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Alahdab F, Ahmed AI, Nayfeh M, Han Y, Abdelkarim O, Alfawara MS, Little SH, Reardon MJ, Faza NN, Goel SS, Alkhouli M, Zoghbi W, Al-Mallah MH. Myocardial Blood Flow Reserve, Microvascular Coronary Health, and Myocardial Remodeling in Patients With Aortic Stenosis. J Am Heart Assoc 2024; 13:e033447. [PMID: 38780160 DOI: 10.1161/jaha.123.033447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 04/18/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Coronary microvascular function and hemodynamics may play a role in coronary circulation and myocardial remodeling in patients with aortic stenosis (AS). We aimed to evaluate the relationship between myocardial blood flow and myocardial function in patients with AS, no AS, and aortic valve sclerosis. METHODS AND RESULTS We included consecutive patients who had resting transthoracic echocardiography and clinically indicated positron emission tomography myocardial perfusion imaging to capture their left ventricular ejection fraction, global longitudinal strain (GLS), and myocardial flow reserve (MFR). The primary outcome was major adverse cardiovascular event (all-cause mortality, myocardial infarction, or late revascularization). There were 2778 patients (208 with aortic sclerosis, 39 with prosthetic aortic valve, 2406 with no AS, and 54, 49, and 22 with mild, moderate, and severe AS, respectively). Increasing AS severity was associated with impaired MFR (P<0.001) and GLS (P<0.001), even when perfusion was normal. Statistically significant associations were noted between MFR and GLS, MFR and left ventricular ejection fraction, and MFR and left ventricular ejection fraction reserve. After a median follow-up of 349 (interquartile range, 116-662) days, 4 (7.4%), 5 (10.2%), and 6 (27.3%) patients experienced a major adverse cardiovascular event in the mild, moderate, and severe AS groups, respectively. In a matched-control analysis, patients with mild-to-moderate AS had higher rates of impaired MFR (52.9% versus 39.9%; P=0.048) and major adverse cardiovascular event (11.8% versus 3.0%; P=0.002). CONCLUSIONS Despite lack of ischemia, as severity of AS increased, MFR decreased and GLS worsened, reflecting worse coronary microvascular health and myocardial remodeling. Positron emission tomography-derived MFR showed a significant independent correlation with left ventricular ejection fraction and GLS. Patients with prosthetic aortic valve showed a high prevalence of impaired MFR.
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Affiliation(s)
- Fares Alahdab
- Houston Methodist DeBakey Heart and Vascular Center Houston TX
| | - Ahmed I Ahmed
- Houston Methodist DeBakey Heart and Vascular Center Houston TX
| | - Malek Nayfeh
- Houston Methodist DeBakey Heart and Vascular Center Houston TX
| | - Yushui Han
- Houston Methodist DeBakey Heart and Vascular Center Houston TX
| | - Ola Abdelkarim
- Department of Cardiology, Faculty of Medicine Alexandria University Alexandria Egypt
| | | | | | | | - Nadeen N Faza
- Houston Methodist DeBakey Heart and Vascular Center Houston TX
| | - Sachin S Goel
- Houston Methodist DeBakey Heart and Vascular Center Houston TX
| | | | - William Zoghbi
- Houston Methodist DeBakey Heart and Vascular Center Houston TX
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2
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Lopes MAAADM, Campos CM, Rosa VEE, Sampaio RO, Morais TC, de Brito Júnior FS, Vieira MLC, Mathias W, Fernandes JRC, de Santis A, Santos LDM, Rochitte CE, Capodanno D, Tamburino C, Abizaid A, Tarasoutchi F. Multimodality imaging methods and systemic biomarkers in classical low-flow low-gradient aortic stenosis: Key findings for risk stratification. Front Cardiovasc Med 2023; 10:1149613. [PMID: 37180790 PMCID: PMC10174252 DOI: 10.3389/fcvm.2023.1149613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Accepted: 04/04/2023] [Indexed: 05/16/2023] Open
Abstract
Objectives The aim of the present study is to assess multimodality imaging findings according to systemic biomarkers, high-sensitivity troponin I (hsTnI) and B-type natriuretic peptide (BNP) levels, in low-flow, low-gradient aortic stenosis (LFLG-AS). Background Elevated levels of BNP and hsTnI have been related with poor prognosis in patients with LFLG-AS. Methods Prospective study with LFLG-AS patients that underwent hsTnI, BNP, coronary angiography, cardiac magnetic resonance (CMR) with T1 mapping, echocardiogram and dobutamine stress echocardiogram. Patients were divided into 3 groups according to BNP and hsTnI levels: Group 1 (n = 17) when BNP and hsTnI levels were below median [BNP < 1.98 fold upper reference limit (URL) and hsTnI < 1.8 fold URL]; Group 2 (n = 14) when BNP or hsTnI were higher than median; and Group 3 (n = 18) when both hsTnI and BNP were higher than median. Results 49 patients included in 3 groups. Clinical characteristics (including risk scores) were similar among groups. Group 3 patients had lower valvuloarterial impedance (P = 0.03) and lower left ventricular ejection fraction (P = 0.02) by echocardiogram. CMR identified a progressive increase of right and left ventricular chamber from Group 1 to Group 3, and worsening of left ventricular ejection fraction (EF) (40 [31-47] vs. 32 [29-41] vs. 26 [19-33]%; p < 0.01) and right ventricular EF (62 [53-69] vs. 51 [35-63] vs. 30 [24-46]%; p < 0.01). Besides, there was a marked increase in myocardial fibrosis assessed by extracellular volume fraction (ECV) (28.4 [24.8-30.7] vs. 28.2 [26.9-34.5] vs. 31.8 [28.9-35.5]%; p = 0.03) and indexed ECV (iECV) (28.7 [21.2-39.1] vs. 28.8 [25.4-39.9] vs. 44.2 [36.4-51.2] ml/m2, respectively; p < 0.01) from Group 1 to Group 3. Conclusions Higher levels of BNP and hsTnI in LFLG-AS patients are associated with worse multi-modality evidence of cardiac remodeling and fibrosis.
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Affiliation(s)
- Maria Antonieta Albanez A. de M. Lopes
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
- Real Hospital Português, Real Cardiologia, Recife, PE, Brazil
| | - Carlos M. Campos
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
- Insituto Prevent Senior, São Paulo, SP, Brazil
| | - Vitor Emer Egypto Rosa
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
- Correspondence: Vitor Emer Egypto Rosa
| | - Roney O. Sampaio
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Thamara C. Morais
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Fábio Sândoli de Brito Júnior
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Marcelo L. C. Vieira
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Wilson Mathias
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Joao Ricardo Cordeiro Fernandes
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Antonio de Santis
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Luciano de Moura Santos
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Carlos E. Rochitte
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Davide Capodanno
- CardioT Division of Cardiology, Policlinico-Vittorio Emanuele Hospital University of Catania, Catania, Italy
| | - Corrado Tamburino
- CardioT Division of Cardiology, Policlinico-Vittorio Emanuele Hospital University of Catania, Catania, Italy
| | - Alexandre Abizaid
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Flavio Tarasoutchi
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
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Gupta K, Dixit P, Ananthasubramaniam K. Cardiac PET in aortic stenosis: Potential role in risk refinement? J Nucl Cardiol 2022; 29:3474-3479. [PMID: 34228335 DOI: 10.1007/s12350-021-02714-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 06/17/2021] [Indexed: 01/18/2023]
Affiliation(s)
- Kartik Gupta
- Department of Internal Medicine, Henry Ford Hospital, Detroit, MI, USA
| | | | - Karthik Ananthasubramaniam
- Department of Internal Medicine, Heart and Vascular Institute, Henry Ford West Bloomfield Hospital, West Bloomfield, MI, USA.
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Choudhary KV, Kakouros N, Aurigemma GP, Parker MW, Fitzgibbons T. Differentiating Pseudo Versus True Aortic Stenosis in Patients Without Contractile Reserve: A Diagnostic Dilemma. Cureus 2021; 13:e14086. [PMID: 33903843 PMCID: PMC8064426 DOI: 10.7759/cureus.14086] [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] [Indexed: 12/01/2022] Open
Abstract
Low-flow, low-gradient (LF-LG) aortic stenosis with depressed left ventricular (LV) ejection fraction is a diagnostic challenge that is frequently encountered in the management of valvular heart disease. True-severe LF-LG aortic stenosis is amenable to valve replacement, whereas pseudo-severe aortic stenosis requires management of the underlying cardiomyopathy. This distinction is important as it serves as a critical branch point in guiding therapeutic decisions. We present the case of a 71-year-old male with LF-LG aortic stenosis who had a reduced and biphasic augmentation of LV flow during dobutamine stress echocardiography (DSE). Further evaluation revealed a stenotic left subclavian artery proximal to the left internal mammary artery graft to the left anterior descending (LAD) artery. Bypass of the subclavian stenosis reversed the LAD territory ischemia and confirmed pseudo-severe aortic stenosis on repeat DSE. Traditional DSE parameters are inconclusive in patients with LF-LG aortic stenosis with poor flow reserve. Calculation of the projected orifice area or measurement of aortic valve calcium via multidetector computed tomography (MDCT) may be required in this scenario. Most importantly, reversible causes of LV dysfunction identified during DSE for LF-LG aortic stenosis require a different treatment approach than that of true aortic stenosis.
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Affiliation(s)
- Khushal V Choudhary
- Department of Internal Medicine, Roger Williams Medical Center, Providence, USA
| | - Nikolaos Kakouros
- Cardiovascular Division, Department of Medicine, University of Massachusetts Medical School, Massachusetts, USA
| | - Gerard P Aurigemma
- Cardiovascular Division, Department of Medicine, University of Massachusetts Medical School, Massachusetts, USA
| | - Matthew W Parker
- Cardiovascular Division, Department of Medicine, University of Massachusetts Medical School, Massachusetts, USA
| | - Timothy Fitzgibbons
- Cardiovascular Division, Department of Medicine, University of Massachusetts Medical School, Massachusetts, USA
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5
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Barbieri A, Antonini-Canterin F, Pepi M, Monte IP, Trocino G, Barchitta A, Ciampi Q, Cresti A, Miceli S, Petrella L, Benedetto F, Zito C, Benfari G, Bursi F, Malagoli A, Bartolacelli Y, Mantovani F, Clavel MA. Discordant Echocardiographic Grading in Low Gradient Aortic Stenosis (DEGAS Study) From the Italian Society of Echocardiography and Cardiovascular Imaging Research Network: Rationale and Study Design. J Cardiovasc Echogr 2020; 30:52-61. [PMID: 33282641 PMCID: PMC7706377 DOI: 10.4103/jcecho.jcecho_68_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 07/13/2020] [Indexed: 11/04/2022] Open
Abstract
Background Low-gradient aortic stenosis (LG-AS) is characterized by the combination of an aortic valve area compatible with severe stenosis and a low transvalvular mean gradient with low-flow state (i.e., indexed stroke volume <35 mL/m2) in the presence of reduced (classical low-flow AS) or preserved (paradoxical low-flow AS) ejection fraction. Furthermore, the occurrence of a normal-flow LG-AS is still advocated by many authors. Within this diagnostic complexity, the diagnosis of severe AS remains challenging. Objective The general objective of the Discordant Echocardiographic Grading in Low-gradient AS (DEGAS Study) study will be to assess the prevalence of true severe AS in this population and validate new parameters to improve the assessment and the clinical decision-making in patients with LG-AS. Methods and Analyses The DEGAS Study of the Italian Society of Echocardiography and Cardiovascular Imaging is a prospective, multicenter, observational diagnostic study that will enroll consecutively adult patients with LG-AS over 2 years. AS severity will be ideally confirmed by a multimodality approach, but only the quantification of calcium score by multidetector computed tomography will be mandatory. The primary clinical outcome variable will be 12-month all-cause mortality. The secondary outcome variables will be (i) 30-day mortality (for patients treated by Surgical aortic valve replacement or TAVR); (ii) 12-month cardiovascular mortality; (iii) 12-month new major cardiovascular events such as myocardial infarction, stroke, vascular complications, and rehospitalization for heart failure; and (iv) composite endpoint of cardiovascular mortality and hospitalization for heart failure. Data collection will take place through a web platform (REDCap), absolutely secure based on current standards concerning the ethical requirements and data integrity.
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Affiliation(s)
- Andrea Barbieri
- Division of Cardiology, Department of Diagnostics, Clinical and Public Health Medicine, Policlinico University Hospital of Modena, Milano, Italy
| | - Francesco Antonini-Canterin
- Rehabilitative Cardiology, Ospedale Riabilitativo di Alta Specializzazione di Motta di Livenza (TV), Milano, Italy
| | - Mauro Pepi
- Monzino Cardiology Center, IRCCS, Milano, Italy
| | | | - Giuseppe Trocino
- Cardiology, Hospital of Desio, S. Antonio Hospital, AO Padova, Italy
| | | | | | - Alberto Cresti
- Cardiology, Dip. Cardio Neuro Vascolare Asl sudest Toscana, Hospital of Grosseto, Italy
| | | | | | - Frank Benedetto
- Cardiology, G.O.M. "Bianchi Melacrino Morelli", Reggio Calabria, Italy
| | - Concetta Zito
- Department of Clinical and Experimental Medicine - Section of Cardiology, G. Martino General Hospital, University of Messina, Italy
| | - Giovanni Benfari
- Section of Cardiology, Department of Medicine, University of Verona, Italy
| | - Francesca Bursi
- Division of Cardiology, Heart and Lung Department, San Paolo Hospital, ASST Santi Paolo and Carlo, University of Milan, Italy
| | | | - Ylenia Bartolacelli
- Pediatric and Adult Congenital Heart Cardiac Surgery, S.Orsola Malpighi Hospital, University of Bologna, Italy
| | | | - Marie-Annick Clavel
- Institut universitaire de cardiologie et de pneumologie de Québec, Université Laval, Quebec City, Quebec, Canada
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Coronary Microcirculation in Aortic Stenosis: Pathophysiology, Invasive Assessment, and Future Directions. J Interv Cardiol 2020; 2020:4603169. [PMID: 32774184 PMCID: PMC7396014 DOI: 10.1155/2020/4603169] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 06/22/2020] [Accepted: 07/01/2020] [Indexed: 01/09/2023] Open
Abstract
With the increasing prevalence of aortic stenosis (AS) due to a growing elderly population, a proper understanding of its physiology is paramount to guide therapy and define severity. A better understanding of the microvasculature in AS could improve clinical care by predicting left ventricular remodeling or anticipate the interplay between epicardial stenosis and myocardial dysfunction. In this review, we combine five decades of literature regarding microvascular, coronary, and aortic valve physiology with emerging insights from newly developed invasive tools for quantifying microcirculatory function. Furthermore, we describe the coupling between microcirculation and epicardial stenosis, which is currently under investigation in several randomized trials enrolling subjects with concomitant AS and coronary disease. To clarify the physiology explained previously, we present two instructive cases with invasive pressure measurements quantifying coexisting valve and coronary stenoses. Finally, we pose open clinical and research questions whose answers would further expand our knowledge of microvascular dysfunction in AS. These trials were registered with NCT03042104, NCT03094143, and NCT02436655.
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7
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Hemodynamic effects of aortic valve and heart rate on coronary perfusion. Clin Biomech (Bristol, Avon) 2020; 78:105075. [PMID: 32535477 DOI: 10.1016/j.clinbiomech.2020.105075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 04/29/2020] [Accepted: 06/04/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Reduced coronary flow reserve in aortic stenosis and after transcatheter aortic valve implantation is usually attributed to physiological factors taking place during systole, such as an increase in coronary resistance, and backward waves intensity. In this paper, we suggest an additional factor related to the diastolic hemodynamics in the aortic root. METHODS We measured left ventricle, aortic and coronary pressure and coronary perfusion in in-vitro models of healthy, aortic stenosis and an artificial valve at different heart rates and cardiac output conditions, to isolate the effect of hemodynamic factors in the aortic root during diastole. FINDINGS Our results show that during diastole, coronary perfusion depends on the pressure gradient between the aorta and the coronary inlet. This aorta-coronary pressure gradient is influenced by the hemodynamic flow field in the aortic root. The ratio between the aorta-coronary pressure gradient magnitude in stress to that under rest conditions of a healthy model is ten times higher than the same ratio in the aortic stenosis model and twice higher as compared to the artificial valve model result. The coronary flow reserve of the healthy model is correspondingly higher compared to the artificial valve and the aortic stenosis models. These results are in agreement with the clinical evidence. INTERPRETATION This study supports the hypothesis of a hemodynamic mechanism in the aortic root that increases coronary flow during rest but reduces the coronary flow reserve in aortic stenosis and artificial valve cases. The results may provide valuable insights regarding valve design.
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8
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Low Gradient Aortic Stenosis: Role of Echocardiography. CURRENT CARDIOVASCULAR IMAGING REPORTS 2019. [DOI: 10.1007/s12410-019-9518-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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9
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Liu FS, Wang SY, Shiau YC, Wu YW. The clinical value and safety of ECG-gated dipyridamole myocardial perfusion imaging in patients with aortic stenosis. Sci Rep 2019; 9:12443. [PMID: 31455862 PMCID: PMC6712027 DOI: 10.1038/s41598-019-48901-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 08/15/2019] [Indexed: 12/31/2022] Open
Abstract
The role of vasodilator myocardial perfusion imaging (MPI) for aortic stenosis (AS) is controversial due to safety and accuracy concerns. In addition, its utility after aortic valve (AV) interventions remains unclear. Patients with AS who underwent thallium-201-gated dipyridamole MPI using a cadmium-zinc-telluride camera were retrospectively reviewed and divided into three groups: mild AS, moderate-to-severe AS, and prior AV interventions. Patients with coronary artery disease with ≥50% stenosis, severe arrhythmia, left ventricular ejection fraction (LVEF) <40%, left bundle branch block or no follow-up were excluded. Relationships between the severity of AS, clinical characteristics, hemodynamic response, serious adverse events (SAE) and MPI parameters were analyzed. None of the 47 patients had SAE, including significant hypotension or LVEF reduction. The moderate-to-severe AS group had higher summed stress scores (SSSs) and depressed LVEF than the mild AS group, however there were no differences after AV interventions. SSS was positively correlated with AV mean pressure gradient, post-stress lung-heart ratio (LHRs), and post-stress end-diastolic volume (EDVs) (P < 0.05). In multivariate analysis, LHRs and EDVs were independent contributors to SSS. Dipyridamole-induced ischemia and LV dysfunction is common, and dipyridamole stress could be a safe diagnostic tool in evaluation and follow-up in patients with AS.
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Affiliation(s)
- Fang-Shin Liu
- Department of Nuclear Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Shan-Ying Wang
- Department of Nuclear Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan.,Department of Nuclear Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei City, Taiwan
| | - Yu-Chien Shiau
- Department of Nuclear Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Yen-Wen Wu
- Department of Nuclear Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan. .,Division of Cardiology, Cardiovascular Medical Center, Far Eastern Memorial Hospital, New Taipei City, Taiwan. .,National Yang-Ming University School of Medicine, Taipei, Taiwan. .,Department of Nuclear Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei City, Taiwan.
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10
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A numerical study of the hemodynamic effect of the aortic valve on coronary flow. Biomech Model Mechanobiol 2017; 17:319-338. [DOI: 10.1007/s10237-017-0962-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 09/05/2017] [Indexed: 01/09/2023]
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11
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Safi LM, Passeri JJ, Picard MH. New considerations in the assessment of aortic stenosis. Future Cardiol 2017; 13:433-441. [PMID: 28828892 DOI: 10.2217/fca-2017-0031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Calcific aortic stenosis (AS) is one of the most common acquired valvular heart diseases in industrialized nations. It is a slowly progressive disease and with the aging population, the prevalence of AS is expected to increase. Doppler echocardiography is used to classify patients based on severity of stenosis. Research efforts on how to better identify and risk-assess these patients are currently underway using advanced imaging modalities and serum biomarkers. Thus far, medications for AS prevention have been unsuccessful. As technology progresses, the assessment of AS will transition from one heavily weighed on echocardiographic gradients to one of active surveillances with multimodality imaging, serum biomarkers and genetic assessment.
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Affiliation(s)
- Lucy M Safi
- Director of Interventional Echocardiography, Hackensack University Medical Center, Hackensack, NJ 07601, USA
| | - Jonathan J Passeri
- Co-Director Heart Valve Program, Director of Interventional Echocardiography, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Michael H Picard
- Cardiology Division, Massachusetts General Hospital, Professor of Medicine, Harvard Medical School, Boston, MA 02114, USA
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12
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Tastet L, Capoulade R, Clavel MA, Larose É, Shen M, Dahou A, Arsenault M, Mathieu P, Bédard É, Dumesnil JG, Tremblay A, Bossé Y, Després JP, Pibarot P. Systolic hypertension and progression of aortic valve calcification in patients with aortic stenosis: results from the PROGRESSA study. Eur Heart J Cardiovasc Imaging 2016; 18:70-78. [PMID: 26896413 DOI: 10.1093/ehjci/jew013] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 01/14/2016] [Indexed: 01/12/2023] Open
Abstract
AIMS Hypertension is highly prevalent in patients with aortic stenosis (AS) and is associated with worse outcomes. The current prospective study assessed the impact of systolic hypertension (SHPT) on the progression of aortic valve calcification (AVC) measured by multidetector computed tomography (MDCT) in patients with AS. METHODS AND RESULTS The present analysis includes the first series of 101 patients with AS prospectively recruited in the PROGRESSA study. Patients underwent comprehensive Doppler echocardiography and MDCT exams at baseline and after 2-year follow-up. AVC and coronary artery calcification (CAC) were measured using the Agatston method. Patients with SHPT at baseline (i.e. systolic blood pressure ≥140 mmHg; n = 37, 37%) had faster 2-year AVC progression compared with those without SHPT (i.e. systolic blood pressure <140 mmHg) (AVC median [25th percentile-75th percentile]: +370 [126-824] vs. +157 [58-303] AU; P = 0.007, respectively). Similar results were obtained with the analysis of AVC progression divided by the cross-sectional area of the aortic annulus (AVCdensity: +96 [34-218] vs. +45 [14-82] AU/cm2, P = 0.01, respectively). In multivariable analysis, SHPT remained significantly associated with faster progression of AVC or AVCdensity (all P = 0.001). There was no significant difference between groups with respect to progression of CAC (+39 [3-199] vs. +41 [0-156] AU, P = 0.88). CONCLUSION This prospective study shows for the first time that SHPT is associated with faster AVC progression but not with CAC progression in AS patients. These findings provide further support for the elaboration of randomized clinical trials to assess the efficacy of antihypertensive medication to slow the stenosis progression in patients with AS.
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Affiliation(s)
- Lionel Tastet
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, 2725 Chemin Sainte-Foy, Québec city, Québec, Canada G1V-4G5
| | - Romain Capoulade
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, 2725 Chemin Sainte-Foy, Québec city, Québec, Canada G1V-4G5
| | - Marie-Annick Clavel
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, 2725 Chemin Sainte-Foy, Québec city, Québec, Canada G1V-4G5
| | - Éric Larose
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, 2725 Chemin Sainte-Foy, Québec city, Québec, Canada G1V-4G5
| | - Mylène Shen
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, 2725 Chemin Sainte-Foy, Québec city, Québec, Canada G1V-4G5
| | - Abdellaziz Dahou
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, 2725 Chemin Sainte-Foy, Québec city, Québec, Canada G1V-4G5
| | - Marie Arsenault
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, 2725 Chemin Sainte-Foy, Québec city, Québec, Canada G1V-4G5
| | - Patrick Mathieu
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, 2725 Chemin Sainte-Foy, Québec city, Québec, Canada G1V-4G5
| | - Élisabeth Bédard
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, 2725 Chemin Sainte-Foy, Québec city, Québec, Canada G1V-4G5
| | - Jean G Dumesnil
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, 2725 Chemin Sainte-Foy, Québec city, Québec, Canada G1V-4G5
| | - Alexe Tremblay
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, 2725 Chemin Sainte-Foy, Québec city, Québec, Canada G1V-4G5
| | - Yohan Bossé
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, 2725 Chemin Sainte-Foy, Québec city, Québec, Canada G1V-4G5
| | - Jean-Pierre Després
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, 2725 Chemin Sainte-Foy, Québec city, Québec, Canada G1V-4G5
| | - Philippe Pibarot
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, 2725 Chemin Sainte-Foy, Québec city, Québec, Canada G1V-4G5
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Călin A, Roşca M, Beladan CC, Enache R, Mateescu AD, Ginghină C, Popescu BA. The left ventricle in aortic stenosis--imaging assessment and clinical implications. Cardiovasc Ultrasound 2015; 13:22. [PMID: 25928763 PMCID: PMC4425891 DOI: 10.1186/s12947-015-0017-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 04/21/2015] [Indexed: 01/07/2023] Open
Abstract
Aortic stenosis has an increasing prevalence in the context of aging population. In these patients non-invasive imaging allows not only the grading of valve stenosis severity, but also the assessment of left ventricular function. These two goals play a key role in clinical decision-making. Although left ventricular ejection fraction is currently the only left ventricular function parameter that guides intervention, current imaging techniques are able to detect early changes in LV structure and function even in asymptomatic patients with significant aortic stenosis and preserved ejection fraction. Moreover, new imaging parameters emerged as predictors of disease progression in patients with aortic stenosis. Although proper standardization and confirmatory data from large prospective studies are needed, these novel parameters have the potential of becoming useful tools in guiding intervention in asymptomatic patients with aortic stenosis and stratify risk in symptomatic patients undergoing aortic valve replacement. This review focuses on the mechanisms of transition from compensatory left ventricular hypertrophy to left ventricular dysfunction and heart failure in aortic stenosis and the role of non-invasive imaging assessment of the left ventricular geometry and function in these patients.
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Affiliation(s)
- Andreea Călin
- Department of Cardiology, University of Medicine and Pharmacy "Carol Davila", Euroecolab, Bucharest, Romania.
| | - Monica Roşca
- Department of Cardiology, University of Medicine and Pharmacy "Carol Davila", Euroecolab, Bucharest, Romania.
| | - Carmen Cristiana Beladan
- Department of Cardiology, University of Medicine and Pharmacy "Carol Davila", Euroecolab, Bucharest, Romania. .,Institute of Cardiovascular Diseases "Prof. Dr. C. C. Iliescu", Sos Fundeni 258 sector 2, 022328, Bucharest, Romania.
| | - Roxana Enache
- Department of Cardiology, University of Medicine and Pharmacy "Carol Davila", Euroecolab, Bucharest, Romania. .,Institute of Cardiovascular Diseases "Prof. Dr. C. C. Iliescu", Sos Fundeni 258 sector 2, 022328, Bucharest, Romania.
| | - Anca Doina Mateescu
- Department of Cardiology, University of Medicine and Pharmacy "Carol Davila", Euroecolab, Bucharest, Romania.
| | - Carmen Ginghină
- Department of Cardiology, University of Medicine and Pharmacy "Carol Davila", Euroecolab, Bucharest, Romania. .,Institute of Cardiovascular Diseases "Prof. Dr. C. C. Iliescu", Sos Fundeni 258 sector 2, 022328, Bucharest, Romania.
| | - Bogdan Alexandru Popescu
- Department of Cardiology, University of Medicine and Pharmacy "Carol Davila", Euroecolab, Bucharest, Romania. .,Institute of Cardiovascular Diseases "Prof. Dr. C. C. Iliescu", Sos Fundeni 258 sector 2, 022328, Bucharest, Romania.
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Abstract
OPINION STATEMENT Severe low-gradient (LG) aortic stenosis (AS) [aortic valve area (AVA) ≤ 1.0 cm(2), mean pressure gradient (MG) < 40 mmHg] represents a frequently encountered and challenging clinical dilemma. A systematic approach, which often requires several imaging modalities, should be undertaken to confirm the hemodynamic findings and rule out measurement error. Low-flow conditions often account for the discrepancy and can be present whether the left ventricular ejection fraction (LVEF) is depressed or normal. In patients with classical low-flow (LF), LG AS in which LVEF is reduced (<40-50 %), dobutamine stress echocardiography (DSE) should be used to distinguish patients with true severe AS and pseudo-severe AS, as well as to evaluate for the presence of left ventricular contractile or flow reserve. Surgical or transcatheter aortic valve replacement (AVR) should likely be reserved for those patients with true severe AS. Patient outcome with medical or surgical management generally relates to patient functional capacity, stenosis severity, and left ventricular functional reserve. Patients with severe LG AS with preserved LVEF can have a stroke volume that is either normal (>35 mL/m(2)) or low (<35 mL/m(2)). New data suggest that DSE can identify pseudo-severe AS in up to 30 % of patients with severe LF-LG AS with preserved LVEF. AVR should likely be restricted to those patients with true severe AS, although there is currently little data to support this strategy. Symptomatic patients with severe LG AS with preserved LVEF, whether they have normal or low flow, should be offered AVR. Transcatheter AVR provides an alternative therapeutic option in the high-risk patient.
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15
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Mahmod M, Piechnik SK, Levelt E, Ferreira VM, Francis JM, Lewis A, Pal N, Dass S, Ashrafian H, Neubauer S, Karamitsos TD. Adenosine stress native T1 mapping in severe aortic stenosis: evidence for a role of the intravascular compartment on myocardial T1 values. J Cardiovasc Magn Reson 2014; 16:92. [PMID: 25410203 PMCID: PMC4237748 DOI: 10.1186/s12968-014-0092-y] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Accepted: 11/04/2014] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Myocardial T1 relaxation times have been reported to be markedly abnormal in diverse myocardial pathologies, ascribed to interstitial changes, evaluated by T1 mapping and calculation of extracellular volume (ECV). T1 mapping is sensitive to myocardial water content of both intra- and extracellular in origin, but the effect of intravascular compartment changes on T1 has been largely neglected. We aimed to assess the role of intravascular compartment on native (pre-contrast) T1 values by studying the effect of adenosine-induced vasodilatation in patients with severe aortic stenosis (AS) before and after aortic valve replacement (AVR). METHODS 42 subjects (26 patients with severe AS without obstructive coronary artery disease and 16 controls) underwent cardiovascular magnetic resonance at 3 T for native T1-mapping (ShMOLLI), first-pass perfusion (myocardial perfusion reserve index-MPRI) at rest and during adenosine stress, and late gadolinium enhancement (LGE). RESULTS AS patients had increased resting myocardial T1 (1196±47 ms vs. 1168±27 ms, p=0.037), reduced MPRI (0.92±0.31 vs. 1.74±0.32, p<0.001), and increased left ventricular mass index (LVMI) and LGE volume compared to controls. During adenosine stress, T1 in AS was similar to controls (1240±51 ms vs. 1238±54 ms, p=0.88), possibly reflecting a similar level of maximal coronary vasodilatation in both groups. Conversely, the T1 response to stress was blunted in AS (ΔT1 3.7±2.7% vs. 6.0±4.2% in controls, p=0.013). Seven months after AVR (n=16) myocardial T1 and response to adenosine stress recovered towards normal. Native T1 values correlated with reduced MPRI, aortic valve area, and increased LVMI. CONCLUSIONS Our study suggests that native myocardial T1 values are not only influenced by interstitial and intracellular water changes, but also by changes in the intravascular compartment. Performing T1 mapping during or soon after vasodilator stress may affect ECV measurements given that hyperemia alone appears to substantially alter T1 values.
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Affiliation(s)
- Masliza Mahmod
- />University of Oxford Centre for Clinical Magnetic Resonance Research (OCMR), Division of Cardiovascular Medicine, Radcliffe Department of Medicine, John Radcliffe Hospital, Oxford, OX3 9DU UK
| | - Stefan K Piechnik
- />University of Oxford Centre for Clinical Magnetic Resonance Research (OCMR), Division of Cardiovascular Medicine, Radcliffe Department of Medicine, John Radcliffe Hospital, Oxford, OX3 9DU UK
| | - Eylem Levelt
- />University of Oxford Centre for Clinical Magnetic Resonance Research (OCMR), Division of Cardiovascular Medicine, Radcliffe Department of Medicine, John Radcliffe Hospital, Oxford, OX3 9DU UK
| | - Vanessa M Ferreira
- />University of Oxford Centre for Clinical Magnetic Resonance Research (OCMR), Division of Cardiovascular Medicine, Radcliffe Department of Medicine, John Radcliffe Hospital, Oxford, OX3 9DU UK
| | - Jane M Francis
- />University of Oxford Centre for Clinical Magnetic Resonance Research (OCMR), Division of Cardiovascular Medicine, Radcliffe Department of Medicine, John Radcliffe Hospital, Oxford, OX3 9DU UK
| | - Andrew Lewis
- />University of Oxford Centre for Clinical Magnetic Resonance Research (OCMR), Division of Cardiovascular Medicine, Radcliffe Department of Medicine, John Radcliffe Hospital, Oxford, OX3 9DU UK
| | - Nikhil Pal
- />University of Oxford Centre for Clinical Magnetic Resonance Research (OCMR), Division of Cardiovascular Medicine, Radcliffe Department of Medicine, John Radcliffe Hospital, Oxford, OX3 9DU UK
| | - Sairia Dass
- />University of Oxford Centre for Clinical Magnetic Resonance Research (OCMR), Division of Cardiovascular Medicine, Radcliffe Department of Medicine, John Radcliffe Hospital, Oxford, OX3 9DU UK
| | - Houman Ashrafian
- />University of Oxford Centre for Clinical Magnetic Resonance Research (OCMR), Division of Cardiovascular Medicine, Radcliffe Department of Medicine, John Radcliffe Hospital, Oxford, OX3 9DU UK
| | - Stefan Neubauer
- />University of Oxford Centre for Clinical Magnetic Resonance Research (OCMR), Division of Cardiovascular Medicine, Radcliffe Department of Medicine, John Radcliffe Hospital, Oxford, OX3 9DU UK
| | - Theodoros D Karamitsos
- />University of Oxford Centre for Clinical Magnetic Resonance Research (OCMR), Division of Cardiovascular Medicine, Radcliffe Department of Medicine, John Radcliffe Hospital, Oxford, OX3 9DU UK
- />1st Department of Cardiology, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, 54636 Greece
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16
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Meimoun P, Czitrom D. [Coronary microvascular dysfunction and aortic stenosis: an update]. Ann Cardiol Angeiol (Paris) 2014; 63:353-361. [PMID: 25261167 DOI: 10.1016/j.ancard.2014.08.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Accepted: 08/24/2014] [Indexed: 06/03/2023]
Abstract
The coronary microcirculatory impairment is a key feature of the pathophysiology of aortic stenosis (AS), the most operated valvular disease over the world. Several studies showed this coronary microcirculatory impairment in AS, using different tools and protocols, in various patient population of AS. This article will review the impairment of the coronary microcirculation in AS underlining its multifactorial origin, its functional part related to the hemodynamic consequences of AS, its complex relationship with left ventricular hypertrophy, and its potential diagnostic and prognostic value.
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Affiliation(s)
- P Meimoun
- Service de cardiologie-USIC, centre hospitalier de Compiègne, 8, rue Henri-Adnot, 60200 Compiègne, France.
| | - D Czitrom
- Service de cardiologie, institut mutualiste Montsouris, 75014 Paris, France
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Cremer PC, Khalaf S, Lou J, Rodriguez L, Cerqueira MD, Jaber WA. Stress positron emission tomography is safe and can guide coronary revascularization in high-risk patients being considered for transcatheter aortic valve replacement. J Nucl Cardiol 2014; 21:1001-10. [PMID: 24942611 DOI: 10.1007/s12350-014-9928-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Accepted: 05/15/2014] [Indexed: 01/12/2023]
Abstract
BACKGROUND The safety and accuracy of regadenoson stress positron emission tomography (PET) in patients with significant aortic stenosis (AS) is unknown. In patients undergoing surgical aortic valve replacement, coronary artery bypass grafting for coronary artery disease is standard, but the appropriate revascularization strategy in patients undergoing TAVR is uncertain. Stress PET may identify patients that benefit from revascularization. METHODS Fifty consecutive patients who were referred for consideration of TAVR and underwent a stress PET study were retrospectively identified. We assessed major adverse cardiac events and significant decreases in systolic blood pressure. The percentage of jeopardized myocardium was determined by combining ischemic and hibernating myocardium. RESULTS Our patients were high risk with a mean Society of Thoracic Surgeons mortality score of 11.4% and had severe AS with a moderately reduced left ventricular ejection fraction (EF) (mean aortic valve area of 0.78 ± 0.25 cm(2) and mean EF of 39 ± 16%). There were no major adverse events during testing. Transient hypotension occurred in 16% of the patients. Revascularization was performed in 44% of patients, and 91% of these patients had revascularization to territories jeopardized on PET. These patients had substantial jeopardized myocardium (median 19%), and only 3 patients underwent revascularization despite less than 10% jeopardized myocardium. CONCLUSIONS Stress cardiac PET with regadenoson can be performed safely in patients with severe AS. Results of the PET study can accurately direct subsequent revascularization.
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Affiliation(s)
- Paul C Cremer
- Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Avenue: Desk J1, Cleveland, OH, 44195, USA,
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18
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Giordano C, Thorn SL, Renaud JM, Al-Atassi T, Boodhwani M, Klein R, Kuraitis D, Dwivedi G, Zhang P, Dasilva JN, Ascah KJ, Dekemp RA, Suuronen EJ, Beanlands RSB, Ruel M. Preclinical evaluation of biopolymer-delivered circulating angiogenic cells in a swine model of hibernating myocardium. Circ Cardiovasc Imaging 2013; 6:982-91. [PMID: 24089461 DOI: 10.1161/circimaging.113.000185] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Vasculogenic cell-based therapy combined with tissue engineering is a promising revascularization approach targeted at patients with advanced coronary artery disease, many of whom exhibit myocardial hibernation. However, to date, no experimental data have been available in this context; we therefore examined the biopolymer-supported delivery of circulating angiogenic cells using a clinically relevant swine model of hibernating myocardium. METHODS AND RESULTS Twenty-five swine underwent placement of an ameroid constrictor on the left circumflex artery. After 2 weeks, animals underwent echocardiography, rest and stress ammonia-positron emission tomography perfusion, and fluorodeoxyglucose positron emission tomography viability scans. The following week, swine were randomized to receive intramyocardial injections of PBS control (n=10), circulating angiogenic cells (n=8), or circulating angiogenic cells+collagen-based matrix (n=7). The imaging protocol was repeated after 7 weeks. Baseline positron emission tomography myocardial blood flow and myocardial flow reserve were reduced in the left circumflex artery territory (both P<0.001), and hibernation (mismatch) was observed. At follow-up, stress myocardial blood flow had increased (P≤0.01) and hibernation decreased (P<0.01) in the cells+matrix group only. Microsphere-measured myocardial blood flow validated the perfusion results. Arteriole density and wall motion abnormalities improved in the cells+matrix group. There was also a strong trend toward an improvement in ejection fraction (P=0.07). CONCLUSIONS In this preclinical swine model of ischemic and hibernating myocardium, the combined delivery of circulating angiogenic cells and a collagen-based matrix restored perfusion, reduced hibernation, and improved myocardial wall motion.
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Affiliation(s)
- Céline Giordano
- Division of Cardiac Surgery, Molecular Function and Imaging Program at the Cardiac PET Centre, Division of Cardiology, and Department of Cellular and Molecular Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
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Bartko PE, Heinze G, Graf S, Clavel MA, Khorsand A, Bergler-Klein J, Burwash IG, Dumesnil JG, Sénéchal M, Baumgartner H, Rosenhek R, Pibarot P, Mundigler G. Two-Dimensional Strain for the Assessment of Left Ventricular Function in Low Flow–Low Gradient Aortic Stenosis, Relationship to Hemodynamics, and Outcome. Circ Cardiovasc Imaging 2013; 6:268-76. [DOI: 10.1161/circimaging.112.980201] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- Philipp Emanuel Bartko
- From the Department of Internal Medicine II, Division of Cardiology, (P.E.B., S.G., A.K., J.B.-K., R.R., G.M.) and Center for Medical Statistics, Informatics and Intelligent Systems (G.H.), Medical University of Vienna, Vienna, Austria; Laval Hospital/Québec Heart Institute, Laval University, Québec, Canada (M.A.C., J.G.D., M.S., P.P.); University of Ottawa Heart Institute, Ottawa, Ontario, Canada (I.G.B.); and Department of Cardiovascular Medicine, Divsion of Adult Congenital and Valvular Heart
| | - Georg Heinze
- From the Department of Internal Medicine II, Division of Cardiology, (P.E.B., S.G., A.K., J.B.-K., R.R., G.M.) and Center for Medical Statistics, Informatics and Intelligent Systems (G.H.), Medical University of Vienna, Vienna, Austria; Laval Hospital/Québec Heart Institute, Laval University, Québec, Canada (M.A.C., J.G.D., M.S., P.P.); University of Ottawa Heart Institute, Ottawa, Ontario, Canada (I.G.B.); and Department of Cardiovascular Medicine, Divsion of Adult Congenital and Valvular Heart
| | - Senta Graf
- From the Department of Internal Medicine II, Division of Cardiology, (P.E.B., S.G., A.K., J.B.-K., R.R., G.M.) and Center for Medical Statistics, Informatics and Intelligent Systems (G.H.), Medical University of Vienna, Vienna, Austria; Laval Hospital/Québec Heart Institute, Laval University, Québec, Canada (M.A.C., J.G.D., M.S., P.P.); University of Ottawa Heart Institute, Ottawa, Ontario, Canada (I.G.B.); and Department of Cardiovascular Medicine, Divsion of Adult Congenital and Valvular Heart
| | - Marie-Annick Clavel
- From the Department of Internal Medicine II, Division of Cardiology, (P.E.B., S.G., A.K., J.B.-K., R.R., G.M.) and Center for Medical Statistics, Informatics and Intelligent Systems (G.H.), Medical University of Vienna, Vienna, Austria; Laval Hospital/Québec Heart Institute, Laval University, Québec, Canada (M.A.C., J.G.D., M.S., P.P.); University of Ottawa Heart Institute, Ottawa, Ontario, Canada (I.G.B.); and Department of Cardiovascular Medicine, Divsion of Adult Congenital and Valvular Heart
| | - Aliasghar Khorsand
- From the Department of Internal Medicine II, Division of Cardiology, (P.E.B., S.G., A.K., J.B.-K., R.R., G.M.) and Center for Medical Statistics, Informatics and Intelligent Systems (G.H.), Medical University of Vienna, Vienna, Austria; Laval Hospital/Québec Heart Institute, Laval University, Québec, Canada (M.A.C., J.G.D., M.S., P.P.); University of Ottawa Heart Institute, Ottawa, Ontario, Canada (I.G.B.); and Department of Cardiovascular Medicine, Divsion of Adult Congenital and Valvular Heart
| | - Jutta Bergler-Klein
- From the Department of Internal Medicine II, Division of Cardiology, (P.E.B., S.G., A.K., J.B.-K., R.R., G.M.) and Center for Medical Statistics, Informatics and Intelligent Systems (G.H.), Medical University of Vienna, Vienna, Austria; Laval Hospital/Québec Heart Institute, Laval University, Québec, Canada (M.A.C., J.G.D., M.S., P.P.); University of Ottawa Heart Institute, Ottawa, Ontario, Canada (I.G.B.); and Department of Cardiovascular Medicine, Divsion of Adult Congenital and Valvular Heart
| | - Ian Gordon Burwash
- From the Department of Internal Medicine II, Division of Cardiology, (P.E.B., S.G., A.K., J.B.-K., R.R., G.M.) and Center for Medical Statistics, Informatics and Intelligent Systems (G.H.), Medical University of Vienna, Vienna, Austria; Laval Hospital/Québec Heart Institute, Laval University, Québec, Canada (M.A.C., J.G.D., M.S., P.P.); University of Ottawa Heart Institute, Ottawa, Ontario, Canada (I.G.B.); and Department of Cardiovascular Medicine, Divsion of Adult Congenital and Valvular Heart
| | - Jean Gaston Dumesnil
- From the Department of Internal Medicine II, Division of Cardiology, (P.E.B., S.G., A.K., J.B.-K., R.R., G.M.) and Center for Medical Statistics, Informatics and Intelligent Systems (G.H.), Medical University of Vienna, Vienna, Austria; Laval Hospital/Québec Heart Institute, Laval University, Québec, Canada (M.A.C., J.G.D., M.S., P.P.); University of Ottawa Heart Institute, Ottawa, Ontario, Canada (I.G.B.); and Department of Cardiovascular Medicine, Divsion of Adult Congenital and Valvular Heart
| | - Mario Sénéchal
- From the Department of Internal Medicine II, Division of Cardiology, (P.E.B., S.G., A.K., J.B.-K., R.R., G.M.) and Center for Medical Statistics, Informatics and Intelligent Systems (G.H.), Medical University of Vienna, Vienna, Austria; Laval Hospital/Québec Heart Institute, Laval University, Québec, Canada (M.A.C., J.G.D., M.S., P.P.); University of Ottawa Heart Institute, Ottawa, Ontario, Canada (I.G.B.); and Department of Cardiovascular Medicine, Divsion of Adult Congenital and Valvular Heart
| | - Helmut Baumgartner
- From the Department of Internal Medicine II, Division of Cardiology, (P.E.B., S.G., A.K., J.B.-K., R.R., G.M.) and Center for Medical Statistics, Informatics and Intelligent Systems (G.H.), Medical University of Vienna, Vienna, Austria; Laval Hospital/Québec Heart Institute, Laval University, Québec, Canada (M.A.C., J.G.D., M.S., P.P.); University of Ottawa Heart Institute, Ottawa, Ontario, Canada (I.G.B.); and Department of Cardiovascular Medicine, Divsion of Adult Congenital and Valvular Heart
| | - Raphael Rosenhek
- From the Department of Internal Medicine II, Division of Cardiology, (P.E.B., S.G., A.K., J.B.-K., R.R., G.M.) and Center for Medical Statistics, Informatics and Intelligent Systems (G.H.), Medical University of Vienna, Vienna, Austria; Laval Hospital/Québec Heart Institute, Laval University, Québec, Canada (M.A.C., J.G.D., M.S., P.P.); University of Ottawa Heart Institute, Ottawa, Ontario, Canada (I.G.B.); and Department of Cardiovascular Medicine, Divsion of Adult Congenital and Valvular Heart
| | - Philippe Pibarot
- From the Department of Internal Medicine II, Division of Cardiology, (P.E.B., S.G., A.K., J.B.-K., R.R., G.M.) and Center for Medical Statistics, Informatics and Intelligent Systems (G.H.), Medical University of Vienna, Vienna, Austria; Laval Hospital/Québec Heart Institute, Laval University, Québec, Canada (M.A.C., J.G.D., M.S., P.P.); University of Ottawa Heart Institute, Ottawa, Ontario, Canada (I.G.B.); and Department of Cardiovascular Medicine, Divsion of Adult Congenital and Valvular Heart
| | - Gerald Mundigler
- From the Department of Internal Medicine II, Division of Cardiology, (P.E.B., S.G., A.K., J.B.-K., R.R., G.M.) and Center for Medical Statistics, Informatics and Intelligent Systems (G.H.), Medical University of Vienna, Vienna, Austria; Laval Hospital/Québec Heart Institute, Laval University, Québec, Canada (M.A.C., J.G.D., M.S., P.P.); University of Ottawa Heart Institute, Ottawa, Ontario, Canada (I.G.B.); and Department of Cardiovascular Medicine, Divsion of Adult Congenital and Valvular Heart
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Tandon A, Grayburn PA. Imaging of Low-Gradient Severe Aortic Stenosis. JACC Cardiovasc Imaging 2013; 6:184-95. [DOI: 10.1016/j.jcmg.2012.11.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2012] [Revised: 11/20/2012] [Accepted: 11/26/2012] [Indexed: 02/06/2023]
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Larsen LH, Kofoed KF, Dalsgaard M, Kristensen T, Elming H, Steinbrüchel DA, Køber L, Kelbæk H, Hassager C. Assessment of coronary artery disease using coronary computed tomography angiography in patients with aortic valve stenosis referred for surgical aortic valve replacement. Int J Cardiol 2012; 168:126-31. [PMID: 23073274 DOI: 10.1016/j.ijcard.2012.09.057] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2012] [Revised: 06/22/2012] [Accepted: 09/14/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND In patients referred for aortic valve replacement (AVR) a pre-surgical assessment of coronary artery disease is mandatory to determine the possible need for additional coronary artery bypass grafting. The diagnostic accuracy of coronary computed tomography angiography (coronary CTA) was evaluated in patients with aortic valve stenosis referred for surgical AVR. METHODS Between March 2008 and March 2010 a total of 181 consecutive patients were included. All patients underwent pre-surgical coronary CTA (64- or 320-detector CT scanner) and invasive coronary angiography (ICA). The analyses were performed blinded to each other. RESULTS The mean ± SD age of the included patients was 71 ± 9 years and 59% were male. The prevalence of significant coronary artery stenosis >70% by ICA was 36%. Average heart rate during coronary CTA was 65 ± 16 b pm. In a patient based analysis 94% of the patients (171/181) were considered fully evaluable. Coronary CTA had a sensitivity of 68%, a specificity of 91%, a positive predictive value of 81%, and a negative predictive value of 83%. Advanced age, obstructive lung disease, NYHA function class III/IV, and high Agatston score were found to be significantly associated with disagreement between ICA and coronary CTA in univariate analysis. CONCLUSION In patients with aortic valve stenosis referred for surgical AVR the diagnostic accuracy of coronary CTA to identify significant coronary artery disease is moderate. Coronary CTA may be used successfully in a subset of patients with low age, no chronic obstructive lung disease, NYHA function class<III and low coronary Agatston score.
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Affiliation(s)
- L Hornbech Larsen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark.
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22
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Low-flow, low-gradient aortic stenosis with normal and depressed left ventricular ejection fraction. J Am Coll Cardiol 2012; 60:1845-53. [PMID: 23062546 DOI: 10.1016/j.jacc.2012.06.051] [Citation(s) in RCA: 299] [Impact Index Per Article: 24.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2011] [Revised: 05/08/2012] [Accepted: 06/05/2012] [Indexed: 12/18/2022]
Abstract
Low-flow, low-gradient (LF-LG) aortic stenosis (AS) may occur with depressed or preserved left ventricular ejection fraction (LVEF), and both situations are among the most challenging encountered in patients with valvular heart disease. In both cases, the decrease in gradient relative to AS severity is due to a reduction in transvalvular flow. The main challenge in patients with depressed LVEF is to distinguish between true severe versus pseudosevere stenosis and to accurately assess the severity of myocardial impairment. Paradoxical LF-LG severe AS despite a normal LVEF is a recently described entity that is characterized by pronounced LV concentric remodeling, small LV cavity size, and a restrictive physiology leading to impaired LV filling, altered myocardial function, and worse prognosis. Until recently, this entity was often misdiagnosed, thereby causing underestimation of AS severity and inappropriate delays for surgery. Hence, the main challenge in these patients is proper diagnosis, often requiring diagnostic tests other than Doppler echocardiography. The present paper proposes to review the diagnostic and therapeutic management specificities of LF-LG AS with and without depressed LV function.
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23
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The coronary circulation and blood flow in left ventricular hypertrophy. J Mol Cell Cardiol 2012; 52:857-64. [DOI: 10.1016/j.yjmcc.2011.08.028] [Citation(s) in RCA: 119] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2011] [Revised: 07/28/2011] [Accepted: 08/29/2011] [Indexed: 12/17/2022]
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Bravo PE, Pinheiro A, Higuchi T, Rischpler C, Merrill J, Santaularia-Tomas M, Abraham MR, Wahl RL, Abraham TP, Bengel FM. PET/CT assessment of symptomatic individuals with obstructive and nonobstructive hypertrophic cardiomyopathy. J Nucl Med 2012; 53:407-14. [PMID: 22315440 DOI: 10.2967/jnumed.111.096156] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
UNLABELLED Patients with obstructive hypertrophic cardiomyopathy (HCM) exhibit elevated left ventricular outflow tract gradients (LVOTGs) and appear to have a worse prognosis than those with nonobstructive HCM. The aim of this study was to evaluate whether patients with obstruction, compared with nonobstructive HCM, demonstrate significant differences in PET parameters of microvascular function. METHODS PET was performed in 33 symptomatic HCM patients at rest and during dipyridamole stress (peak) for the assessment of regional myocardial perfusion (rMP), left ventricular ejection fraction (LVEF), myocardial blood flow (MBF), and myocardial flow reserve (MFR). Myocardial wall thickness and LVOTG were measured with an echocardiogram. Patients were divided into the following 3 groups: nonobstructive (LVOTG < 30 mm Hg at rest and after provocation test with amyl nitrite), obstructive (LVOTG ≥ 30 mm Hg at rest and with provocation), and latent HCM (LVOTG < 30 at rest but ≥ 30 mm Hg with provocation). RESULTS Eleven patients were classified as nonobstructive (group 1), 12 as obstructive (group 2), and 10 as latent HCM (group 3). Except for age (42 ± 18 y for group 1, 58 ± 7 y for group 2, and 58 ± 12 y for group 3; P = 0.01), all 3 groups had similar baseline characteristics, including maximal wall thickness (2.3 ± 0.5 cm for group 1, 2.2 ± 0.4 cm for group 2, and 2.1 ± 0.7 cm for group 3; P = 0.7). During peak flow, most patients in groups 1 and 2, but fewer in group 3, exhibited rMP defects (73% for group 1, 100% for group 2, and 40% for group 3; P = 0.007) and a drop in LVEF (73% for group 1, 92% for group 2, and 50% for group 3; P = 0.09). Peak MBF (1.58 ± 0.49 mL/min/g for group 1, 1.72 ± 0.46 mL/min/g for group 2, and 1.97 ± 0.32 mL/min/g for group 3; P = 0.14) and MFR (1.62 ± 0.57 for group 1, 1.90 ± 0.31 for group 2, and 2.27 ± 0.51 for group 3; P = 0.01) were lower in the nonobstructive and higher in the latent HCM group. LVOTGs demonstrated no significant correlation with any flow dynamics. In a multivariate regression analysis, maximal wall thickness was the only significant predictor for reduced peak MBF (β = -0.45, P = 0.003) and MFR (β = -0.63, P = 0.0001). CONCLUSION Maximal wall thickness was identified as the strongest predictor of impaired dipyridamole-induced hyperemia and flow reserve in our study, whereas outflow tract obstruction was not an independent determinant.
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Affiliation(s)
- Paco E Bravo
- Division of Nuclear Medicine, Department of Radiology, Johns Hopkins University, Baltimore, MD, USA.
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Ziadi MC, deKemp RA, Beanlands RSB. Quantification of myocardial perfusion: What will it take to make it to prime time? CURRENT CARDIOVASCULAR IMAGING REPORTS 2009. [DOI: 10.1007/s12410-009-0029-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
Quantification of myocardial blood flow (MBF) and flow reserve has been used extensively with positron emission tomography (PET) to investigate the functional significance of coronary artery disease. Increasingly, flow quantification is being applied to investigations of microvascular dysfunction in early atherosclerosis and in nonatherosclerotic microvascular disease associated with primary and secondary cardiomyopathies. Fully three-dimensional (3D) acquisition is becoming the standard imaging mode on new equipment, bringing with it certain challenges for cardiac PET, but also the potential for MBF to be measured simultaneously with routine electrocardiography (ECG)-gated perfusion imaging. Existing 3D versus 2D comparative studies support the use of 3D cardiac PET for flow quantification, and these protocols can be translated to PET-CT, which offers a virtually noise-free attenuation correction. This technology combines the strengths of cardiac CT for evaluation of anatomy with cardiac PET for quantification of the hemodynamic impact on the myocardium. High throughput clinical imaging protocols are needed to evaluate the incremental diagnostic and prognostic value of this technology.
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