [PMID: 22286601 DOI: 10.1093/icvts/ivr062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Discrete subaortic stenosis (DSS) is uncommon in adults after surgical correction of congenital heart defects. There are only a few published reports on the occurrence of DSS in adults. We present an adult case with DSS after repair of a ventricular septal defect (VSD). The case was a 44-year old female patient who underwent VSD closure at 7 years of age. Thirty-seven years later, she presented with congestive heart failure associated with severe subaortic membranous stenosis and atrial fibrillation (AF) that required surgical repair. We report successful surgical treatment of this adult patient with DSS and AF 37 years after repair of a VSD.
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Affiliation(s)
- Shinji Kanemitsu
- Department of Thoracic and Cardiovascular Surgery, Mie University Graduate School of Medicine, Tsu, Japan.
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42
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Laksman ZW, Silversides CK, Sedlak T, Samman AM, Williams WG, Webb GD, Liu PP. Valvular Aortic Stenosis as a Major Sequelae in Patients With Pre-Existing Subaortic Stenosis. J Am Coll Cardiol 2011; 58:962-5. [DOI: 10.1016/j.jacc.2011.04.029] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2011] [Revised: 04/21/2011] [Accepted: 04/27/2011] [Indexed: 11/28/2022]
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Drolet C, Miro J, Côté JM, Finley J, Gardin L, Rohlicek CV. Long-Term Pediatric Outcome of Isolated Discrete Subaortic Stenosis. Can J Cardiol 2011; 27:389.e19-24. [DOI: 10.1016/j.cjca.2010.12.051] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2010] [Accepted: 03/25/2010] [Indexed: 10/18/2022] Open
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Beddy P, Raj V, Williams I, Gopalan D. Multidetector computed tomographic assessment of subvalvular aortic stenosis. Clin Radiol 2011; 66:187-9. [DOI: 10.1016/j.crad.2010.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2010] [Revised: 08/24/2010] [Accepted: 09/03/2010] [Indexed: 11/25/2022]
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Abstract
An 80-year-old woman was referred for transcatheter aortic valve implantation for correction of aortic stenosis. An echocardiogram at the author's institution revealed severe hypertrophy of the left ventricle with deep recesses into the myocardium and hypokinesis involving the left ventricular apex. In addition, there was subaortic stenosis secondary to a muscular ridge. The aortic valve was only mildly stenotic. In this Cardiology Grand Rounds, the authors present a rare case of ventricular noncompaction and review the literature on this subject and its association with other cardiac abnormalities.
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Yamamoto H, Motomura H, Yamachika S, Eishi K, Moriuchi H. Severe subaortic stenosis that progressed over a 12-year period after cardiac surgery. J Med Ultrason (2001) 2009; 36:211. [PMID: 27277442 DOI: 10.1007/s10396-009-0232-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2008] [Accepted: 06/11/2009] [Indexed: 10/20/2022]
Abstract
A 12-year-old girl who had undergone cardiac surgery for ventricular septal defect (VSD), atrial septal defect (ASD), and patent ductus arteriosus (PDA) in infancy was referred to our institution for fatigue and excessive sweating. Transthoracic and transesophageal echocardiographic studies revealed tunnel-type subaortic stenosis with aortic valvular stenosis, for which she underwent aortic valve replacement and myomectomy of left ventricular outflow tract. Progression of subaortic stenosis should be considered in patients with only mild aortic valve stenosis after previous cardiovascular surgery. Echocardiography contributed significantly to making the diagnosis and therapeutic decision in our patient.
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Affiliation(s)
- Hirokazu Yamamoto
- Department of Pediatrics, Nagasaki University School of Medicine, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan.
| | - Hideki Motomura
- Department of Pediatrics, Nagasaki University School of Medicine, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Shirou Yamachika
- Department of Cardiovascular Surgery, Nagasaki University School of Medicine, Nagasaki, Japan
| | - Kiyoyuki Eishi
- Department of Cardiovascular Surgery, Nagasaki University School of Medicine, Nagasaki, Japan
| | - Hiroyuki Moriuchi
- Department of Pediatrics, Nagasaki University School of Medicine, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
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Sandoval-Tress C, Martínez-Baumbach EB, Rodríguez-Mora EA, López-Terrazas JH. [Valvular and subvalvular aortic stenosis. Unusual expression of tuberous sclerosis]. An Pediatr (Barc) 2009; 71:467-8. [PMID: 19726254 DOI: 10.1016/j.anpedi.2009.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2009] [Revised: 06/14/2009] [Accepted: 07/13/2009] [Indexed: 11/28/2022] Open
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Quintavalla C, Guazzetti S, Mavropoulou A, Bussadori C. Aorto-septal angle in Boxer dogs with subaortic stenosis: an echocardiographic study. Vet J 2009; 185:332-7. [PMID: 19665399 DOI: 10.1016/j.tvjl.2009.06.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2008] [Revised: 05/28/2009] [Accepted: 06/27/2009] [Indexed: 10/20/2022]
Abstract
The present study was designed to determine the aorto-septal angle (AoSA) in Boxer dogs with or without subaortic stenosis (SAS) by using two-dimensional echocardiography. Forty-five Boxer dogs were prospectively included in the study. The AoSA was steeper in the group with SAS than in healthy Boxers with a mean difference of 10 degrees . According to the proposed regression model, the AoSA is associated with SAS in Boxers, particularly because it becomes steeper as SAS severity increases. Several studies in humans demonstrate that small changes in the AoSA produce important changes in septal shear stress, which in turn causes proliferation of the endocardial cells resulting in subaortic obstruction. A definite conclusion about the role of the AoSA on the formation and/or progression of subvalvular lesions in Boxers cannot be drawn from the data analysed due to the transversal nature of the observations.
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Affiliation(s)
- Cecilia Quintavalla
- Dept. Animal Health, Parma University, Via del Taglio, 8, 43100 Parma, Italy.
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49
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Reed SD, Evans DE. Tracheal hypoplasia with a discrete subaortic septal ridge in a Rottweiler puppy. J Vet Diagn Invest 2009; 21:117-9. [PMID: 19139511 DOI: 10.1177/104063870902100118] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Concurrent tracheal hypoplasia and discrete subaortic stenosis are described in a 12-week-old Rottweiler puppy that presumably died of pulmonary edema. A brief literature review and comparison to previously published cases of tracheal hypoplasia in other breeds is presented along with a description of a subaortic septal ridge and comparison to the analogous condition in humans.
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Affiliation(s)
- Scott D Reed
- Department of Pathobiological Sciences, School of Veterinary Medicine, Lousiana State University, Baton Rogue, LA 70808, USA.
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50
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Butany J, Vaideeswar P, David TE. Discrete subaortic membranes in adults--a clinicopathological analysis. Cardiovasc Pathol 2008; 18:236-42. [PMID: 18823798 DOI: 10.1016/j.carpath.2008.06.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2006] [Revised: 02/20/2008] [Accepted: 06/26/2008] [Indexed: 10/21/2022] Open
Abstract
INTRODUCTION A discrete subaortic membrane (DSM) is one of the causes of subaortic stenosis in children. The incidence, characteristics, and the therapeutic options for such membranes in adults have not been well documented. This report documents the clinical and pathological features of DSM in adults. METHODS DSMs, surgically excised over a 10-year period in a large adult tertiary care center, were reviewed with regard to the age and gender of the patients, clinical findings, and the morphological features. RESULTS Among the 19 adults, there were six males and 13 females, with age ranging from 26 to 75 years. The patients most often presented with dyspnea, fatigability, and palpitation for 3 months to 2 years. Four patients (21%) had other congenital heart disease in association with the DSM; in the rest, the membranes were isolated occurrences (79%). A cardiac murmur or the presence of membranes had been noted in childhood in four patients. Tissue growths over the ventricular surface of the anterior mitral leaflet were seen in 18 cases. Irrespective of the gross appearance, the stenosing lesions exhibited five tissue layers, beginning from the luminal aspect, endothelium, acid mucopolysaccharide-rich subendothelial layer, collagen-rich fibrous layer, fibroelastotic layer, and a smooth muscle layer. Twelve patients (63%) had aortic regurgitation, which necessitated repair or replacement in seven. Septal myectomy resulted in conduction abnormalities in nine. CONCLUSIONS The study describes the occurrence of DSM in adults. It is important to remember that it can occur following a repair of underlying congenital heart disease.
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Affiliation(s)
- Jagdish Butany
- Department of Pathology, Toronto General Hospital/University Health Network, Toronto, Ontario, Canada.
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