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Thirunavukarasu S, Ansari F, Kotha S, Giannoudi M, Procter H, Cash L, Chowdhary A, Jex N, Shiwani H, Forbes K, Valkovič L, Kellman P, Plein S, Greenwood JP, Everett T, Scott EM, Levelt E. Cardiac structural, functional, and energetic assessments during and after pregnancy in women with gestational diabetes mellitus, preeclampsia, and healthy pregnancy. Am J Obstet Gynecol 2025; 232:565.e1-565.e16. [PMID: 39581289 DOI: 10.1016/j.ajog.2024.11.018] [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: 06/02/2024] [Revised: 11/09/2024] [Accepted: 11/16/2024] [Indexed: 11/26/2024]
Abstract
BACKGROUND Gestational diabetes mellitus (GDM) and preeclampsia are common complications of pregnancy, for which overweight/obesity is a common risk factor. Both conditions are associated with a two-to-four-fold increase in future incident heart failure, which may be linked to early maladaptive myocardial changes. OBJECTIVE To determine maternal myocardial structural, functional, and energetic responses to pregnancies complicated by GDM or preeclampsia compared to healthy pregnancies (HP) at third-trimester of pregnancy and 12-months postpartum. STUDY DESIGN Thirty-eight women with HP, 30 GDM, 20 preeclampsia, 10 nonpregnant controls with overweight (Overweight-NC), and 10 with normal-weight were recruited. Cardiovascular magnetic resonance spectroscopy and imaging were used to define myocardial energetics (phosphocreatine: ATP ratio [PCr/ATP]), left ventricular (LV) volumes, mass, and ejection fraction and global longitudinal shortening (GLS). Pregnancy groups underwent repeat scans 12-months postpartum, nulliparous-controls were assessed once. RESULTS During third-trimester, compared to HP, women with either GDM or preeclampsia displayed higher BMI, higher LV-mass (HP: 90 [85, 94] g, GDM: 103 [96, 112], Preeclampsia: 118 [111, 125] g; P=.001) and lower PCr/ATP (HP: 2.2 [2.1, 2.4], GDM: 1.9 [1.7, 2], Preeclampsia: 1.9 [1.8, 2.1]; P=.0004) and GLS (HP: 20 [18, 21]%, GDM: 18 [17, 19]%, Preeclampsia: 16 [14, 17]%; P=.01). Post-pregnancy, no group saw significant changes in LV-mass, PCr/ATP, or GLS. There were no significant differences in LV-mass, PCr/ATP or GLS between the GDM and preeclampsia groups during or post-pregnancy. Moreover, the Overweight-NC showed no significant differences in LV-mass (53 [43, 63])g, PCr/ATP (2.0 [1.8, 2.2]), or GLS (-19 [17, 21]%) compared to GDM or preeclampsia groups during or post-pregnancy. CONCLUSION Women with GDM or preeclampsia exhibit similar myocardial phenotypes during pregnancy with persistent subclinical alterations in LV mass, energetics, and GLS 12-months postpartum. These myocardial alterations are similar to those detected in Overweight-NC, potentially suggesting the myocardial changes may predominantly be driven by overweight/obesity.
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Affiliation(s)
- Sharmaine Thirunavukarasu
- University of Leeds, Leeds Institute of Cardiovascular and Metabolic Medicine, Leeds, United Kingdom
| | - Faiza Ansari
- Department of Fetal Medicine, Leeds General Infirmary, The Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Sindhoora Kotha
- University of Leeds, Leeds Institute of Cardiovascular and Metabolic Medicine, Leeds, United Kingdom
| | - Marilena Giannoudi
- University of Leeds, Leeds Institute of Cardiovascular and Metabolic Medicine, Leeds, United Kingdom
| | - Henry Procter
- University of Leeds, Leeds Institute of Cardiovascular and Metabolic Medicine, Leeds, United Kingdom
| | - Lizette Cash
- University of Leeds, Leeds Institute of Cardiovascular and Metabolic Medicine, Leeds, United Kingdom
| | - Amrit Chowdhary
- University of Leeds, Leeds Institute of Cardiovascular and Metabolic Medicine, Leeds, United Kingdom
| | - Nicholas Jex
- University of Leeds, Leeds Institute of Cardiovascular and Metabolic Medicine, Leeds, United Kingdom
| | - Hunain Shiwani
- Cardiac Imaging Department, Barts Heart Centre St Bartholomew's Hospital, London, United Kingdom
| | - Karen Forbes
- University of Leeds, Leeds Institute of Cardiovascular and Metabolic Medicine, Leeds, United Kingdom
| | - Ladislav Valkovič
- University of Oxford Centre for Clinical Magnetic Resonance Research (OCMR), RDM Cardiovascular Medicine, University of Oxford, Oxford, United Kingdom; Department of Imaging Methods, Institute of Measurement Science, Slovak Academy of Sciences, Bratislava, Slovakia
| | - Peter Kellman
- National Heart, Lung, and Blood Institute, National Institutes of Health, DHHS, Bethesda, MD
| | - Sven Plein
- University of Leeds, Leeds Institute of Cardiovascular and Metabolic Medicine, Leeds, United Kingdom
| | - John P Greenwood
- University of Leeds, Leeds Institute of Cardiovascular and Metabolic Medicine, Leeds, United Kingdom; Baker Heart and Diabetes Institute, Melbourne, Australia; Monash University, Melbourne, Australia; University of Melbourne, Melbourne, Australia
| | - Thomas Everett
- Department of Fetal Medicine, Leeds General Infirmary, The Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Eleanor M Scott
- University of Leeds, Leeds Institute of Cardiovascular and Metabolic Medicine, Leeds, United Kingdom
| | - Eylem Levelt
- University of Leeds, Leeds Institute of Cardiovascular and Metabolic Medicine, Leeds, United Kingdom.
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2
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Giuliani C, Zanuttini A, Nuche J, Farjat Pasos JI, Bernard J, Lionel T, Jacob S, Abu-Alhayja'a R, Beaudoin J, Côté N, DeLarochellière R, Paradis JM, Clavel MA, Arsenault BJ, Rodés-Cabau J, Pibarot P, Hecht S. Human Epididymis Protein 4 in Transcatheter Aortic Valve Implantation: Diagnostic and Prognostic Value. JACC. ADVANCES 2025; 4:101722. [PMID: 40286377 PMCID: PMC12103096 DOI: 10.1016/j.jacadv.2025.101722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/25/2024] [Revised: 02/12/2025] [Accepted: 03/06/2025] [Indexed: 04/29/2025]
Abstract
BACKGROUND The utility of the human epididymis protein 4 (HE4) in patients undergoing transcatheter aortic valve implantation (TAVI) has not been established yet. OBJECTIVES The present study aimed at examining the prognostic value of HE4 in patients undergoing TAVI. METHODS In this prospective study, the prognostic value of HE4 to predict adverse clinical events was evaluated in 362 patients who underwent TAVI. The association between HE4 and diffuse myocardial fibrosis was also assessed using T1 mapping on cardiac magnetic resonance in a subgroup of 43 patients. RESULTS During a median follow-up of 2.5 (IQR: 1.9-3.2) years, 34/362 (9.4%) patients were rehospitalized for heart failure, 99/362 (27.3%) died, and 113/362 (31.2%) met the composite endpoint of rehospitalization for heart failure or all-cause mortality. In multivariable Cox regression analyses, patients with higher HE4 serum levels (ie, HE4 ≥130 pmol/L) vs lower serum levels (ie, HE4 <130 pmol/L) had increased risk of all-cause mortality (adjusted HR: 3.26 [95% CI: 2.04-5.20], P < 0.001), and of the composite endpoint (adjusted HR: 2.48 [95% CI: 1.64-3.74], P < 0.001) following TAVI, respectively. Patients with higher HE4 serum levels had higher median native T1 mapping values (1,278 [95% CI: 1,239-1,280] ms vs 1,352 [95% CI: 1,303-1,376] ms, P < 0.001) at 1 to 3 months following the procedure. CONCLUSIONS Elevated HE4 serum levels are associated with diffuse myocardial fibrosis and increased risk of adverse clinical events following TAVI. This promising blood biomarker may be helpful to enhance risk stratification in patients undergoing TAVI.
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Affiliation(s)
- Carlos Giuliani
- Centre de recherche de l'Institut universitaire de cardiologie et de pneumologie de Québec (IUCPQ), Québec City, Québec, Canada; Faculté de médecine, Université Laval, Québec City, Québec, Canada
| | - Antonela Zanuttini
- Centre de recherche de l'Institut universitaire de cardiologie et de pneumologie de Québec (IUCPQ), Québec City, Québec, Canada; Faculté de médecine, Université Laval, Québec City, Québec, Canada
| | - Jorge Nuche
- Centre de recherche de l'Institut universitaire de cardiologie et de pneumologie de Québec (IUCPQ), Québec City, Québec, Canada; Faculté de médecine, Université Laval, Québec City, Québec, Canada
| | - Julio I Farjat Pasos
- Centre de recherche de l'Institut universitaire de cardiologie et de pneumologie de Québec (IUCPQ), Québec City, Québec, Canada; Faculté de médecine, Université Laval, Québec City, Québec, Canada
| | - Jérémy Bernard
- Centre de recherche de l'Institut universitaire de cardiologie et de pneumologie de Québec (IUCPQ), Québec City, Québec, Canada; Faculté de médecine, Université Laval, Québec City, Québec, Canada
| | - Tastet Lionel
- Centre de recherche de l'Institut universitaire de cardiologie et de pneumologie de Québec (IUCPQ), Québec City, Québec, Canada; Faculté de médecine, Université Laval, Québec City, Québec, Canada
| | - Simon Jacob
- Centre de recherche de l'Institut universitaire de cardiologie et de pneumologie de Québec (IUCPQ), Québec City, Québec, Canada; Faculté de médecine, Université Laval, Québec City, Québec, Canada
| | - Rami Abu-Alhayja'a
- Centre de recherche de l'Institut universitaire de cardiologie et de pneumologie de Québec (IUCPQ), Québec City, Québec, Canada; Faculté de médecine, Université Laval, Québec City, Québec, Canada
| | - Jonathan Beaudoin
- Centre de recherche de l'Institut universitaire de cardiologie et de pneumologie de Québec (IUCPQ), Québec City, Québec, Canada; Faculté de médecine, Université Laval, Québec City, Québec, Canada
| | - Nancy Côté
- Centre de recherche de l'Institut universitaire de cardiologie et de pneumologie de Québec (IUCPQ), Québec City, Québec, Canada; Faculté de médecine, Université Laval, Québec City, Québec, Canada
| | - Robert DeLarochellière
- Centre de recherche de l'Institut universitaire de cardiologie et de pneumologie de Québec (IUCPQ), Québec City, Québec, Canada; Faculté de médecine, Université Laval, Québec City, Québec, Canada
| | - Jean-Michel Paradis
- Centre de recherche de l'Institut universitaire de cardiologie et de pneumologie de Québec (IUCPQ), Québec City, Québec, Canada; Faculté de médecine, Université Laval, Québec City, Québec, Canada
| | - Marie-Annick Clavel
- Centre de recherche de l'Institut universitaire de cardiologie et de pneumologie de Québec (IUCPQ), Québec City, Québec, Canada; Faculté de médecine, Université Laval, Québec City, Québec, Canada
| | - Benoit J Arsenault
- Centre de recherche de l'Institut universitaire de cardiologie et de pneumologie de Québec (IUCPQ), Québec City, Québec, Canada; Faculté de médecine, Université Laval, Québec City, Québec, Canada
| | - Josep Rodés-Cabau
- Centre de recherche de l'Institut universitaire de cardiologie et de pneumologie de Québec (IUCPQ), Québec City, Québec, Canada; Faculté de médecine, Université Laval, Québec City, Québec, Canada
| | - Philippe Pibarot
- Centre de recherche de l'Institut universitaire de cardiologie et de pneumologie de Québec (IUCPQ), Québec City, Québec, Canada; Faculté de médecine, Université Laval, Québec City, Québec, Canada
| | - Sébastien Hecht
- Centre de recherche de l'Institut universitaire de cardiologie et de pneumologie de Québec (IUCPQ), Québec City, Québec, Canada; Faculté de médecine, Université Laval, Québec City, Québec, Canada.
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3
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Kwak S, Singh A, Everett RJ, Treibel TA, Lim J, Won S, Williams MC, Loganathan K, Bing R, Craig N, Singh T, Joshi S, Lee H, Lee W, Kim YJ, Chin CWL, Fukui M, Al Musa T, Rigolli M, Tastet L, Dobson LE, Wiesemann S, Ferreira VM, Captur G, Lee S, Schulz-Menger J, Schelbert EB, Clavel MA, Park SJ, Pellegrini C, Hadamitzky M, Gerber BL, Newby DE, Myerson SG, Pibarot P, Cavalcante JL, McCann GP, Greenwood JP, Moon JC, Dweck MR, Lee SP. Sex-Specific Association of Myocardial Fibrosis With Mortality in Patients With Aortic Stenosis. JAMA Cardiol 2025; 10:446-455. [PMID: 39969863 PMCID: PMC11840686 DOI: 10.1001/jamacardio.2024.5593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2024] [Accepted: 12/13/2024] [Indexed: 02/20/2025]
Abstract
Importance Myocardial fibrosis in aortic stenosis (AS) may exhibit sex differences. However, its prognostic significance in women with AS remains unclear. Objective To investigate sex differences in myocardial fibrosis assessed by cardiovascular magnetic resonance (CMR) and evaluate its prognostic value in women and men with AS. Design, Setting, and Participants Patients with severe AS who underwent CMR before aortic valve replacement (AVR) were prospectively enrolled from 13 international sites between March 2011 and September 2021. Myocardial fibrosis was evaluated using extracellular volume fraction (ECV%) and late gadolinium enhancement (LGE). The main analysis was conducted on patients without obstructive coronary artery disease (CAD), defined as those with no history of myocardial infarction and no concomitant coronary artery bypass grafting. Data were analyzed from December 2023 to February 2024. Exposures Surgical or transcatheter AVR. Main Outcomes and Measures The primary outcome was post-AVR all-cause mortality and the secondary outcome was cardiovascular mortality. Results Of 822 patients, 670 were without obstructive CAD (368 men [55%] and 302 women [45%]). Among these, women and men had a similar age (median, 72 years vs 71 years, respectively), comorbidities, and AS severity. ECV% was similar between sexes; however, women had less LGE (both infarct and noninfarct LGE). After a median follow-up of 3.7 (IQR, 2.1-4.7) years, there were 76 deaths (11.3%), including 29 adjudicated cardiovascular deaths, in patients without obstructive CAD. Increasing ECV% and LGE were associated with higher all-cause and cardiovascular mortality in both sexes. Cox analyses demonstrated that both ECV% and LGE were associated with higher all-cause mortality without significant interaction by sex (women: adjusted hazard ratio [HR], 1.08 per 1% ECV% increase; 95% CI, 1.04-1.12; P < .001; men: adjusted HR, 1.01; 95% CI, 0.96-1.06; P = .66; P for interaction by sex = .09 and women: adjusted HR, 2.49 for the presence of LGE; 95% CI, 1.07-5.80; P = .03; men: adjusted HR, 1.82; 95% CI, 1.00-3.32; P = .04; P for interaction by sex = .68). In the entire population (n = 822), both noninfarct and infarct-related LGE were associated with increased mortality without significant interaction by sex. Conclusions and Relevance In this study, patients with severe AS who underwent AVR exhibited similar ECV% between sexes, while women had lower LGE. Increased myocardial fibrosis provided important prognostic value for both sexes.
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Affiliation(s)
- Soongu Kwak
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Anvesha Singh
- Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, United Kingdom
| | - Russell J. Everett
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Thomas A. Treibel
- Barts Health NHS Trust and University College London, London, United Kingdom
| | - Jaehyun Lim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Sungho Won
- Department of Public Health Sciences, Seoul National University, Seoul, South Korea
| | - Michelle C. Williams
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Krithika Loganathan
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Rong Bing
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Neil Craig
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Trisha Singh
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Shruti Joshi
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Heesun Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Whal Lee
- Department of Radiology, Seoul National University Hospital, Seoul, Korea
| | - Yong-Jin Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | | | - Miho Fukui
- Cardiovascular Imaging Research Center and Core Lab, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Tarique Al Musa
- Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK and Baker Heart and Diabetes Institute & Monash University, Melbourne, Australia
| | - Marzia Rigolli
- University of Oxford Centre for Clinical Magnetic Resonance Research, BHF Centre of Research Excellence (Oxford), NIHR Biomedical Research Centre (Oxford), Oxford, United Kingdom
| | - Lionel Tastet
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Université Laval, Québec city, Québec, Canada
| | - Laura E. Dobson
- Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK and Baker Heart and Diabetes Institute & Monash University, Melbourne, Australia
| | - Stephanie Wiesemann
- Charité Campus Buch ECRC and Helios Clinics Cardiology Germany, DZHK partner site, Berlin, Germany
| | - Vanessa M. Ferreira
- University of Oxford Centre for Clinical Magnetic Resonance Research, BHF Centre of Research Excellence (Oxford), NIHR Biomedical Research Centre (Oxford), Oxford, United Kingdom
| | - Gabriella Captur
- Inherited Heart Muscle Disease Clinic, Department of Cardiology, Royal Free Hospital, NHS Foundation Trust, London, United Kingdom
| | - Sahmin Lee
- Division of Cardiology, Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jeanette Schulz-Menger
- Charité Campus Buch ECRC and Helios Clinics Cardiology Germany, DZHK partner site, Berlin, Germany
| | | | - Marie-Annick Clavel
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Université Laval, Québec city, Québec, Canada
| | - Sung-Ji Park
- Division of Cardiology, Department of Medicine, Cardiovascular Imaging Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | | | - Martin Hadamitzky
- Department of Radiology and Nuclear Medicine, German Heart Center Munich, Munich, Germany
| | - Bernhard L. Gerber
- Division of Cardiology, Department of Cardiovascular Diseases, Cliniques Universitaires St Luc and Institut de Recherche Cardiovasculaire (IREC), Université Catholique de Louvain (UCLouvain), Brussels, Belgium
| | - David E. Newby
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Saul G. Myerson
- University of Oxford Centre for Clinical Magnetic Resonance Research, BHF Centre of Research Excellence (Oxford), NIHR Biomedical Research Centre (Oxford), Oxford, United Kingdom
| | - Phillipe Pibarot
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Université Laval, Québec city, Québec, Canada
| | - João L. Cavalcante
- Cardiovascular Imaging Research Center and Core Lab, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
- Allina Health Minneapolis Heart Institute, Minneapolis, Minnesota
| | - Gerry P. McCann
- Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, United Kingdom
| | - John P. Greenwood
- Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK and Baker Heart and Diabetes Institute & Monash University, Melbourne, Australia
| | - James C. Moon
- Barts Health NHS Trust and University College London, London, United Kingdom
| | - Marc R. Dweck
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Seung-Pyo Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
- Center for Precision Medicine, Seoul National University Hospital, Seoul, South Korea
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Rajah MR, Marais E, Maarman GJ, Doubell E, Doubell AF, Herbst PG. Utility of Serum Biomarkers of Myocardial Fibrosis in High-Gradient Severe Aortic Stenosis: An Explorative Cardiovascular Magnetic Resonance Imaging-Based Study. Diagnostics (Basel) 2025; 15:1143. [PMID: 40361961 PMCID: PMC12072075 DOI: 10.3390/diagnostics15091143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2025] [Revised: 04/12/2025] [Accepted: 04/28/2025] [Indexed: 05/15/2025] Open
Abstract
Background: Myocardial fibrosis in aortic stenosis (AS) is associated with a significant risk of poor clinical outcomes. Myocardial fibrosis can be evaluated using cardiovascular magnetic resonance (CMR) imaging and may be useful for risk-stratifying patients at high risk for poorer outcomes. A circulating biomarker of fibrosis may be a cheaper, more accessible alternative to CMR in lower-to-middle-income countries. This study evaluated the correlation between serum biomarkers of myocardial fibrosis (TGF-β1, PICP, and PIIINP) with CMR markers of myocardial fibrosis (T1 mapping, extracellular volume fraction (ECV), and late gadolinium enhancement (LGE)). Methods: Twenty-one high-gradient (mean gradient ≥ 40 mmHg) severe AS (aortic valve area < 1.0 cm2) participants underwent T1 mapping and LGE imaging using CMR. Blood serum was collected for enzyme-linked immunosorbent assays of the listed biomarkers. Results: Serum TGF-β1 was associated significantly with the global T1 relaxation time on CMR (r = 0.46 with 95% CI 0.03 to 0.74, p = 0.04). In the high T1 time group (1056 vs. 1023 ms), trends toward elevated serum TGF-β1 concentration (13,044 vs. 10,341 pg/mL, p = 0.08) and ECV (26% vs. 24%, p = 0.07) were observed. The high T1 and trend towards elevated TGF-β1 concentration in this group tracked adverse LV remodeling and systolic dysfunction. There were no significant associations between PICP/PIIINP and T1 mapping or between the biomarkers and LGE quantity. Conclusions: Serum TGF-β1 is a potential surrogate for diffuse interstitial fibrosis measured by T1 mapping and ECV on CMR. Serum PICP and PIIINP may be less appropriate as surrogate markers of fibrosis in view of their temporal trends over the course of AS. Larger studies are needed to validate the utility of TGF-β1 as a marker of diffuse fibrosis and to evaluate the utility of serial PICP/PIIINP measurements to predict decompensation.
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Affiliation(s)
- Megan R. Rajah
- Division of Cardiology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town 8000, South Africa
- Centre for Cardio-Metabolic Research in Africa, Division of Medical Physiology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town 8000, South Africa; (E.M.)
| | - Erna Marais
- Centre for Cardio-Metabolic Research in Africa, Division of Medical Physiology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town 8000, South Africa; (E.M.)
| | - Gerald J. Maarman
- Centre for Cardio-Metabolic Research in Africa, Division of Medical Physiology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town 8000, South Africa; (E.M.)
| | - Emma Doubell
- Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town 8000, South Africa;
| | - Anton F. Doubell
- Division of Cardiology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town 8000, South Africa
| | - Philip G. Herbst
- Division of Cardiology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town 8000, South Africa
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Baessato F, Ruzzarin A, Meierhofer C. Cardiovascular magnetic resonance and valvular heart diseases: a suggested protocol for congenital lesions. Cardiovasc Diagn Ther 2025; 15:441-454. [PMID: 40385267 PMCID: PMC12082240 DOI: 10.21037/cdt-24-470] [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: 09/18/2024] [Accepted: 03/24/2025] [Indexed: 05/20/2025]
Abstract
Valvular heart diseases (VHDs) require definition of anatomy, severity, and risk stratification to best define procedural need, type of intervention and seriate follow-up. Congenital lesions are much rarer and often associated with more complex lesions. Among noninvasive imaging modalities, cardiovascular magnetic resonance (CMR) represents a fundamental tool for complete assessment and quantification of VHDs. CMR can provide wide anatomical views on cardiac and extra-cardiac structures in any plane orientation, flow and volume quantification, as well as information on ventricular remodeling and viability. In the context of valve stenosis, quantification by CMR is based primarily on direct measurement of valve orifice at maximal valve opening, although CMR data remain less reliable than standard echocardiography due to reduced temporal resolution. Definition of great vessels anatomy by CMR can allow differentiation of valvular, subvalvular or supravalvular lesions. For valve regurgitation, CMR is the gold standard for quantification of ventricular volumes and function and for direct calculation of regurgitation of the semilunar valves with through-plane phase-contrast images. Additional flow measurements can be integrated to cross-check quantitative data on great vessels flow and stroke volumes. A standardized approach is recommended in CMR studies. A minimum CMR dataset should include two-dimensional cine and phase-contrast sequences, and three-dimensional whole heart imaging. This should be applied in the clinical practice to assess VHDs, including most complex congenital lesions.
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Affiliation(s)
- Francesca Baessato
- Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, TUM University Hospital, Technical University of Munich, School of Medicine and Health, Munich, Germany
- Department of Cardiology, Regional Hospital S. Maurizio, Bolzano, Italy
| | | | - Christian Meierhofer
- Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, TUM University Hospital, Technical University of Munich, School of Medicine and Health, Munich, Germany
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Kitahara H, Okita S, Sugawara T, Yaginuma H, Goto H, Yamamoto H, Kanda T, Matsuura K, Inaba Y, Hanaoka H, Matsumiya G, Kobayashi Y. Evaluation of the efficacy of angiotensin receptor-neprilysin inhibitor in patients with aortic stenosis undergoing transcatheter aortic valve implantation: protocol for a randomised, open-label, controlled study. BMJ Open 2025; 15:e095105. [PMID: 40295134 PMCID: PMC12039011 DOI: 10.1136/bmjopen-2024-095105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2024] [Accepted: 04/08/2025] [Indexed: 04/30/2025] Open
Abstract
INTRODUCTION There are a substantial number of patients developing heart failure after transcatheter aortic valve implantation (TAVI) for severe aortic stenosis (AS), even though AS has been successfully treated. The purpose of this randomised controlled trial was to determine whether the addition of an angiotensin receptor-neprilysin inhibitor (ARNI), sacubitril/valsartan, is superior to conventional medications in lowering N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels in patients undergoing TAVI for AS. METHODS AND ANALYSIS The study design is a prospective, single-centre, open-label, randomised, parallel-group, two-arm study, in which participants will be randomised in a 1:1 ratio to receive either conventional medications plus ARNI or conventional medications only. In the ARNI group, if a patient was on an ACE inhibitor or angiotensin II receptor blocker before TAVI, it will be switched to ARNI 100 mg/day (50 mg two times per day) on the first postoperative day. If not, candesartan 4 mg/day will be started 1-2 days before TAVI, and switched to ARNI 100 mg/day on the first postoperative day. As the patient has tolerability to ARNI, dosage will be increased stepwise to 400 mg/day 2-4 weeks apart. ARNI will be continued until at least 6-month follow-up. In the control group, the patient will receive conventional medications. The primary endpoint is the serum NT-proBNP value at 6-month follow-up after TAVI. Each group includes 42 patients (84 total patients). ETHICS AND DISSEMINATION Ethical approval for this study has been obtained from the Chiba University Hospital Certified Clinical Research Review Board (CRB3180015). The study is ongoing. Findings from this study will be disseminated through peer-reviewed publications and conference presentations. TRIAL REGISTRATION NUMBER This trial has been registered on the Japan Registry of Clinical Trials: jRCT1031220344.
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Affiliation(s)
- Hideki Kitahara
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Shogo Okita
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | | | - Hiroaki Yaginuma
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Hiroki Goto
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Hiroaki Yamamoto
- Department of Cardiovascular Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Tomoyoshi Kanda
- Department of Cardiovascular Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Kaoru Matsuura
- Department of Cardiovascular Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Yosuke Inaba
- Clinical Research Center, Chiba University Hospital, Chiba, Japan
| | - Hideki Hanaoka
- Clinical Research Center, Chiba University Hospital, Chiba, Japan
| | - Goro Matsumiya
- Department of Cardiovascular Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
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7
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Oikonomou EK, Craig NJ, Holste G, Shankar SV, White A, Mahendran M, Newby DE, Dweck MR, Khera R. Artificial intelligence-enabled echocardiography as a surrogate for multi-modality aortic stenosis imaging: post-hoc analysis of a clinical trial. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2025:2025.03.26.25324690. [PMID: 40196287 PMCID: PMC11974988 DOI: 10.1101/2025.03.26.25324690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 04/09/2025]
Abstract
Background Accurate aortic stenosis (AS) phenotyping requires access to multimodality imaging which has limited availability. The Digital Aortic Stenosis Severity Index (DASSi), an AI biomarker of AS-related remodeling on 2D echocardiography, predicts AS progression independent of Doppler measurements. Whether DASSi-enhanced echocardiography provides a scalable alternative to multimodality AS imaging remains unknown. We sought to evaluate the ability of DASSi to define personalized AS progression profiles and validate its performance against multimodality imaging features of functional, structural, and biological disease severity. Methods In the SALTIRE-2 trial of participants with mild-or-moderate AS, we performed blinded DASSi measurements (probability of severe AS, 0-to-1) on baseline transthoracic echocardiograms. We evaluated the association between baseline DASSi and (i) disease severity by hemodynamic (peak aortic valve velocity [AV-Vmax]), structural (CT-derived aortic valve calcium score [AVCS]) and biological features ([18F]sodium fluoride [NaF] uptake on Positron Emission Tomography-CT), (ii) disease progression (change in AV-Vmax and AVCS), and (iii) incident aortic valve replacement (AVR). We used generalized linear mixed, or Cox models adjusted for risk factors and aortic valve area, as appropriate. Results We analyzed 134 participants (72 [IQR: 69-78] years, 27 [20.1%] women) with a mean baseline DASSi of 0.51 (standard deviation [SD]: 0.19). DASSi was independently associated with disease severity: each SD increase was associated with higher AV-Vmax (+0.21 [95%CI: 0.12-0.30] m/sec), AVCS (+284 [95%CI: 101-467] AU) and [18F]NaF TBRmax (+0.17 [95%CI: 0.04-0.31]). Higher DASSi was also associated with disease progression by Doppler (AV-Vmax) and CT (AVCS) at 24 months (p interaction for DASSi (x) time<0.001), and future AVR (75 events over 5.5 [IQR: 2.4-7.2] years, adj.HR 1.47 [95%CI: 1.12-1.94] per SD). Conclusions DASSi is associated with functional, structural and biological features of AS severity as well as disease progression and outcomes. DASSi-enhanced echocardiography provides a readily accessible alternative to multimodality imaging of AS which has potential value both in clinical practice and as a clinical trial biomarker.
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Affiliation(s)
- Evangelos K. Oikonomou
- Section of Cardiovascular Medicine, Dept of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Cardiovascular Data Science (CarDS) Lab, Yale School of Medicine, New Haven, CT, USA
| | - Neil J. Craig
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Gregory Holste
- Cardiovascular Data Science (CarDS) Lab, Yale School of Medicine, New Haven, CT, USA
- Department of Electrical and Computer Engineering, University of Texas in Austin, Austin, TX, USA
| | - Sumukh Vasisht Shankar
- Section of Cardiovascular Medicine, Dept of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Cardiovascular Data Science (CarDS) Lab, Yale School of Medicine, New Haven, CT, USA
| | - Audrey White
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Menaka Mahendran
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - David E. Newby
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Marc R. Dweck
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Rohan Khera
- Section of Cardiovascular Medicine, Dept of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Cardiovascular Data Science (CarDS) Lab, Yale School of Medicine, New Haven, CT, USA
- Section of Biomedical Informatics and Data Science, Yale School of Medicine, New Haven, CT, USA
- Section of Health Informatics, Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
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8
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Donal E, Unger P, Coisne A, Pibarot P, Magne J, Sitges M, Habib G, Clavel MA, von Bardeleben RS, Plein S, Pezel T, Dweck MR, Zamorano PL, Bertrand PB, Dahl JS, Popescu BA, Cosyns B, Ajmone-Marsan N, Bohbot Y, Di Salvo G, Keenan N, Petrescu AM, Stankovic I. The role of multi-modality imaging in multiple valvular heart diseases: a clinical consensus statement of the European Association of Cardiovascular Imaging of the European Society of Cardiology. Eur Heart J Cardiovasc Imaging 2025; 26:593-608. [PMID: 39874243 DOI: 10.1093/ehjci/jeaf026] [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: 11/09/2024] [Revised: 12/28/2024] [Accepted: 12/31/2024] [Indexed: 01/30/2025] Open
Abstract
With this document, the European Association of Cardiovascular Imaging provides an Expert Consensus on the role of multi-modality imaging (MMI) in the management of patients with multiple valvular heart disease (MVD). Emphasis is given to the use of MMI to unravel the diagnostic challenges that characterize these patients and to improve risk stratification. Complementing the last European Society of Cardiology and European Association of Cardio-Thoracic Surgery guidelines on valvular heart disease, this Expert Consensus document also outlines how MMI assessment should form an integral part of the multi-disciplinary heart team discussion for patients with MVD to help with complex decision-making regarding the choice and timing of treatment.
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Affiliation(s)
- Erwan Donal
- Department of Cardiology, University of Rennes, CHU Rennes, Inserm, LTSI-UMR 1099, Pontchaillou Hospital-CHU Rennes, F-35033 Rennes, France
| | - Philippe Unger
- Department of Cardiology, University Hospital Brussels, Laarbeeklaan 101, Jette, Brussels 1090, Belgium
- Department of Cardiology, Centre Hospitalier Universitaire Saint-Pierre, Université libre de Bruxelles, 322 rue Haute, Brussels 1000, Belgium
| | - Augustin Coisne
- University of Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1011-EGID, F-59000 Lille, France
| | - Philippe Pibarot
- Institut Universitaire de Cardiologie et de Pneumologie, Université Laval, Québec, Canada
| | - Julien Magne
- INSERM, Université de Limoges, CHU de Limoges, EpiMaCT-Epidemiology of Chronic Diseases in Tropical Zone, OmegaHealth, Limoges, France
- Center of Clinical and Research Data, CHU de Limoges, 87000 Limoges, France
| | - Marta Sitges
- Cardiovascular Institute, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- CIBER, Centro de Investigación Biomédica en Red, Barcelona, Spain
| | - Gilbert Habib
- Cardiology Department, Hôpital La Timone, Marseille, France
| | | | | | - Sven Plein
- Department of Cardiology, Université Paris Cité, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Inserm U-942, MIRACL.ai, Paris, France
| | - Theo Pezel
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh
| | - Marc R Dweck
- Cardiology Department, University Hospital Ramón y Cajal, Madrid, Spain
| | - Pepe L Zamorano
- Cardiology Department, University Hospital Ramón y Cajal, Madrid, Spain
- Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
- CIBERCV, Instituto de Salud Carlos III (ISCIII), Spain
| | | | - Jordi S Dahl
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Bogdan A Popescu
- University of Medicine and Pharmacy 'Carol Davila'-Euroecolab, Emergency Institute for Cardiovascular Diseases 'Prof. Dr. C.C. Iliescu', Bucharest, Romania
| | - Bernard Cosyns
- Department of Cardiology, University Hospital Brussels, Laarbeeklaan 101, Jette, Brussels 1090, Belgium
| | - Nina Ajmone-Marsan
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2300RC Leiden, The Netherlands
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9
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Boeckling F, Rasper T, Zanders L, Pergola G, Cremer S, Mas-Peiro S, Vasa-Nicotera M, Leistner D, Dimmeler S, Kattih B. Extracellular Matrix Proteins Improve Risk Prediction in Patients Undergoing Transcatheter Aortic Valve Replacement. J Am Heart Assoc 2025; 14:e037296. [PMID: 40008512 DOI: 10.1161/jaha.124.037296] [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: 06/22/2024] [Accepted: 12/03/2024] [Indexed: 02/27/2025]
Abstract
BACKGROUND Cardiac fibrosis is common in patients with severe aortic stenosis and an independent predictor of death. Therefore, we examined the additional value of circulating fibrosis markers as a putative biomarker platform to identify patients with aortic stenosis undergoing transcatheter aortic valve replacement (TAVR) who are at a higher risk of death. METHODS In this study, 2-year survival analyses were conducted in 378 consecutive patients undergoing TAVR to evaluate the association between fibrosis marker and risk of adverse long-term outcome. Implementation of fibrosis marker into TAVR risk stratification was tested by a machine-learning algorithm. RESULTS Among 20 circulating fibrosis markers involved in pathological extracellular matrix remodeling, high tissue inhibitor of metalloproteinase-1 (TIMP-1) levels independently predicted risk of death in univariable (hazard ratio, 5.0 [95% CI, 2.6-9.7]; P<0.001) and multivariable (adjusted hazard ratio, 2.2 [95% CI, 1.0-4.7]; P=0.046) Cox regression analyses. Consequently, higher TIMP-1 levels offered a significantly higher overall prediction of reduced survival compared with the conventional Society of Thoracic Surgeons Predicted Risk of Mortality score (area under the curve, 0.753 [95% CI, 0.682-0.824] versus area under the curve, 0.656 [95% CI, 0.578-0.734]; P<0.05). Applying an independent machine-learning algorithm allowed identification of a simple combination of 2 biomarkers (TIMP-1 and high-sensitivity cardiac troponin T) with superior prognostic value compared with Society of Thoracic Surgeons Predicted Risk of Mortality alone (area under the curve, 0.757 [95% CI, 0.686-0.828] versus 0.656 [95% CI, 0.578-0.34]; P<0.05). CONCLUSIONS Circulating TIMP-1 is an independent predictor of reduced 2-year overall survival in patients undergoing TAVR. Combined with high-sensitivity cardiac troponin T, circulating TIMP-1 should be incorporated into risk stratification to identify patients undergoing TAVR who are at a higher risk of death.
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Affiliation(s)
- Felicitas Boeckling
- Institute for Cardiovascular Regeneration, Goethe University Frankfurt am Main Germany
- Department of Cardiology Goethe University Frankfurt, University Hospital Frankfurt Germany
- German Centre for Cardiovascular Research, Berlin Partner Site Frankfurt Rhine-Main Frankfurt Germany
| | - Tina Rasper
- Institute for Cardiovascular Regeneration, Goethe University Frankfurt am Main Germany
| | - Lukas Zanders
- Institute for Cardiovascular Regeneration, Goethe University Frankfurt am Main Germany
- Department of Cardiology Goethe University Frankfurt, University Hospital Frankfurt Germany
- German Centre for Cardiovascular Research, Berlin Partner Site Frankfurt Rhine-Main Frankfurt Germany
| | - Graziella Pergola
- Institute for Cardiovascular Regeneration, Goethe University Frankfurt am Main Germany
- Department of Cardiology Goethe University Frankfurt, University Hospital Frankfurt Germany
| | - Sebastian Cremer
- Institute for Cardiovascular Regeneration, Goethe University Frankfurt am Main Germany
- Department of Cardiology Goethe University Frankfurt, University Hospital Frankfurt Germany
- German Centre for Cardiovascular Research, Berlin Partner Site Frankfurt Rhine-Main Frankfurt Germany
| | - Silvia Mas-Peiro
- German Centre for Cardiovascular Research, Berlin Partner Site Frankfurt Rhine-Main Frankfurt Germany
| | - Mariuca Vasa-Nicotera
- German Centre for Cardiovascular Research, Berlin Partner Site Frankfurt Rhine-Main Frankfurt Germany
| | - David Leistner
- Department of Cardiology Goethe University Frankfurt, University Hospital Frankfurt Germany
- German Centre for Cardiovascular Research, Berlin Partner Site Frankfurt Rhine-Main Frankfurt Germany
| | - Stefanie Dimmeler
- Institute for Cardiovascular Regeneration, Goethe University Frankfurt am Main Germany
- German Centre for Cardiovascular Research, Berlin Partner Site Frankfurt Rhine-Main Frankfurt Germany
| | - Badder Kattih
- Institute for Cardiovascular Regeneration, Goethe University Frankfurt am Main Germany
- Department of Cardiology Goethe University Frankfurt, University Hospital Frankfurt Germany
- German Centre for Cardiovascular Research, Berlin Partner Site Frankfurt Rhine-Main Frankfurt Germany
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10
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Faggiano A, Gherbesi E, Carugo S, Brusamolino M, Cozac DA, Cozza E, Savo MT, Cannata F, Guglielmo M, La Mura L, Fazzari F, Carrabba N, Conte E, Mushtaq S, Baggiano A, Guaricci AI, Pedrinelli R, Indolfi C, Sinagra G, Perrone Filardi P, Pergola V, Pontone G. Prognostic value of myocardial computed tomography-derived extracellular volume in severe aortic stenosis requiring aortic valve replacement: a systematic review and meta-analysis. Eur Heart J Cardiovasc Imaging 2025; 26:518-531. [PMID: 39787608 PMCID: PMC11879236 DOI: 10.1093/ehjci/jeae324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2024] [Accepted: 12/03/2024] [Indexed: 01/12/2025] Open
Abstract
Computed tomography (CT)-derived extracellular volume (ECV) fraction is a non-invasive method to quantify myocardial fibrosis. Evaluating CT-ECV during aortic valve replacement (AVR) planning CT in severe aortic stenosis (AS) may aid prognostic stratification. This meta-analysis evaluated the prognostic significance of CT-ECV in severe AS necessitating AVR. Electronic database searches of PubMed, Ovid MEDLINE, and Cochrane Library were performed. The primary outcome was to compare the occurrence of a composite of cardiovascular outcomes in patients with severe AS undergoing AVR with elevated myocardial CT-ECV values vs. patients with normal values. Secondary outcomes included all-cause mortality and heart failure (HF)-related hospitalization. A total of 1223 patients undergoing AVR for severe AS were included in 10 studies: 524 patients with high values of CT-ECV and 699 with normal values of CT-ECV. The pooled CT-ECV cut-off to define elevated values and predict prognosis was 30.7% [95% confidence interval (CI): 28.5-33.7%]. At a mean follow-up of 17.9 ± 2.3 months after AVR, patients with elevated CT-ECV experienced a significantly higher number of cardiovascular events [43.4 vs. 14.0%; odds ratio (OR): 4.3, 95% CI: 3.192-5.764, P < 0.001]. Regarding secondary outcomes, all-cause mortality occurred in 29.3% of patients with elevated CT-ECV vs. 11.6% with CT-ECV below the cut-off (OR: 3.5, 95% CI: 2.276-5.311, P < 0.001), whereas HF hospitalization was observed in 25.5% vs. 5.9% (OR: 4.9, 95% CI: 2.283-10.376, P < 0.001). Patients undergoing AVR for severe AS with elevated CT-ECV values experience a worse post-intervention prognosis. The implementation of CT-ECV evaluation in routine AVR planning protocols should be considered.
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Affiliation(s)
- Andrea Faggiano
- Department of Cardio-Thoracic-Vascular Diseases, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy
| | - Elisa Gherbesi
- Department of Cardio-Thoracic-Vascular Diseases, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Stefano Carugo
- Department of Cardio-Thoracic-Vascular Diseases, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy
| | - Matteo Brusamolino
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy
- Department of Perioperative Cardiology and Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, Via C. Parea 4, 20138 Milan, Italy
| | - Dan Alexandru Cozac
- Cardiology Clinic, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
- Department of Physiology, University of Medicine, Pharmacy, Science and Technology ‘George Emil Palade’ of Târgu Mureș, 540142 Târgu Mureș, Romania
| | - Elena Cozza
- Cardiology Clinic, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Maria Teresa Savo
- Cardiology Clinic, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Francesco Cannata
- Department of Perioperative Cardiology and Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, Via C. Parea 4, 20138 Milan, Italy
| | - Marco Guglielmo
- Division of Heart and Lungs, Department of Cardiology, Utrecht University Medical Center, Utrecht University, Utrecht, The Netherlands
- Department of Cardiology, Haga Teaching Hospital, The Hague, The Netherlands
| | - Lucia La Mura
- Department of Advanced Biomedical Sciences, University Federico II of Naples, Naples, Italy
| | - Fabio Fazzari
- Department of Perioperative Cardiology and Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, Via C. Parea 4, 20138 Milan, Italy
| | - Nazario Carrabba
- Department of Cardiothoracovascular Medicine, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Edoardo Conte
- Department of Clinical Cardiology and Cardiovascular Imaging, Galeazzi-Sant’Ambrogio Hospital IRCCS, Milan, Italy
| | - Saima Mushtaq
- Department of Perioperative Cardiology and Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, Via C. Parea 4, 20138 Milan, Italy
| | - Andrea Baggiano
- Department of Perioperative Cardiology and Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, Via C. Parea 4, 20138 Milan, Italy
| | - Andrea Igoren Guaricci
- University Cardiology Unit, Interdisciplinary Department of Medicine, University of Bari Aldo Moro, Bari, Italy
| | - Roberto Pedrinelli
- Cardiac, Thoracic and Vascular Department, University of Pisa, Pisa, Italy
| | - Ciro Indolfi
- Istituto di Cardiologia, Dipartimento di Scienze Mediche e Chirurgiche, Università degli Studi ‘Magna Graecia’, Catanzaro, Italy
| | - Gianfranco Sinagra
- Cardiology Specialty School, University of Trieste, Trieste, Italy
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), Trieste, Italy
| | | | - Valeria Pergola
- Cardiology Clinic, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Gianluca Pontone
- Department of Perioperative Cardiology and Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, Via C. Parea 4, 20138 Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
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11
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Shahid S, Jain H, Shahzad M, Dey D, Batool A, Passey S, Patel R, Vempati R. Aortic Valve Replacement Versus Conservative Management in Patients With Asymptomatic Aortic Stenosis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Cardiol Rev 2025:00045415-990000000-00428. [PMID: 39982064 DOI: 10.1097/crd.0000000000000879] [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] [Indexed: 02/22/2025]
Abstract
Aortic valve replacement (AVR) is recommended for symptomatic severe aortic stenosis (AS) patients. However, evidence of its role in asymptomatic patients with severe AS remains controversial. Hence, a systematic review and meta-analysis of randomized controlled trials comparing AVR to conservative management in patients with asymptomatic severe AS was conducted. A systematic literature search was performed on electronic databases including MEDLINE (via PubMed), Embase, and Cochrane CENTRAL Library until November 2024. A random effects model was used to pool individual risk ratios (RRs) with their corresponding 95% confidence intervals (CIs) using Review Manager Version 5.4.1 to calculate pooled effect estimates. Three randomized controlled trials with 1203 patients (42% females) were included. On pooled analysis, AVR significantly reduced the risk of hospitalization for heart failure (RR = 0.11, CI: 0.02-0.56, P = 0.008) compared with conservative care. However, there were no significant differences between the 2 groups in all-cause mortality (RR = 0.63, CI: 0.36-1.11, P = 0.11), stroke (RR = 0.59, CI: 0.35-1.01, P = 0.05), myocardial infarction (RR = 0.43, CI: 0.06-2.92, P = 0.38), or thromboembolic events (RR = 0.54, CI: 0.13-2.29, P = 0.40). In asymptomatic patients with severe AS, AVR significantly reduces the risk of hospitalization due to heart failure, with comparable risks in terms of all-cause mortality, myocardial infarction, stroke, and thromboembolic events compared with conservative management.
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Affiliation(s)
- Sufyan Shahid
- From the Department of Cardiology, Khawaja Muhammad Safdar Medical College, Sialkot, Pakistan
| | - Hritvik Jain
- Department of Cardiology, All India Institute of Medical Sciences (AIIMS), Jodhpur, Jodhpur, India
| | - Maryam Shahzad
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Debankur Dey
- Department of Internal Medicine, Medical College Kolkata, Kolkata, India
| | - Ayesha Batool
- Department of Internal Medicine, Allama Iqbal Medical College, Lahore, Pakistan
| | - Siddhant Passey
- Department of Internal Medicine, University of Connecticut Health Center, Hartford, CT
| | - Rahul Patel
- Department of Internal Medicine, University of North Carolina Health Blue Ridge, Morganton, NC
| | - Roopeessh Vempati
- Department of Internal Medicine, Trinity Health Oakland/Wayne State University Program, Pontiac, MI
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12
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Lee HJ, Singh A, Lim J, Craig N, Bing R, Tastet L, Park JB, Kim HK, Kim YJ, Clavel MA, Gerber BL, McCann GP, Dweck MR, Pibarot P, Lee SP. Diffuse Interstitial Fibrosis of the Myocardium Predicts Outcome in Moderate and Asymptomatic Severe Aortic Stenosis. JACC Cardiovasc Imaging 2025; 18:180-191. [PMID: 39340492 DOI: 10.1016/j.jcmg.2024.08.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 06/02/2024] [Accepted: 08/01/2024] [Indexed: 09/30/2024]
Abstract
BACKGROUND Patients with moderate or asymptomatic severe aortic stenosis (AS) are at risk of cardiovascular events. OBJECTIVES The authors investigated the utility of cardiac magnetic resonance (CMR) to identify drivers of outcome in patients with moderate or asymptomatic severe AS. METHODS A prospective, international, multicenter cohort (n = 457) of patients with moderate (aortic valve area [AVA]: 1.0-1.5 cm2) or asymptomatic severe AS (AVA ≤1.0 cm2 and NYHA functional class I-II) patients underwent CMR. Diffuse interstitial fibrosis and scar in the myocardium were analyzed with extracellular volume fraction (ECV%) and late gadolinium enhancement (LGE). The outcome was a composite of mortality and heart failure admission. RESULTS Median ECV% was 26.6% (IQR: 24.4%-29.9%), and LGE was present in 31.5% (median 0.8%; IQR: 0.1%-1.7%). Greater AS severity was associated with greater left ventricular mass and diastolic dysfunction, but not with ECV% or LGE. During a median 5.7 years of follow-up, 83 events occurred. Patients with events had higher ECV% (median ECV% 26.3% vs 28.2%; P = 0.003). Patients in the highest ECV% tertiles (ECV% >28.6%) had worse outcomes both in the entire cohort and in those with NYHA functional class I moderate or severe AS, and ECV% was independently associated with outcome (adjusted HR: 1.05; P = 0.039). The ECV% had significant incremental prognostic value when added to parameters of AS severity and cardiac function, comorbidities, aortic valve replacement, and LGE (P < 0.05). CONCLUSIONS Increased diffuse interstitial fibrosis of the myocardium is associated with poor outcomes in patients with moderate and asymptomatic severe AS and can help identify those who require closer surveillance for adverse outcomes.
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Affiliation(s)
- Hyun-Jung Lee
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea; Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Anvesha Singh
- Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, United Kingdom
| | - Jaehyun Lim
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Neil Craig
- Centre for Cardiovascular Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Rong Bing
- Centre for Cardiovascular Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Lionel Tastet
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Université Laval, Québec City, Québec, Canada
| | - Jun-Bean Park
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea; Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Hyung-Kwan Kim
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea; Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Yong-Jin Kim
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea; Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Marie-Annick Clavel
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Université Laval, Québec City, Québec, Canada
| | - Bernhard L Gerber
- Division of Cardiology, Department of Cardiovascular Diseases, Cliniques Universitaires St. Luc and Institut de Recherche Cardiovasculaire, Université Catholique de Louvain, Brussels, Belgium
| | - Gerry P McCann
- Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, United Kingdom
| | - Marc R Dweck
- Centre for Cardiovascular Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Phillipe Pibarot
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Université Laval, Québec City, Québec, Canada
| | - Seung-Pyo Lee
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea; Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea.
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13
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Bonow RO. Myocardial Fibrosis and Timing of Intervention for Aortic Stenosis. JAMA 2025; 333:207-209. [PMID: 39466632 DOI: 10.1001/jama.2024.22853] [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: 10/30/2024]
Affiliation(s)
- Robert O Bonow
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Editor, JAMA Cardiology
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14
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Loganath K, Craig NJ, Everett RJ, Bing R, Tsampasian V, Molek P, Botezatu S, Aslam S, Lewis S, Graham C, White AC, MacGillivray T, Tuck CE, Rayson P, Cranley D, Irvine S, Armstrong R, Milne L, Chin CWL, Hillis GS, Fairbairn T, Greenwood JP, Steeds R, Leslie SJ, Lang CC, Bucciarelli-Ducci C, Joshi NV, Kunadian V, Vassiliou VS, Dungu JN, Hothi SS, Boon N, Prasad SK, Keenan NG, Dawson D, Treibel TA, Motwani M, Miller CA, Mills NL, Rajani R, Ripley DP, McCann GP, Prendergast B, Singh A, Newby DE, Dweck MR. Early Intervention in Patients With Asymptomatic Severe Aortic Stenosis and Myocardial Fibrosis: The EVOLVED Randomized Clinical Trial. JAMA 2025; 333:213-221. [PMID: 39466640 PMCID: PMC11519785 DOI: 10.1001/jama.2024.22730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2024] [Accepted: 10/10/2024] [Indexed: 10/30/2024]
Abstract
Importance Development of myocardial fibrosis in patients with aortic stenosis precedes left ventricular decompensation and is associated with an adverse long-term prognosis. Objective To investigate whether early valve intervention reduced the incidence of all-cause death or unplanned aortic stenosis-related hospitalization in asymptomatic patients with severe aortic stenosis and myocardial fibrosis. Design, Setting, and Participants This prospective, randomized, open-label, masked end point trial was conducted between August 2017 and October 2022 at 24 cardiac centers across the UK and Australia. Asymptomatic patients with severe aortic stenosis and myocardial fibrosis were included. The final date of follow-up was July 26, 2024. Intervention Early valve intervention with transcatheter or surgical aortic valve replacement or guideline-directed conservative management. Main Outcomes and Measures The primary outcome was a composite of all-cause death or unplanned aortic stenosis-related hospitalization in a time-to-first-event intention-to-treat analysis. There were 9 secondary outcomes, including the components of the primary outcome and symptom status at 12 months. Results The trial enrolled 224 eligible patients (mean [SD] age, 73 [9] years; 63 women [28%]; mean [SD] aortic valve peak velocity of 4.3 [0.5] m/s) of the originally planned sample size of 356 patients. The primary end point occurred in 20 of 113 patients (18%) in the early intervention group and 25 of 111 patients (23%) in the guideline-directed conservative management group (hazard ratio, 0.79 [95% CI, 0.44-1.43]; P = .44; between-group difference, -4.82% [95% CI, -15.31% to 5.66%]). Of 9 prespecified secondary end points, 7 showed no significant difference. All-cause death occurred in 16 of 113 patients (14%) in the early intervention group and 14 of 111 (13%) in the guideline-directed group (hazard ratio, 1.22 [95% CI, 0.59-2.51]) and unplanned aortic stenosis hospitalization occurred in 7 of 113 patients (6%) and 19 of 111 patients (17%), respectively (hazard ratio, 0.37 [95% CI, 0.16-0.88]). Early intervention was associated with a lower 12-month rate of New York Heart Association class II-IV symptoms than guideline-directed conservative management (21 [19.7%] vs 39 [37.9%]; odds ratio, 0.37 [95% CI, 0.20-0.70]). Conclusions and Relevance In asymptomatic patients with severe aortic stenosis and myocardial fibrosis, early aortic valve intervention had no demonstrable effect on all-cause death or unplanned aortic stenosis-related hospitalization. The trial had a wide 95% CI around the primary end point, with further research needed to confirm these findings. Trial Registration ClinicalTrials.gov Identifier: NCT03094143.
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Affiliation(s)
- Krithika Loganath
- British Heart Foundation Centre of Research Excellence, University of Edinburgh, Edinburgh, Scotland
| | - Neil J. Craig
- British Heart Foundation Centre of Research Excellence, University of Edinburgh, Edinburgh, Scotland
- Edinburgh Heart Centre, Royal Infirmary of Edinburgh, Edinburgh, Scotland
| | - Russell J. Everett
- Edinburgh Heart Centre, Royal Infirmary of Edinburgh, Edinburgh, Scotland
| | - Rong Bing
- Edinburgh Heart Centre, Royal Infirmary of Edinburgh, Edinburgh, Scotland
| | - Vasiliki Tsampasian
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich, United Kingdom
| | - Patrycja Molek
- Department of Coronary Disease and Heart Failure, Jagiellonian University Medical College, Krakow, Poland
| | - Simona Botezatu
- University of Medicine and Pharmacy Carol Davila, Cardiology Department, Euroecholab, Bucharest, Romania
| | - Saadia Aslam
- Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, United Kingdom
| | - Steff Lewis
- Edinburgh Clinical Trials Unit, Usher Institute, The University of Edinburgh, Edinburgh, Scotland
| | - Catriona Graham
- Edinburgh Clinical Research Facility, The University of Edinburgh, Edinburgh, Scotland
| | - Audrey C. White
- British Heart Foundation Centre of Research Excellence, University of Edinburgh, Edinburgh, Scotland
- Edinburgh Heart Centre, Royal Infirmary of Edinburgh, Edinburgh, Scotland
| | - Tom MacGillivray
- Edinburgh Imaging, The University of Edinburgh, Edinburgh, Scotland
| | - Christopher E. Tuck
- British Heart Foundation Centre of Research Excellence, University of Edinburgh, Edinburgh, Scotland
| | - Phillip Rayson
- Edinburgh Clinical Trials Unit, Usher Institute, The University of Edinburgh, Edinburgh, Scotland
| | - Denise Cranley
- Edinburgh Clinical Trials Unit, Usher Institute, The University of Edinburgh, Edinburgh, Scotland
| | - Sian Irvine
- Edinburgh Clinical Trials Unit, Usher Institute, The University of Edinburgh, Edinburgh, Scotland
| | - Ruth Armstrong
- Edinburgh Clinical Trials Unit, Usher Institute, The University of Edinburgh, Edinburgh, Scotland
| | - Lynsey Milne
- Edinburgh Clinical Trials Unit, Usher Institute, The University of Edinburgh, Edinburgh, Scotland
| | - Calvin W. L. Chin
- Department of Cardiology, National Heart Centre Singapore, Singapore
- Cardiovascular Medicine ACP Duke NUS Medical School, Singapore
| | - Graham S. Hillis
- Medical School, University of Western Australia, Perth, Western Australia, Australia
- Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Timothy Fairbairn
- Department of Cardiology, Liverpool Centre for Cardiovascular Science, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - John P. Greenwood
- Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Richard Steeds
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, University Hospitals of Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | | | - Chim C. Lang
- Division of Molecular and Clinical Medicine, School of Medicine, University of Dundee, Dundee, Scotland, United Kingdom
- Tuanku Muhriz Chair, National University of Malaysia, Malaysia
| | - Chiara Bucciarelli-Ducci
- Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom
- Royal Brompton and Harefield Hospitals, Guys’ and St Thomas NHS Foundation Trust, London, United Kingdom
| | - Nikhil V. Joshi
- Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom
| | - Vijay Kunadian
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle, United Kingdom
- University and Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Vassilios S. Vassiliou
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich, United Kingdom
| | - Jason N. Dungu
- Essex Cardiothoracic Centre, Nethermayne, Basildon, Essex, United Kingdom
- Anglia Ruskin University, Chelmsford, Essex, United Kingdom
| | - Sandeep S. Hothi
- Department of Cardiology, Royal Wolverhampton NHS Trust, Wolverhampton, UK, Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom
| | | | - Sanjay K. Prasad
- Royal Brompton and Harefield Hospitals, Guys’ and St Thomas NHS Foundation Trust, London, United Kingdom
| | - Niall G. Keenan
- Department of Cardiology, West Hertfordshire Hospitals NHS Trust, Watford, United Kingdom
- Imperial College, London, United Kingdom
| | - Dana Dawson
- Aberdeen Cardiovascular and Diabetes Centre, University of Aberdeen, Aberdeen, Scotland
| | - Thomas A. Treibel
- Institute of Cardiovascular Sciences, University College London, and St Bartholomew’s Hospital, Barts Health NHS Trust, West Smithfield, London, United Kingdom
| | - Mani Motwani
- Department of Cardiology, Manchester Heart Institute, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Christopher A. Miller
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Manchester, United Kingdom
| | - Nicholas L. Mills
- British Heart Foundation Centre of Research Excellence, University of Edinburgh, Edinburgh, Scotland
- Edinburgh Heart Centre, Royal Infirmary of Edinburgh, Edinburgh, Scotland
- Usher Institute, The University of Edinburgh, Edinburgh, Scotland
| | - Ronak Rajani
- Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - David P. Ripley
- Cardiology, Northumbria Healthcare NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Gerry P. McCann
- Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, United Kingdom
| | | | - Anvesha Singh
- Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, United Kingdom
| | - David E. Newby
- British Heart Foundation Centre of Research Excellence, University of Edinburgh, Edinburgh, Scotland
- Edinburgh Heart Centre, Royal Infirmary of Edinburgh, Edinburgh, Scotland
| | - Marc R. Dweck
- British Heart Foundation Centre of Research Excellence, University of Edinburgh, Edinburgh, Scotland
- Edinburgh Heart Centre, Royal Infirmary of Edinburgh, Edinburgh, Scotland
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15
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Helali J, Ramesh K, Brown J, Preciado-Ruiz C, Nguyen T, Silva LT, Ficara A, Wesbey G, Gonzalez JA, Bilchick KC, Salerno M, Robinson AA. Late gadolinium enhancement on cardiac MRI: A systematic review and meta-analysis of prognosis across cardiomyopathies. Int J Cardiol 2025; 419:132711. [PMID: 39515615 DOI: 10.1016/j.ijcard.2024.132711] [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: 07/31/2024] [Revised: 10/12/2024] [Accepted: 11/04/2024] [Indexed: 11/16/2024]
Abstract
BACKGROUND Late gadolinium enhancement (LGE) on cardiac MRI has been shown to predict adverse outcomes in a range of cardiac diseases. However, no study has systematically reviewed and analyzed the literature across all cardiac pathologies including rare diseases. METHODS PubMed, EMBASE and Web of Science were searched for studies evaluating the relationship between LGE burden and cardiovascular outcomes. Outcomes included all-cause mortality, MACE, sudden cardiac death, sustained VT or VF, appropriate ICD shock, heart transplant, and heart failure hospitalization. Only studies reporting hazards ratios with LGE as a continuous variable were included. RESULTS Of the initial 8928 studies, 95 studies (23,313 patients) were included across 19 clinical entities. The studies included ischemic cardiomyopathy (7182 patients, 33 studies), hypertrophic cardiomyopathy (5080 patients, 17 studies), non-ischemic cardiomyopathy not otherwise specified (2627 patients, 11 studies), and dilated cardiomyopathy (2345 patients, 14 studies). Among 42 studies that quantified LGE by percent myocardium, a 1 % increase in LGE burden was associated with life-threatening ventricular arrhythmias (LTVA) with a pooled hazard ratio of 1.04 (CI 1.02-1.05), and MACE with a pooled hazard ratio of 1.06 (CI 1.04-1.07). The risk of these events was similar across disease types, with minimal heterogeneity. CONCLUSIONS Despite mechanistic differences in myocardial injury, LGE appears to have a fairly consistent, dose-dependent effect on risk of LTVA, MACE, and mortality. These data can be applied to derive a patient's absolute risk of LTVA, and therefore can be clinically useful in informing decisions on primary prevention ICD implantation irrespective of the disease etiology.
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Affiliation(s)
- Joshua Helali
- Division of Cardiology, Scripps Clinic, La Jolla, CA, United States of America
| | - Karthik Ramesh
- University of California San Diego School of Medicine, La Jolla, CA, United States of America
| | - John Brown
- Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
| | | | - Thornton Nguyen
- University of California Riverside, Riverside, CA, United States of America
| | - Livia T Silva
- Division of Cardiology, Scripps Clinic, La Jolla, CA, United States of America; University of California San Diego, La Jolla, CA, United States of America
| | - Austin Ficara
- Division of Cardiology, Scripps Clinic, La Jolla, CA, United States of America
| | - George Wesbey
- Division of Cardiology, Scripps Clinic, La Jolla, CA, United States of America; Department of Radiology, Scripps Clinic, La Jolla, CA, United States of America
| | - Jorge A Gonzalez
- Division of Cardiology, Scripps Clinic, La Jolla, CA, United States of America; Department of Radiology, Scripps Clinic, La Jolla, CA, United States of America
| | - Kenneth C Bilchick
- Department of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, VA, United States of America
| | - Michael Salerno
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, United States of America
| | - Austin A Robinson
- Division of Cardiology, Scripps Clinic, La Jolla, CA, United States of America.
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16
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Saloux E, Simard C, Ruello P, Lemaitre A, Hodzic A, Lebrun A, Dupont PA, Tribouilloy C, Eltchaninoff H, Le Garec M, Fraschini C, Saplacan V, Manrique A. Impact of loading, heart rate, and short episodes of ischaemia on myocardial stiffness assessed using shear wave elastography in an open-chest animal model. EUROPEAN HEART JOURNAL. IMAGING METHODS AND PRACTICE 2025; 3:qyaf015. [PMID: 40041036 PMCID: PMC11879029 DOI: 10.1093/ehjimp/qyaf015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/24/2024] [Accepted: 12/26/2024] [Indexed: 03/06/2025]
Abstract
Aims Shear wave elastography (SWE) is a new promising ultrasound modality that enables non-invasive measurement of the dynamic myocardial stiffness. The impact of varying physiological conditions on SWE measurement of left ventricular (LV) myocardial stiffness remains poorly investigated. Methods and results Nineteen sheep were evaluated during open-chest surgery. Epicardial multiframe SWE acquisitions were performed in short-axis view simultaneously with haemodynamic acquisitions during inferior vena cava occlusion, aortic clamping, atrial pacing, and ischaemia-reperfusion. The cyclic variation in the median value of LV myocardial stiffness ranged from 1.1 m/s in diastole (Cmin) to 2.4 m/s in systole (Cmax). At steady state, intra-animal reproducibility was good for Cmin [intraclass correlation coefficient ICC = 0.77 (0.54, 0.90), P < 0.001] and Cmax [ICC = 0.92 (0.84, 0.96), P < 0.001]. Cmin was independent of loading conditions, heart rate, and short 15-minute episodes of ischaemia and reperfusion. Cmax was independent of loading conditions and moderate increase in heart rate but decreased significantly during ischaemia and reperfusion. Compared with baseline, percentage changes in Cmax was correlated to percentage changes in dP/dtmax (R = 0.47, P = 0.001) and in LV systolic pressure (R = 0.35, P = 0.013) and SW (R = 0.31, P = 0.026). Conclusion In this study, LV diastolic myocardial stiffness Cmin assessed using SWE demonstrated the characteristics of a potentially useful clinical marker of LV diastolic function linked to the intrinsic elastic properties of the myocardium, whereas Cmax was an indicator of LV contractility.
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Affiliation(s)
- Eric Saloux
- Centre Hospitalier Universitaire de Caen Normandie, Cardiology Department, Avenue de la Côte de Nacre, Caen cedex 14033, France
- UR 4650 PSIR, Université de Caen Normandie, GIP Cyceron, Campus Jules Horowitz, BP 5229, 14074 Caen cedex 6, France
| | - Christophe Simard
- UR 4650 PSIR, Université de Caen Normandie, GIP Cyceron, Campus Jules Horowitz, BP 5229, 14074 Caen cedex 6, France
| | - Pauline Ruello
- Centre Hospitalier Universitaire de Caen Normandie, Heart Surgery Department, Avenue de la Côte de Nacre, Caen cedex 14033, France
| | - Adrien Lemaitre
- Centre Hospitalier Universitaire de Caen Normandie, Cardiology Department, Avenue de la Côte de Nacre, Caen cedex 14033, France
| | - Amir Hodzic
- Centre Hospitalier Universitaire de Caen Normandie, Cardiology Department, Avenue de la Côte de Nacre, Caen cedex 14033, France
| | - Alexandre Lebrun
- UR 4650 PSIR, Université de Caen Normandie, GIP Cyceron, Campus Jules Horowitz, BP 5229, 14074 Caen cedex 6, France
| | - Pierre-Antoine Dupont
- UR 4650 PSIR, Université de Caen Normandie, GIP Cyceron, Campus Jules Horowitz, BP 5229, 14074 Caen cedex 6, France
| | - Christophe Tribouilloy
- Centre Hospitalier Universitaire Amiens Picardie, Cardiology Department, 1 Rue du Professeur Christian Cabrol, 80000 Amiens, France
| | - Hélène Eltchaninoff
- Centre Hospitalier Universitaire de Rouen Normandie, Cardiology Department, 37 Bd Gambetta, 76000 Rouen, France
| | - Morgane Le Garec
- SuperSonic Imagine.SA, Aix-en-Provence, 153 Rue Emilien Gautier, 13290 Aix-en-Provence, France
| | - Christophe Fraschini
- SuperSonic Imagine.SA, Aix-en-Provence, 153 Rue Emilien Gautier, 13290 Aix-en-Provence, France
| | - Vladimir Saplacan
- Centre Hospitalier Universitaire de Caen Normandie, Heart Surgery Department, Avenue de la Côte de Nacre, Caen cedex 14033, France
| | - Alain Manrique
- Centre Hospitalier Universitaire de Caen Normandie, Cardiology Department, Avenue de la Côte de Nacre, Caen cedex 14033, France
- Centre Hospitalier Universitaire de Caen Normandie, Nuclear Medicine Department, Avenue de la Côte de Nacre, Caen cedex 14033, France
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17
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Otto CM, Newby DE, Hillis GS. Calcific Aortic Stenosis: A Review. JAMA 2024; 332:2014-2026. [PMID: 39527048 DOI: 10.1001/jama.2024.16477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2024]
Abstract
Importance Calcific aortic stenosis (AS) restricts the aortic valve opening during systole due to calcification and fibrosis of either a congenital bicuspid or a normal trileaflet aortic valve. In the US, AS affects 1% to 2% of adults older than 65 years and approximately 12% of adults older than 75 years. Worldwide, AS leads to more than 100 000 deaths annually. Observations Calcific AS is characterized by aortic valve leaflet lipid infiltration and inflammation with subsequent fibrosis and calcification. Symptoms due to severe AS, such as exercise intolerance, exertional dyspnea, and syncope, are associated with a 1-year mortality rate of up to 50% without aortic valve replacement. Echocardiography can detect AS and measure the severity of aortic valve dysfunction. Although progression rates vary, once aortic velocity is higher than 2 m/s, progression to severe AS occurs typically within 10 years. Severe AS is defined by an aortic velocity 4 m/s or higher, a mean gradient 40 mm Hg or higher, or a valve area less than or equal to 1.0 cm2. Management of mild to moderate AS and asymptomatic severe AS consists of patient education about the typical progression of disease; clinical and echocardiographic surveillance at intervals of 3 to 5 years for mild AS, 1 to 2 years for moderate AS, and 6 to 12 months for severe AS; and treatment of hypertension, hyperlipidemia, and cigarette smoking as indicated. When a patient with severe AS develops symptoms, surgical aortic valve replacement (SAVR) or transcatheter aortic valve implantation (TAVI) is recommended, which restores an average life expectancy; in patients aged older than 70 years with a low surgical risk, 10-year all-cause mortality was 62.7% with TAVI and 64.0% with SAVR. TAVI is associated with decreased length of hospitalization, more rapid return to normal activities, and less pain compared with SAVR. However, evidence supporting TAVI for patients aged younger than 65 years and long-term outcomes of TAVI are less well defined than for SAVR. For patients with symptomatic severe AS, the 2020 American College of Cardiology/American Heart Association guideline recommends SAVR for individuals aged 65 years and younger, SAVR or TAVI for those aged 66 to 79 years, and TAVI for individuals aged 80 years and older or those with an estimated surgical mortality of 8% or higher. Conclusions Calcific AS is a common chronic progressive condition among older adults and is diagnosed via echocardiography. Symptomatic patients with severe AS have a mortality rate of up to 50% after 1 year, but treatment with SAVR or TAVI reduces mortality to that of age-matched control patients. The type and timing of valve replacement should be built on evidence-based guidelines, shared decision-making, and involvement of a multidisciplinary heart valve team.
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Affiliation(s)
- Catherine M Otto
- Division of Cardiology, University of Washington School of Medicine, Seattle
| | - David E Newby
- University of Edinburgh, British Heart Foundation Centre of Research Excellence, Royal Infirmary, Edinburgh, United Kingdom
| | - Graham S Hillis
- Department of Cardiology, Royal Perth Hospital and Medical School, University of Western Australia, Perth
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Anastasiou V, Daios S, Karamitsos T, Peteinidou E, Didagelos M, Giannakoulas G, Aggeli C, Tsioufis K, Ziakas A, Kamperidis V. Multimodality imaging for the global evaluation of aortic stenosis: The valve, the ventricle, the afterload. Trends Cardiovasc Med 2024; 34:518-528. [PMID: 38387745 DOI: 10.1016/j.tcm.2024.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Revised: 02/03/2024] [Accepted: 02/04/2024] [Indexed: 02/24/2024]
Abstract
Aortic stenosis (AS) is the most common valvular heart disease growing in parallel to the increment of life expectancy. Besides the valve, the degenerative process affects the aorta, impairing its elastic properties and leading to increased systemic resistance. The composite of valvular and systemic afterload mediates ventricular damage. The first step of a thorough evaluation of AS should include a detailed assessment of valvular anatomy and hemodynamics. Subsequently, the ventricle, and the global afterload should be assessed to define disease stage and prognosis. Multimodality imaging is of paramount importance for the comprehensive evaluation of these three elements. Echocardiography is the cornerstone modality whereas Multi-Detector Computed Tomography and Cardiac Magnetic Resonance provide useful complementary information. This review comprehensively examines the merits of these imaging modalities in AS for the evaluation of the valve, the ventricle, and the afterload and ultimately endeavors to integrate them in a holistic assessment of AS.
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Affiliation(s)
- Vasileios Anastasiou
- 1st Department of Cardiology, AHEPA Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Stylianos Daios
- 1st Department of Cardiology, AHEPA Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Theodoros Karamitsos
- 1st Department of Cardiology, AHEPA Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Emmanouela Peteinidou
- 1st Department of Cardiology, AHEPA Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Matthaios Didagelos
- 1st Department of Cardiology, AHEPA Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - George Giannakoulas
- 1st Department of Cardiology, AHEPA Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Constantina Aggeli
- 1st Department of Cardiology, Hippokration Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos Tsioufis
- 1st Department of Cardiology, Hippokration Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Antonios Ziakas
- 1st Department of Cardiology, AHEPA Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Vasileios Kamperidis
- 1st Department of Cardiology, AHEPA Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece.
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19
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Rajah MR, Doubell AF, Herbst PG. Quantification of Replacement Fibrosis in Aortic Stenosis: A Narrative Review on the Utility of Cardiovascular Magnetic Resonance Imaging. Diagnostics (Basel) 2024; 14:2435. [PMID: 39518402 PMCID: PMC11544846 DOI: 10.3390/diagnostics14212435] [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: 09/28/2024] [Revised: 10/27/2024] [Accepted: 10/29/2024] [Indexed: 11/16/2024] Open
Abstract
Aortic stenosis (AS) is associated with the development of replacement myocardial fibrosis/scar. Given the dose-dependent relationship between scar and clinical outcomes after aortic valve replacement (AVR) surgery, scar quantity may serve as an important risk-stratification tool to aid decision-making on the optimal timing of AVR. Scar is non-invasively assessed and quantified by cardiovascular magnetic resonance (CMR) imaging. Several quantification techniques exist, and consensus on the optimal technique is lacking. These techniques range from a visual manual method to fully automated ones. This review describes the different scar quantification techniques used and highlights their strengths and shortfalls within the context of AS. The two most commonly used techniques in AS include the semi-automated signal threshold versus reference mean (STRM) and full-width half-maximum (FWHM) techniques. The accuracy and reproducibility of these techniques may be hindered in AS by the coexistence of diffuse interstitial fibrosis and the presence of relatively small, non-bright scars. The validation of these techniques against histology, which is the current gold standard for scar quantification in AS, is limited. Based on the best current evidence, the STRM method using a threshold of three standard deviations above the mean signal intensity of remote myocardium is recommended. The high reproducibility of the FWHM technique in non-AS cohorts has been shown and merits further evaluation within the context of AS. Future directions include the use of quantitative T1 mapping for the detection and quantification of scar, as well as the development of serum biomarkers that reflect the fibrotic status of the myocardium in AS.
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Affiliation(s)
- Megan R. Rajah
- Division of Cardiology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town 7505, South Africa
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20
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Magalhães TA, Carneiro ACDC, Moreira VDM, Trad HS, Lopes MMU, Cerci RJ, Nacif MS, Schvartzman PR, Chagas ACP, Costa IBSDS, Schmidt A, Shiozaki AA, Montenegro ST, Piegas LS, Zapparoli M, Nicolau JC, Fernandes F, Hadlich MS, Ghorayeb N, Mesquita ET, Gonçalves LFG, Ramires FJA, Fernandes JDL, Schwartzmann PV, Rassi S, Torreão JA, Mateos JCP, Beck-da-Silva L, Silva MC, Liberato G, Oliveira GMMD, Feitosa Filho GS, Carvalho HDSMD, Markman Filho B, Rocha RPDS, Azevedo Filho CFD, Taratsoutchi F, Coelho-Filho OR, Kalil Filho R, Hajjar LA, Ishikawa WY, Melo CA, Jatene IB, Albuquerque ASD, Rimkus CDM, Silva PSDD, Vieira TDR, Jatene FB, Azevedo GSAAD, Santos RD, Monte GU, Ramires JAF, Bittencourt MS, Avezum A, Silva LSD, Abizaid A, Gottlieb I, Precoma DB, Szarf G, Sousa ACS, Pinto IMF, Medeiros FDM, Caramelli B, Parga Filho JR, Santos TSGD, Prazeres CEED, Lopes MACQ, Avila LFRD, Scanavacca MI, Gowdak LHW, Barberato SH, Nomura CH, Rochitte CE. Cardiovascular Computed Tomography and Magnetic Resonance Imaging Guideline of the Brazilian Society of Cardiology and the Brazilian College of Radiology - 2024. Arq Bras Cardiol 2024; 121:e20240608. [PMID: 39475988 DOI: 10.36660/abc.20240608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2025] Open
Affiliation(s)
- Tiago Augusto Magalhães
- Complexo Hospital de Clínicas da Universidade Federal do Paraná (CHC-UFPR), Curitiba, PR - Brasil
- Hospital do Coração (HCOR), São Paulo, SP - Brasil
- Hospital Sírio Libanês, SP, São Paulo, SP - Brasil
| | | | - Valéria de Melo Moreira
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo SP - Brasil
| | | | - Marly Maria Uellendahl Lopes
- Universidade Federal de São Paulo (UNIFESP), São Paulo, SP - Brasil
- DASA - Diagnósticos da América S/A, São Paulo, SP - Brasil
| | | | - Marcelo Souto Nacif
- Universidade Federal Fluminense, Niterói, RJ - Brasil
- Hospital Universitário Antonio Pedro, Niterói, RJ - Brasil
| | | | - Antônio Carlos Palandrini Chagas
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo SP - Brasil
- Faculdade de Medicina do ABC, Santo André, SP - Brasil
| | | | - André Schmidt
- Universidade de São Paulo (USP), Ribeirão Preto, SP - Brasil
| | - Afonso Akio Shiozaki
- ND Núcleo Diagnóstico, Maringá, PR - Brasil
- Ômega Diagnóstico, Maringá, PR - Brasil
- Hospital Paraná, Maringá, PR - Brasil
| | | | | | - Marcelo Zapparoli
- Quanta Diagnóstico por Imagem, Curitiba, PR - Brasil
- DAPI, Curitiba, PR - Brasil
| | - José Carlos Nicolau
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo SP - Brasil
| | - Fabio Fernandes
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo SP - Brasil
| | - Marcelo Souza Hadlich
- Fleury Medicina e Saúde, Rio de Janeiro, RJ - Brasil
- Rede D'Or RJ, Rio de Janeiro, RJ - Brasil
- Unimed, Rio de Janeiro, RJ - Brasil
- Instituto Nacional de Cardiologia (INC), Rio de Janeiro, RJ - Brasil
| | - Nabil Ghorayeb
- Instituto Dante Pazzanese de Cardiologia, São Paulo, SP - Brasil
- Inspirali Educação, São Paulo, SP - Brasil
- Anhanguera Educacional, São Paulo, SP - Brasil
| | | | - Luiz Flávio Galvão Gonçalves
- Hospital São Lucas, Rede D'Or SE, Aracaju, SE - Brasil
- Hospital Universitário da Universidade Federal de Sergipe, Aracaju, SE - Brasil
- Clínica Climedi, Aracaju, SE - Brasil
| | - Felix José Alvarez Ramires
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo SP - Brasil
| | | | - Pedro Vellosa Schwartzmann
- Hospital Unimed Ribeirão Preto, Ribeirão Preto, SP - Brasil
- Centro Avançado de Pesquisa, Ensino e Diagnóstico (CAPED), Ribeirão Preto, SP - Brasil
| | | | | | - José Carlos Pachón Mateos
- Hospital do Coração (HCOR), São Paulo, SP - Brasil
- Hospital Sírio Libanês, SP, São Paulo, SP - Brasil
| | - Luiz Beck-da-Silva
- Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS - Brasil
| | | | - Gabriela Liberato
- Hospital Sírio Libanês, SP, São Paulo, SP - Brasil
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo SP - Brasil
| | | | | | - Hilka Dos Santos Moraes de Carvalho
- PROCAPE - Universidade de Pernambuco, Recife, PE - Brasil
- Hospital das Clínicas de Pernambuco da Universidade Federal de Pernambuco (UFPE), Recife, PE - Brasil
- Real Hospital Português de Pernambuco, Recife, PE - Brasil
| | - Brivaldo Markman Filho
- Hospital das Clínicas de Pernambuco da Universidade Federal de Pernambuco (UFPE), Recife, PE - Brasil
| | | | | | - Flávio Taratsoutchi
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo SP - Brasil
| | | | - Roberto Kalil Filho
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo SP - Brasil
| | | | - Walther Yoshiharu Ishikawa
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo SP - Brasil
| | - Cíntia Acosta Melo
- Hospital Beneficência Portuguesa de São Paulo, São Paulo, SP - Brasil
- Hospital Infantil Sabará, São Paulo, SP - Brasil
| | | | | | - Carolina de Medeiros Rimkus
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo SP - Brasil
- Instituto D'Or de Pesquisa e Ensino (IDOR), São Paulo SP - Brasil
| | - Paulo Savoia Dias da Silva
- Fleury Medicina e Saúde, Rio de Janeiro, RJ - Brasil
- University of Iowa Hospitals and Clinics, Iowa City - EUA
| | - Thiago Dieb Ristum Vieira
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo SP - Brasil
| | - Fabio Biscegli Jatene
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo SP - Brasil
| | - Guilherme Sant Anna Antunes de Azevedo
- ECOMAX, Blumenau, SC - Brasil
- Hospital Unimed Blumenau, Blumenau, SC - Brasil
- Hospital São José de Jaraguá do Sul, Blumenau, SC - Brasil
- Cliniimagem Criciúma, Blumenau, SC - Brasil
| | - Raul D Santos
- Hospital Sírio Libanês, SP, São Paulo, SP - Brasil
- Universidade de São Paulo (USP), Ribeirão Preto, SP - Brasil
| | | | - José Antonio Franchini Ramires
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo SP - Brasil
| | | | - Alvaro Avezum
- Hospital Alemão Oswaldo Cruz, São Paulo, SP - Brasil
| | | | | | - Ilan Gottlieb
- Fonte Imagem Medicina Diagnostica, Rio de Janeiro, RJ - Brasil
| | | | - Gilberto Szarf
- Universidade Federal de São Paulo (UNIFESP), São Paulo, SP - Brasil
| | - Antônio Carlos Sobral Sousa
- Universidade Federal de Sergipe, Aracaju, SE - Brasil
- Hospital São Lucas, Aracaju, SE - Brasil
- Rede D'Or de Aracaju, Aracaju, SE - Brasil
| | | | | | - Bruno Caramelli
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo SP - Brasil
| | - José Rodrigues Parga Filho
- Hospital Sírio Libanês, SP, São Paulo, SP - Brasil
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo SP - Brasil
| | | | | | | | | | - Mauricio Ibrahim Scanavacca
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo SP - Brasil
| | - Luis Henrique Wolff Gowdak
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo SP - Brasil
- Universidade de São Paulo (USP), Ribeirão Preto, SP - Brasil
| | - Silvio Henrique Barberato
- Quanta Diagnóstico por Imagem, Curitiba, PR - Brasil
- Cardioeco, Centro de Diagnóstico Cardiovascular, Curitiba, PR - Brasil
| | | | - Carlos Eduardo Rochitte
- Hospital do Coração (HCOR), São Paulo, SP - Brasil
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo SP - Brasil
- DASA - Diagnósticos da América S/A, São Paulo, SP - Brasil
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21
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Weyrich M, Cremer S, Gerster M, Sarakpi T, Rasper T, Zewinger S, Patyna SR, Leistner DM, Heine GH, Wanner C, März W, Fliser D, Dimmeler S, Zeiher AM, Speer T. Loss of Y Chromosome and Cardiovascular Events in Chronic Kidney Disease. Circulation 2024; 150:746-757. [PMID: 39005209 PMCID: PMC11361358 DOI: 10.1161/circulationaha.124.069139] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Accepted: 06/24/2024] [Indexed: 07/16/2024]
Abstract
BACKGROUND Chronic kidney disease represents one of the strongest risk factors for cardiovascular diseases, and particularly for heart failure. Despite improved pharmaceutical treatments, mortality remains high. Recently, experimental studies demonstrated that mosaic loss of Y chromosome (LOY) associates with cardiac fibrosis in male mice. Since diffuse cardiac fibrosis is the common denominator for progression of all forms of heart failure, we determined the association of LOY on mortality and cardiovascular disease outcomes in patients with chronic kidney disease. METHODS LOY was quantified in men with stable chronic kidney disease (CARE for HOMe study, n=279) and dialysis patients (4D study, n=544). The association between LOY and mortality, combined cardiovascular and heart failure-specific end points, and echocardiographic measures was assessed. RESULTS In CARE for HOMe, the frequency of LOY increased with age. LOY >17% was associated with increased mortality (heart rate, 2.58 [95% CI, 1.33-5.03]) and risk for cardiac decompensation or death (heart rate, 2.30 [95% CI, 1.23-4.27]). Patients with LOY >17% showed a significant decline of ejection fraction and an increase of E/E' within 5 years. Consistently, in the 4D study, LOY >17% was significantly associated with increased mortality (heart rate, 2.76 [95% CI, 1.83-4.16]), higher risk of death due to heart failure and sudden cardiac death (heart rate, 4.11 [95% CI, 2.09-8.08]), but not atherosclerotic events. Patients with LOY >17% showed significantly higher plasma levels of soluble interleukin 1 receptor-like 1, a biomarker for myocardial fibrosis. Mechanistically, intermediate monocytes from patients with LOY >17% showed significantly higher C-C chemokine receptor type 2 expression and higher plasma levels of the C-C chemokine receptor type 2 chemokine (C-C motif) ligand 2, which may have contributed to increased heart failure events. CONCLUSIONS LOY identifies male patients with chronic kidney disease at high risk for mortality and heart failure events.
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Affiliation(s)
- Michael Weyrich
- 1Goethe University Frankfurt’s University Hospital, Department of Internal Medicine 4, Nephrology (T.S., S.R.P., M.G., T.S., M.W.)
| | - Sebastian Cremer
- University Hospital, Department of Medicine, Cardiology (S.C., D.M.L.)
- German Center for Cardiovascular Research DZHK, Berlin, Germany (S.C., D.M.L., S.D., A.M.Z.)
| | - Martin Gerster
- Else Kroener-Fresenius Center for Nephrological Research (T.S., S.R.P., M.G., T.S., M.W.)
| | - Tamim Sarakpi
- 1Goethe University Frankfurt’s University Hospital, Department of Internal Medicine 4, Nephrology (T.S., S.R.P., M.G., T.S., M.W.)
- Else Kroener-Fresenius Center for Nephrological Research (T.S., S.R.P., M.G., T.S., M.W.)
| | - Tina Rasper
- Institute for Cardiovascular Regeneration (T.R., S.D., A.M.Z.), Germany
| | - Stephen Zewinger
- Hôpital Robert Schumann, Hôpital Kirchberg, Luxembourg City, Luxembourg (S.Z.)
- Saarland University, Department of Internal Medicine 4, Homburg/Saar, Germany (D.F., G.H.H., S.Z.)
| | - Sammy R. Patyna
- 1Goethe University Frankfurt’s University Hospital, Department of Internal Medicine 4, Nephrology (T.S., S.R.P., M.G., T.S., M.W.)
- Else Kroener-Fresenius Center for Nephrological Research (T.S., S.R.P., M.G., T.S., M.W.)
| | - David M. Leistner
- University Hospital, Department of Medicine, Cardiology (S.C., D.M.L.)
- German Center for Cardiovascular Research DZHK, Berlin, Germany (S.C., D.M.L., S.D., A.M.Z.)
| | - Gunnar H. Heine
- Saarland University, Department of Internal Medicine 4, Homburg/Saar, Germany (D.F., G.H.H., S.Z.)
| | - Christoph Wanner
- University of Wuerzburg, University Hospital, Department of Clinical Research and Epidemiology, Comprehensive Heart Failure Center, Germany (C.W.)
| | - Winfried März
- Else Kroener-Fresenius Center for Nephrological Research (T.S., S.R.P., M.G., T.S., M.W.)
- University of Heidelberg, University Medical Center, Medical Faculty Mannheim, Vth Department of Medicine, Germany (W.M.)
- Medical University of Graz, Clinical Institute of Medical and Chemical Laboratory Diagnostics, Austria (W.M.)
- SYNLAB Holding Deutschland GmbH, SYNLAB Academy, Mannheim, Germany (W.M.)
| | - Danilo Fliser
- Saarland University, Department of Internal Medicine 4, Homburg/Saar, Germany (D.F., G.H.H., S.Z.)
| | - Stefanie Dimmeler
- Institute for Cardiovascular Regeneration (T.R., S.D., A.M.Z.), Germany
- German Center for Cardiovascular Research DZHK, Berlin, Germany (S.C., D.M.L., S.D., A.M.Z.)
| | - Andreas M. Zeiher
- Institute for Cardiovascular Regeneration (T.R., S.D., A.M.Z.), Germany
- German Center for Cardiovascular Research DZHK, Berlin, Germany (S.C., D.M.L., S.D., A.M.Z.)
| | - Thimoteus Speer
- 1Goethe University Frankfurt’s University Hospital, Department of Internal Medicine 4, Nephrology (T.S., S.R.P., M.G., T.S., M.W.)
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22
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Adrichem R, van den Dorpel MMP, Hirsch A, Geleijnse ML, Budde RPJ, Van Mieghem NM. Moderate Aortic Stenosis-Advanced Imaging, Risk Assessment, and Treatment Strategies. STRUCTURAL HEART : THE JOURNAL OF THE HEART TEAM 2024; 8:100279. [PMID: 39290682 PMCID: PMC11403096 DOI: 10.1016/j.shj.2023.100279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 12/02/2023] [Accepted: 12/21/2023] [Indexed: 09/19/2024]
Abstract
Moderate aortic stenosis is increasingly recognized as a disease entity with poor prognosis. Diagnosis of moderate aortic stenosis may be complemented by laboratory tests and advanced imaging techniques focused at detecting signs of cardiac damage such as increase of cardiac enzymes (N-terminal pro-B-type Natriuretic Peptide, troponin), left ventricular remodeling (hypertrophy, reduced left ventricular ejection fraction), or myocardial fibrosis. Therapy should include guideline-directed optimal medical therapy for heart failure. Patients with signs of cardiac damage may benefit from early intervention, which is the focus of several ongoing randomized controlled trials. As yet, no evidence-based therapy exists to halt the progression of aortic valve calcification.
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Affiliation(s)
- Rik Adrichem
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Mark M P van den Dorpel
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Alexander Hirsch
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Marcel L Geleijnse
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Ricardo P J Budde
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Nicolas M Van Mieghem
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, The Netherlands
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23
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Ferrández-Escarabajal M, Hadley M, Sanz J. Cardiac Magnetic Resonance for Structural Aortic Valve Stenosis Procedures. J Clin Med 2024; 13:5184. [PMID: 39274397 PMCID: PMC11396107 DOI: 10.3390/jcm13175184] [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: 06/16/2024] [Revised: 08/29/2024] [Accepted: 08/30/2024] [Indexed: 09/16/2024] Open
Abstract
The number of structural aortic valve procedures has increased significantly in recent years. Pre-procedural planning and follow-up with noninvasive testing are essential. Although cardiac magnetic resonance (CMR) is the gold standard for assessing left ventricular mass, volume, and function, it is not performed routinely in patients undergoing structural interventions. CMR can provide useful information for pre- and post-procedural assessment, including quantification of cardiac function, myocardial assessment, grading of the severity of valvular heart disease, and evaluation of extracardiac anatomy while avoiding the limitations of other non-invasive modalities. Here, we review the use cases, future perspectives, and limitations of CMR for patients undergoing structural aortic valve procedures.
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Affiliation(s)
- Marcos Ferrández-Escarabajal
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Michael Hadley
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Javier Sanz
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
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24
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Thornton GD, Bennett JB, Nitsche C, Gama F, Aziminia N, Knott K, Davies RH, Moon JC, Kellman P, Treibel TA. Myocardial Hypoperfusion in Severe Aortic Stenosis Is Reversed Early After Aortic Valve Replacement. JACC Cardiovasc Imaging 2024; 17:1006-1008. [PMID: 38661608 DOI: 10.1016/j.jcmg.2024.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 03/05/2024] [Accepted: 03/12/2024] [Indexed: 04/26/2024]
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25
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Thornton GD, Vassiliou VS, Musa TA, Aziminia N, Craig N, Dattani A, Davies RH, Captur G, Moon JC, Dweck MR, Myerson SG, Prasad SK, McCann GP, Greenwood JP, Singh A, Treibel TA. Myocardial scar and remodelling predict long-term mortality in severe aortic stenosis beyond 10 years. Eur Heart J 2024; 45:2019-2022. [PMID: 38271583 PMCID: PMC11156486 DOI: 10.1093/eurheartj/ehae067] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 01/22/2024] [Accepted: 01/23/2024] [Indexed: 01/27/2024] Open
Affiliation(s)
- George D Thornton
- Institute of Cardiovascular Science, University College London, 62 Huntley St, London WC1E 6DD, UK
- St Bartholomew’s Hospital, Barts Health NHS Trust, West Smithfield, London EC1A 7BE, UK
| | - Vassilios S Vassiliou
- National Heart & Lung Institute, Imperial College London and Royal Brompton Hospital, London, UK
- University of East Anglia, Norwich, UK
| | | | - Nikoo Aziminia
- Institute of Cardiovascular Science, University College London, 62 Huntley St, London WC1E 6DD, UK
- St Bartholomew’s Hospital, Barts Health NHS Trust, West Smithfield, London EC1A 7BE, UK
| | - Neil Craig
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Abhishek Dattani
- Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Rhodri H Davies
- Institute of Cardiovascular Science, University College London, 62 Huntley St, London WC1E 6DD, UK
| | - Gabriella Captur
- Institute of Cardiovascular Science, University College London, 62 Huntley St, London WC1E 6DD, UK
| | - James C Moon
- Institute of Cardiovascular Science, University College London, 62 Huntley St, London WC1E 6DD, UK
- St Bartholomew’s Hospital, Barts Health NHS Trust, West Smithfield, London EC1A 7BE, UK
| | - Marc R Dweck
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Saul G Myerson
- University of Oxford Centre for Clinical Magnetic Resonance Research, Oxford, UK
| | - Sanjay K Prasad
- National Heart & Lung Institute, Imperial College London and Royal Brompton Hospital, London, UK
| | - Gerry P McCann
- Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - John P Greenwood
- Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
- The Baker Heart and Diabetes Institute & Monash University, Melbourne, Australia
| | - Anvesha Singh
- Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Thomas A Treibel
- Institute of Cardiovascular Science, University College London, 62 Huntley St, London WC1E 6DD, UK
- St Bartholomew’s Hospital, Barts Health NHS Trust, West Smithfield, London EC1A 7BE, UK
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26
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Piayda K, Heilemann JT, Keranov S, Schulz L, Arsalan M, Liebetrau C, Kim WK, Hofmann FJ, Bauer P, Voss S, Troidl C, Sossalla ST, Hamm CW, Nef HM, Dörr O. The role of Matrix Metalloproteinase-2 and Galectin-3 as predictive biomarkers for all-cause mortality in patients undergoing transfemoral transcatheter aortic valve implantation. Biomarkers 2024; 29:205-210. [PMID: 38588595 DOI: 10.1080/1354750x.2024.2341409] [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: 12/28/2023] [Accepted: 04/03/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Currently available risk scores fail to accurately predict morbidity and mortality in patients with severe symptomatic aortic stenosis who undergo transcatheter aortic valve implantation (TAVI). In this context, biomarkers like matrix metalloproteinase-2 (MMP-2) and Galectin-3 (Gal-3) may provide additional prognostic information. METHODS Patients with severe aortic stenosis undergoing consecutive, elective, transfemoral TAVI were included. Baseline demographic data, functional status, echocardiographic findings, clinical outcomes and biomarker levels were collected and analysed. RESULTS The study cohort consisted of 89 patients (age 80.4 ± 5.1 years, EuroScore II 7.1 ± 5.8%). During a median follow-up period of 526 d, 28 patients (31.4%) died. Among those who died, median baseline MMP-2 (alive: 221.6 [170.4; 263] pg/mL vs. deceased: 272.1 [225; 308.8] pg/mL, p < 0.001) and Gal-3 levels (alive: 19.1 [13.5; 24.6] pg/mL vs. deceased: 25 [17.6; 29.5] pg/mL, p = 0.006) were higher than in survivors. In ROC analysis, MMP-2 reached an acceptable level of discrimination to predict mortality (AUC 0.733, 95% CI [0.62; 0.83], p < 0.001), but the predictive value of Gal-3 was poor (AUC 0.677, 95% CI [0.56; 0.79], p = 0.002). Kaplan-Meier and Cox regression analyses showed that patients with MMP-2 and Gal-3 concentrations above the median at baseline had significantly impaired long-term survival (p = 0.004 and p = 0.02, respectively). CONCLUSIONS In patients with severe aortic stenosis undergoing transfemoral TAVI, MMP-2 and to a lesser extent Gal-3, seem to have additive value in optimizing risk prediction and streamlining decision-making.
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Affiliation(s)
- Kerstin Piayda
- Department of Cardiology, Justus-Liebig-University Giessen, Medical Clinic I, Giessen, Germany
| | - Julian Tim Heilemann
- Department of Cardiology, Justus-Liebig-University Giessen, Medical Clinic I, Giessen, Germany
| | - Stanislav Keranov
- Department of Cardiology, Justus-Liebig-University Giessen, Medical Clinic I, Giessen, Germany
| | - Luisa Schulz
- Department of Cardiology, Justus-Liebig-University Giessen, Medical Clinic I, Giessen, Germany
| | - Mani Arsalan
- Department of Cardiology, Justus-Liebig-University Giessen, Medical Clinic I, Giessen, Germany
- Department of Cardiothoracic Surgery, Medical Faculty, Goethe-University Frankfurt, Frankfurt, Germany
| | | | - Won-Keun Kim
- Department of Cardiology, Kerckhoff-Klinik, Bad Nauheim, Germany
| | - Felix J Hofmann
- Department of Cardiology, Justus-Liebig-University Giessen, Medical Clinic I, Giessen, Germany
| | - Pascal Bauer
- Department of Cardiology, Justus-Liebig-University Giessen, Medical Clinic I, Giessen, Germany
| | - Sandra Voss
- Department of Cardiology, Kerckhoff-Klinik, Bad Nauheim, Germany
- Kerckhoff Herzforschungsinstitut, Bad Nauheim, Germany
| | | | - Samuel T Sossalla
- Department of Cardiology, Justus-Liebig-University Giessen, Medical Clinic I, Giessen, Germany
- Department of Cardiology, Kerckhoff-Klinik, Bad Nauheim, Germany
- Kerckhoff Herzforschungsinstitut, Bad Nauheim, Germany
| | - Christian W Hamm
- Department of Cardiology, Justus-Liebig-University Giessen, Medical Clinic I, Giessen, Germany
| | - Holger M Nef
- Department of Cardiology, Justus-Liebig-University Giessen, Medical Clinic I, Giessen, Germany
- Kerckhoff Herzforschungsinstitut, Bad Nauheim, Germany
| | - Oliver Dörr
- Department of Cardiology, Justus-Liebig-University Giessen, Medical Clinic I, Giessen, Germany
- Cardioangiologisches Centrum Bethanien, Frankfurt am Main, Germany
- Kerckhoff Herzforschungsinstitut, Bad Nauheim, Germany
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27
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Caprio MV, De Donno F, Bisaccia G, Mantini C, Di Baldassarre A, Gallina S, Khanji MY, Ricci F. Moderate aortic stenosis: Navigating the uncharted. Echocardiography 2024; 41:e15859. [PMID: 38853624 DOI: 10.1111/echo.15859] [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: 03/16/2024] [Revised: 05/18/2024] [Accepted: 05/25/2024] [Indexed: 06/11/2024] Open
Abstract
Aortic stenosis (AS) stands as the most common valvular heart disease in developed countries and is characterized by progressive narrowing of the aortic valve orifice resulting in elevated transvalvular flow resistance, left ventricular hypertrophy, and progressive increased risk of heart failure and sudden death. This narrative review explores clinical challenges and evolving perspectives in moderate AS, where discrepancies between aortic valve area and pressure gradient measurements may pose diagnostic and therapeutic quandaries. Transthoracic echocardiography is the first-line imaging modality for AS evaluation, yet cases of discordance may require the application of ancillary noninvasive diagnostic modalities. This review underscores the importance of accurate grading of AS severity, especially in low-gradient phenotypes, emphasizing the need for vigilant follow-up. Current clinical guidelines primarily recommend aortic valve replacement for severe AS, potentially overlooking latent risks in moderate disease stages. The noninvasive multimodality imaging approach-including echocardiography, cardiac magnetic resonance, computed tomography, and nuclear techniques-provides unique insights into adaptive and maladaptive cardiac remodeling in AS and offers a promising avenue to deliver precise indications and exact timing for intervention in moderate AS phenotypes and asymptomatic patients, potentially improving long-term outcomes. Nevertheless, what we may have gleaned from a large amount of observational data is still insufficient to build a robust framework for clinical decision-making in moderate AS. Future research will prioritize randomized clinical trials designed to weigh the benefits and risks of preemptive aortic valve replacement in the management of moderate AS, as directed by specific imaging and nonimaging biomarkers.
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Affiliation(s)
- Maria Vittoria Caprio
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University of Chieti-Pescara, Chieti, Italy
- SS Annunziata Polyclinic University Hospital, University Cardiology Division, Chieti, Italy
| | - Federica De Donno
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University of Chieti-Pescara, Chieti, Italy
- SS Annunziata Polyclinic University Hospital, University Cardiology Division, Chieti, Italy
| | - Giandomenico Bisaccia
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University of Chieti-Pescara, Chieti, Italy
| | - Cesare Mantini
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University of Chieti-Pescara, Chieti, Italy
| | - Angela Di Baldassarre
- Department of Medicine and Aging Sciences, and Reprogramming and Cell Differentiation Lab, Center for Advanced Studies and Technology (CAST), G. D'Annunzio University of Chieti-Pescara, Chieti, Italy
| | - Sabina Gallina
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University of Chieti-Pescara, Chieti, Italy
- SS Annunziata Polyclinic University Hospital, University Cardiology Division, Chieti, Italy
| | - Mohammed Y Khanji
- Newham University Hospital, Barts Health NHS Trust, Plaistow, London, UK
- Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, UK
- NIHR Barts Biomedical Research Centre, William Harvey Research Institute, Queen Mary University, London, UK
| | - Fabrizio Ricci
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University of Chieti-Pescara, Chieti, Italy
- SS Annunziata Polyclinic University Hospital, University Cardiology Division, Chieti, Italy
- Department of Clinical Sciences, Lund University, Malmö, Sweden
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González-García A, Pazos-López P, Calvo-Iglesias FE, Matajira-Chía TM, Bilbao-Quesada R, Blanco-González E, González-Ríos C, Castiñeira-Busto M, Barreiro-Pérez M, Íñiguez-Romo A. Diagnostic Challenges in Aortic Stenosis. J Cardiovasc Dev Dis 2024; 11:162. [PMID: 38921662 PMCID: PMC11203729 DOI: 10.3390/jcdd11060162] [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: 03/30/2024] [Revised: 05/15/2024] [Accepted: 05/16/2024] [Indexed: 06/27/2024] Open
Abstract
Aortic stenosis (AS) is the most prevalent degenerative valvular disease in western countries. Transthoracic echocardiography (TTE) is considered, nowadays, to be the main imaging technique for the work-up of AS due to high availability, safety, low cost, and excellent capacity to evaluate aortic valve (AV) morphology and function. Despite the diagnosis of AS being considered straightforward for a very long time, based on high gradients and reduced aortic valve area (AVA), many patients with AS represent a real dilemma for cardiologist. On the one hand, the acoustic window may be inadequate and the TTE limited in some cases. On the other hand, a growing body of evidence shows that patients with low gradients (due to systolic dysfunction, concentric hypertrophy or coexistence of another valve disease such as mitral stenosis or regurgitation) may develop severe AS (low-flow low-gradient severe AS) with a similar or even worse prognosis. The use of complementary imaging techniques such as transesophageal echocardiography (TEE), multidetector computed tomography (MDTC), or cardiac magnetic resonance (CMR) plays a key role in such scenarios. The aim of this review is to summarize the diagnostic challenges associated with patients with AS and the advantages of a comprehensive multimodality cardiac imaging (MCI) approach to reach a precise grading of the disease, a crucial factor to warrant an adequate management of patients.
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Affiliation(s)
- André González-García
- Department of Cardiology, Hospital Alvaro Cunqueiro, Complexo Hospitalario Universitario de Vigo, 36312 Vigo, Spain; (F.E.C.-I.); (T.M.M.-C.); (R.B.-Q.); (E.B.-G.); (C.G.-R.); (M.C.-B.); (M.B.-P.); (A.Í.-R.)
| | - Pablo Pazos-López
- Department of Cardiology, Hospital Alvaro Cunqueiro, Complexo Hospitalario Universitario de Vigo, 36312 Vigo, Spain; (F.E.C.-I.); (T.M.M.-C.); (R.B.-Q.); (E.B.-G.); (C.G.-R.); (M.C.-B.); (M.B.-P.); (A.Í.-R.)
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29
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Banovic M, Iung B, Putnik S, Mahendiran T, Vanderheyden M, Barbato E, Bartunek J. Asymptomatic Aortic Stenosis: From Risk Stratification to Treatment. Am J Cardiol 2024; 218:51-62. [PMID: 38432341 DOI: 10.1016/j.amjcard.2024.02.034] [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: 10/02/2023] [Revised: 02/05/2024] [Accepted: 02/23/2024] [Indexed: 03/05/2024]
Abstract
Our understanding of the natural history of aortic stenosis has significantly increased over the last decade. There have been considerable advances in the diagnosis and risk stratification of patients with aortic stenosis and in surgical and anesthetic techniques. In addition, transcatheter aortic valve replacement has established itself as a viable alternative to surgical management. Inevitably, these developments have raised questions regarding the merits of waiting for symptom onset in asymptomatic patients with severe aortic stenosis before offering treatment. Recent observational and randomized trial data suggest that early intervention in asymptomatic patients with severe aortic stenosis and normal left ventricular function may confer a prognostic advantage to a watchful waiting strategy. In this review, we highlight advances in the management and risk stratification of patients with asymptomatic severe aortic stenosis with particular consideration of recent findings supporting early valvular intervention.
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Affiliation(s)
- Marko Banovic
- Cardiology Department, University Clinical Center of Serbia, Belgrade, Serbia; Belgrade Medical Faculty, University of Belgrade, Serbia.
| | - Bernard Iung
- Cardiology Department, Bichat Hospital APHP and Université Paris Cité, France
| | - Svetozar Putnik
- Belgrade Medical Faculty, University of Belgrade, Serbia; Cardiac-Surgery Department, University Clinical Center of Serbia, Belgrade, Serbia
| | - Thabo Mahendiran
- Cardiovascular Center, OLV Hospital, Aalst, Belgium; Cardiology Department, Lausanne University Hospital, Lausanne, Switzerland
| | | | - Emanuele Barbato
- Cardiovascular Center, OLV Hospital, Aalst, Belgium; Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
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30
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San Román JA, Ybarra-Falcón C, García-Gómez M, Ramos N, Nombela L, Carnero M, Amat-Santos IJ, Sevilla T, Revilla A, Carrasco M, López-Díaz J, Vilacosta I. Evolution and Prognostic Significance of Patient-Reported Symptoms After Intervention in Severe Aortic Stenosis. Mayo Clin Proc 2024; 99:400-410. [PMID: 38432746 DOI: 10.1016/j.mayocp.2023.09.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 08/24/2023] [Accepted: 09/27/2023] [Indexed: 03/05/2024]
Abstract
OBJECTIVE To describe the evolution of symptoms in patients with symptomatic severe aortic stenosis (sSAS) undergoing valve replacement, the predictors of the persistence of these symptoms, and their prognostic significance. The evolution of symptoms after intervention in sSAS and their association with outcome are unknown. PATIENTS AND METHODS Data from patients with sSAS who underwent intervention were collected. All-cause mortality and cardiovascular mortality were considered events. The evolution of symptoms and their association with events were studied. RESULTS In this study, 451 consecutive patients with sSAS and no other valvular or coronary disease who were alive 30 days after intervention were included. Before valve replacement, 133 of the 451 patients (29.5%) had congestive heart failure requiring hospitalization. Of the remaining 318 patients, 287 (90.2%) had dyspnea on effort, 129 (40.6%) had angina, and 59 had syncope (18.6%). Symptoms disappeared after intervention in 192 of the 451 patients (42.6%) and remained in 259 (57.4%): 193 dyspnea, 9 angina, 17 syncope, and 60 admission for heart failure. Syncope on effort persisted in 4 of 33 patients (12.1%) and at rest in 11 of 20 (55.0%; P<.001). Age, body mass index, previous admission for heart failure, and chronic obstructive pulmonary disease were independently related to persistence of symptoms. Over a median follow-up of 56 months in our cohort of 451 patients, 129 deaths were registered (28.6%), 40 of which were cardiovascular (8.9%). Age, chronic obstructive pulmonary disease, chronic kidney disease, atrial fibrillation, heart failure, and persistence of symptoms were independently associated with all-cause mortality. CONCLUSION Symptoms attributed to SAS remain after intervention in a high proportion of patients, particularly dyspnea on effort and syncope at rest. The persistence of symptoms after intervention identifies patients with poor outcome.
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Affiliation(s)
- J Alberto San Román
- Cardiology Department, Hospital Clínico Universitario, Valladolid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.
| | | | - Mario García-Gómez
- Cardiology Department, Hospital Clínico Universitario, Valladolid, Spain
| | - Noemí Ramos
- Cardiology Department, Hospital Clínico San Carlos, Madrid, Spain
| | - Luis Nombela
- Cardiology Department, Hospital Clínico San Carlos, Madrid, Spain
| | - Manuel Carnero
- Department of Cardiac Surgery, Hospital Clínico San Carlos, Madrid, Spain
| | - Ignacio J Amat-Santos
- Cardiology Department, Hospital Clínico Universitario, Valladolid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Teresa Sevilla
- Cardiology Department, Hospital Clínico Universitario, Valladolid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Ana Revilla
- Cardiology Department, Hospital Clínico Universitario, Valladolid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Manuel Carrasco
- Cardiology Department, Hospital Clínico Universitario, Valladolid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Javier López-Díaz
- Cardiology Department, Hospital Clínico Universitario, Valladolid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Isidre Vilacosta
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain; Cardiology Department, Hospital Clínico San Carlos, Madrid, Spain
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31
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Fang Cheng J, Jia YY, Wu BB, Wu T, Yu B, Zhu X. The interventional care for patients undergoing transcatheter aortic valve replacement: Establishing indicators for optimal interventional care. Curr Probl Cardiol 2024; 49:102361. [PMID: 38145633 DOI: 10.1016/j.cpcardiol.2023.102361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 12/19/2023] [Indexed: 12/27/2023]
Abstract
OBJECTIVE We evaluate the quality of interventional care for patients undergoing transcatheter aortic valve replacement (TAVR) using a set of quality indicators. METHODS We developed an initial list of quality indicators by incorporating current guidelines, observing practice discrepancies, and basing it on the Donabedian "structure, process, and outcome" three-dimensional quality evaluation model as the framework. The Delphi method was utilized in two rounds of consultation involving 31 experts to evaluate and revise indicators at all levels. RESULTS The response rate of expert questionnaires was 100% for both rounds, and the expert authority coefficients were 0.913 and 0.940, respectively. The Kendall harmony coefficients were 0.221 and 0.195, respectively, with P < 0.05. Eventually, a quality evaluation system of interventional care for patients undergoing TAVR was constructed, consisting of three structural indicators, nine process indicators, and 42 outcome indicators. CONCLUSIONS The quality evaluation system for interventional care of TAVR sought to establish specific, objective, and quantifiable criteria for assessing the quality of care. It is recommended to apply the set of quality indicators across hospitals to enhance the quality of care for TAVR.
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Affiliation(s)
- Ji Fang Cheng
- Cardiovascular Intervention Center, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Ying Ying Jia
- Department of Nursing, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China; Nursing Department, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.
| | - Bing Bing Wu
- Department of Nursing, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Ting Wu
- School of Nursing, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Bing Yu
- Cardiovascular Intervention Center, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Xia Zhu
- Cardiovascular Intervention Center, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
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De Azevedo D, Boute M, Tribouilloy C, Maréchaux S, Pouleur AC, Bohbot Y, Rusinaru D, Altes A, Thellier N, Beauloye C, Pasquet A, Gerber BL, de Kerchove L, Vanoverschelde JLJ, Vancraeynest D. Quantifying the Survival Loss Linked to Late Therapeutic Indication in High-Gradient Severe Aortic Stenosis. JACC. ADVANCES 2024; 3:100830. [PMID: 38938822 PMCID: PMC11198331 DOI: 10.1016/j.jacadv.2024.100830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 11/17/2023] [Accepted: 12/05/2023] [Indexed: 06/29/2024]
Abstract
Background International guidelines recommend aortic valve replacement (AVR) as Class I triggers in high-gradient severe aortic stenosis (HGSAS) patients with symptoms and/or left ventricular ejection fraction (LVEF) <50%. The association between waiting for these triggers and postoperative survival penalty is poorly studied. Objectives The purpose of this study was to examine the impact of guideline-based Class I triggers on long-term postoperative survival in HGSAS patients. Methods 2,030 patients operated for HGSAS were included and classified as follows: no Class I triggers (no symptoms and LVEF >50%, n = 853), symptoms with LVEF >50% (n = 965), or LVEF <50% regardless of symptoms (n = 212). Survival was compared after matching (inverse probability weighting) for clinical differences. Restricted mean survival time was analyzed to quantify lifetime loss. Results Ten-year survival was better without any Class I trigger than with symptoms or LVEF <50% (67.1% ± 3% vs 56.4% ± 3% vs 53.1% ± 7%, respectively, P < 0.001). Adjusted death risks increased significantly in operated patients with symptoms (HR: 1.45 [95% CI: 1.15-1.82]) or LVEF <50% (HR: 1.47 [95% CI: 1.05-2.06]) than in those without Class I triggers. Performing AVR with LVEF >60% produced similar outcomes to that of the general population, whereas operated patients with LVEF <60% was associated with a 10-year postoperative survival penalty. Furthermore, according to restricted mean survival time analyses, operating on symptomatic patients or with LVEF <60% led to 8.3- and 11.4-month survival losses, respectively, after 10 years, compared with operated asymptomatic patients with a LVEF >60%. Conclusions Guideline-based Class I triggers for AVR in HGSAS have profound consequences on long-term postoperative survival, suggesting that HGSAS patients should undergo AVR before trigger onset. Operating on patients with LVEF <60% is already associated with a 10-year postoperative survival penalty questioning the need for an EF threshold recommending AVR in HGSAS patients.
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Affiliation(s)
- David De Azevedo
- Department of Cardiovascular Diseases, Cliniques Universitaires St. Luc, and IREC/CARD UCLouvain, Brussels, Belgium
| | - Marin Boute
- Department of Cardiovascular Diseases, Cliniques Universitaires St. Luc, and IREC/CARD UCLouvain, Brussels, Belgium
| | - Christophe Tribouilloy
- Department of Cardiology, University Hospital Amiens, Amiens, France
- UR UPJV 7517, Jules Verne University of Picardie, Amiens, France
| | - Sylvestre Maréchaux
- Laboratoire ETHICS, Groupement des Hôpitaux de l’Institut Catholique de Lille, Service de cardiologie-USIC, Université Catholique de Lille, Lille, France
| | - Anne-Catherine Pouleur
- Department of Cardiovascular Diseases, Cliniques Universitaires St. Luc, and IREC/CARD UCLouvain, Brussels, Belgium
| | - Yohann Bohbot
- Department of Cardiology, University Hospital Amiens, Amiens, France
- UR UPJV 7517, Jules Verne University of Picardie, Amiens, France
| | - Dan Rusinaru
- Department of Cardiology, University Hospital Amiens, Amiens, France
- UR UPJV 7517, Jules Verne University of Picardie, Amiens, France
| | - Alexandre Altes
- Laboratoire ETHICS, Groupement des Hôpitaux de l’Institut Catholique de Lille, Service de cardiologie-USIC, Université Catholique de Lille, Lille, France
| | - Nicolas Thellier
- Laboratoire ETHICS, Groupement des Hôpitaux de l’Institut Catholique de Lille, Service de cardiologie-USIC, Université Catholique de Lille, Lille, France
| | - Christophe Beauloye
- Department of Cardiovascular Diseases, Cliniques Universitaires St. Luc, and IREC/CARD UCLouvain, Brussels, Belgium
| | - Agnès Pasquet
- Department of Cardiovascular Diseases, Cliniques Universitaires St. Luc, and IREC/CARD UCLouvain, Brussels, Belgium
| | - Bernhard L. Gerber
- Department of Cardiovascular Diseases, Cliniques Universitaires St. Luc, and IREC/CARD UCLouvain, Brussels, Belgium
| | - Laurent de Kerchove
- Department of Cardiovascular Diseases, Cliniques Universitaires St. Luc, and IREC/CARD UCLouvain, Brussels, Belgium
| | - Jean-Louis J. Vanoverschelde
- Department of Cardiovascular Diseases, Cliniques Universitaires St. Luc, and IREC/CARD UCLouvain, Brussels, Belgium
| | - David Vancraeynest
- Department of Cardiovascular Diseases, Cliniques Universitaires St. Luc, and IREC/CARD UCLouvain, Brussels, Belgium
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Magruder JT, Holst KA, Stewart J, Yadav PK, Thourani VH. Early Intervention in Asymptomatic Aortic Stenosis: What Are We Waiting For? Can J Cardiol 2024; 40:201-209. [PMID: 38036025 DOI: 10.1016/j.cjca.2023.11.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 11/06/2023] [Accepted: 11/25/2023] [Indexed: 12/02/2023] Open
Abstract
Aortic stenosis (AS) contributes to significant cardiovascular morbidity and mortality worldwide, and the natural history from symptoms to ventricular decompensation, heart failure, and death has been well documented. For more than 2 decades, technologies including imaging and biomarkers have shown a promising ability to detect myocardial damage associated with AS before symptoms arise. Current treatment guidelines rely heavily on symptoms or ventricular decompensation as triggers for aortic valve intervention. There is increasing appreciation of the relationship between myocardial damage due to AS before the emergence of symptoms, and a number of published randomised trials suggest a benefit to early intervention in asymptomatic AS, with additional trials actively enrolling. Future treatment paradigms may incorporate early detection of ventricular damage by noninvasive new technologies as triggers for asymptomatic intervention. Enthusiasm for early aortic valve replacement should be tempered by consideration of the competing risks of early valve intervention, but an increasing preponderance of evidence continues to suggest that earlier intervention in AS is warranted.
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Affiliation(s)
- J Trent Magruder
- Department of Cardiovascular Surgery, Piedmont Heart Institute, Athens, Georgia, USA
| | - Kimberly A Holst
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Jim Stewart
- Department of Cardiology, Marcus Heart Valve Center, Piedmont Heart Institute, Atlanta, Georgia, USA
| | - Pradeep K Yadav
- Department of Cardiology, Marcus Heart Valve Center, Piedmont Heart Institute, Atlanta, Georgia, USA
| | - Vinod H Thourani
- Department of Cardiovascular Surgery, Marcus Heart Valve Center, Piedmont Heart Institute, Marcus Valve Center, Atlanta, Georgia, USA.
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Scisciola L, Paolisso P, Belmonte M, Gallinoro E, Delrue L, Taktaz F, Fontanella RA, Degrieck I, Pesapane A, Casselman F, Puocci A, Franzese M, Van Praet F, Torella M, Marfella R, De Feo M, Bartunek J, Paolisso G, Barbato E, Barbieri M, Vanderheyden M. Myocardial sodium-glucose cotransporter 2 expression and cardiac remodelling in patients with severe aortic stenosis: The BIO-AS study. Eur J Heart Fail 2024; 26:471-482. [PMID: 38247224 DOI: 10.1002/ejhf.3145] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 12/22/2023] [Accepted: 01/08/2024] [Indexed: 01/23/2024] Open
Abstract
AIM Cardiac remodelling plays a major role in the prognosis of patients with aortic stenosis (AS) and could impact the benefits of aortic valve replacement. Our study aimed to evaluate the expression of sodium-glucose cotransporter 2 (SGLT2) gene and protein in patients with severe AS stratified in high gradient (HG) and low flow-low gradient (LF-LG) AS and its association with cardiac functional impairments. METHODS AND RESULTS Gene expression and protein levels of main biomarkers of cardiac fibrosis (galectin-3, sST2, serpin-4, procollagen type I amino-terminal peptide, procollagen type I carboxy-terminal propeptide, collagen, transforming growth factor [TGF]-β), inflammation (growth differentiation factor-15, interleukin-6, nuclear factor-κB [NF-κB]), oxidative stress (superoxide dismutase 1 [SOD1] and 2 [SOD2]), and cardiac metabolism (sodium-hydrogen exchanger, peroxisome proliferator-activated receptor [PPAR]-α, PPAR-γ, glucose transporter 1 [GLUT1] and 4 [GLUT4]) were evaluated in blood samples and heart biopsies of 45 patients with AS. Our study showed SGLT2 gene and protein hyper-expression in patients with LF-LG AS, compared to controls and HG AS (p < 0.05). These differences remained significant even after adjusting for age, gender, body mass index, history of diabetes mellitus, arterial hypertension, and coronary artery disease. SGLT2 gene expression was positively correlated with: (i) TGF-β (r = 0.72, p < 0.001) and collagen (r = 0.73, p < 0.001) as markers of fibrosis; (ii) NF-κB (r = 0.36, p < 0.01) and myocardial interleukin-6 (r = 0.68, p < 0.001) as markers of inflammation: (iii) SOD2 (r = -0.38, p < 0.006) as a marker of oxidative stress; (iv) GLUT4 (r = 0.33, p < 0.02) and PPAR-α (r = 0.36, p < 0.01) as markers of cardiac metabolism. CONCLUSION In patients with LF-LG AS, SGLT2 gene and protein were hyper-expressed in cardiomyocytes and associated with myocardial fibrosis, inflammation, and oxidative stress.
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Affiliation(s)
- Lucia Scisciola
- Department of Advanced Medical and Surgical Science, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - Pasquale Paolisso
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
- Department of Advanced Biomedical Sciences, 'Federico II' University, Naples, Italy
| | - Marta Belmonte
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
- Department of Advanced Biomedical Sciences, 'Federico II' University, Naples, Italy
| | - Emanuele Gallinoro
- IRCCS Ospedale Galeazzi Sant'Ambrogio, Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Leen Delrue
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
| | - Fatemeh Taktaz
- Department of Advanced Medical and Surgical Science, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - Rosaria Anna Fontanella
- Department of Advanced Medical and Surgical Science, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - Ivan Degrieck
- Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium
| | - Ada Pesapane
- Department of Advanced Medical and Surgical Science, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | | | - Armando Puocci
- Department of Advanced Medical and Surgical Science, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - Martina Franzese
- Department of Advanced Medical and Surgical Science, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | | | - Michele Torella
- Department of Translation Medical Science, University of Campania 'Luigi Vanvitelli' and Monaldi Hospital, Naples, Italy
| | - Raffaele Marfella
- Department of Advanced Medical and Surgical Science, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - Marisa De Feo
- Department of Translation Medical Science, University of Campania 'Luigi Vanvitelli' and Monaldi Hospital, Naples, Italy
| | | | - Giuseppe Paolisso
- Department of Advanced Medical and Surgical Science, University of Campania 'Luigi Vanvitelli', Naples, Italy
- UniCamillus, International Medical University, Rome, Italy
| | - Emanuele Barbato
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Michelangela Barbieri
- Department of Advanced Medical and Surgical Science, University of Campania 'Luigi Vanvitelli', Naples, Italy
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Tsampasian V, Merinopoulos I, Ravindrarajah T, Ring L, Heng EL, Prasad S, Vassiliou VS. Prognostic Value of Cardiac Magnetic Resonance Feature Tracking Strain in Aortic Stenosis. J Cardiovasc Dev Dis 2024; 11:30. [PMID: 38276656 PMCID: PMC10816900 DOI: 10.3390/jcdd11010030] [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: 12/21/2023] [Revised: 01/13/2024] [Accepted: 01/17/2024] [Indexed: 01/27/2024] Open
Abstract
BACKGROUND Recent data have suggested that global longitudinal strain (GLS) could be useful for risk stratification of patients with severe aortic stenosis (AS). In this study, we aimed to investigate the prognostic role of GLS in patients with AS and also its incremental value in relation to left ventricular ejection fraction (LVEF) and late gadolinium enhancement (LGE). METHODS We analysed all consecutive patients with AS and LGE-CMR in our institution. Survival data were obtained from office of national statistics, a national body where all deaths in England are registered by law. Death certificates were obtained from the general register office. RESULTS Some 194 consecutive patients with aortic stenosis were investigated with CMR at baseline and followed up for 7.3 ± 4 years. On multivariate Cox regression analysis, only increasing age remained significant for both all-cause and cardiac mortality, while LGE (any pattern) retained significance for all-cause mortality and had a trend to significance for cardiac mortality. Kaplan-Meier survival analysis demonstrated that patients in the best and middle GLS tertiles had significantly better mortality compared to patients in the worst GLS tertiles. Importantly though, sequential Cox proportional-hazard analysis demonstrated that GLS did not have significant incremental prognostic value for all-cause mortality or cardiac mortality in addition to LVEF and LGE. CONCLUSIONS Our study has demonstrated that age and LGE but not GLS are significant poor prognostic indicators in patients with moderate and severe AS.
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Affiliation(s)
- Vasiliki Tsampasian
- Department of Cardiology, Norfolk and Norwich University Hospital, Colney Lane, Norwich NR4 7UY, UK; (I.M.); (T.R.)
- Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich Research Park, Norwich NR4 7UG, UK
| | - Ioannis Merinopoulos
- Department of Cardiology, Norfolk and Norwich University Hospital, Colney Lane, Norwich NR4 7UY, UK; (I.M.); (T.R.)
| | - Thuwarahan Ravindrarajah
- Department of Cardiology, Norfolk and Norwich University Hospital, Colney Lane, Norwich NR4 7UY, UK; (I.M.); (T.R.)
| | - Liam Ring
- Department of Cardiology, West Suffolk Hospital, Hardwick Ln, Bury Saint Edmunds IP33 2QZ, UK;
| | - Ee Ling Heng
- Royal Brompton Hospital, Royal Brompton and Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation Trust, Sydney Street, London SW3 6NP, UK;
| | - Sanjay Prasad
- Faculty of Medicine, Imperial College London, London SW7 5NH, UK;
| | - Vassilios S. Vassiliou
- Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich Research Park, Norwich NR4 7UG, UK
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Zoghbi WA, Jone PN, Chamsi-Pasha MA, Chen T, Collins KA, Desai MY, Grayburn P, Groves DW, Hahn RT, Little SH, Kruse E, Sanborn D, Shah SB, Sugeng L, Swaminathan M, Thaden J, Thavendiranathan P, Tsang W, Weir-McCall JR, Gill E. Guidelines for the Evaluation of Prosthetic Valve Function With Cardiovascular Imaging: A Report From the American Society of Echocardiography Developed in Collaboration With the Society for Cardiovascular Magnetic Resonance and the Society of Cardiovascular Computed Tomography. J Am Soc Echocardiogr 2024; 37:2-63. [PMID: 38182282 DOI: 10.1016/j.echo.2023.10.004] [Citation(s) in RCA: 42] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2024]
Abstract
In patients with significant cardiac valvular disease, intervention with either valve repair or valve replacement may be inevitable. Although valve repair is frequently performed, especially for mitral and tricuspid regurgitation, valve replacement remains common, particularly in adults. Diagnostic methods are often needed to assess the function of the prosthesis. Echocardiography is the first-line method for noninvasive evaluation of prosthetic valve function. The transthoracic approach is complemented with two-dimensional and three-dimensional transesophageal echocardiography for further refinement of valve morphology and function when needed. More recently, advances in computed tomography and cardiac magnetic resonance have enhanced their roles in evaluating valvular heart disease. This document offers a review of the echocardiographic techniques used and provides recommendations and general guidelines for evaluation of prosthetic valve function on the basis of the scientific literature and consensus of a panel of experts. This guideline discusses the role of advanced imaging with transesophageal echocardiography, cardiac computed tomography, and cardiac magnetic resonance in evaluating prosthetic valve structure, function, and regurgitation. It replaces the 2009 American Society of Echocardiography guideline on prosthetic valves and complements the 2019 guideline on the evaluation of valvular regurgitation after percutaneous valve repair or replacement.
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Affiliation(s)
- William A Zoghbi
- Houston Methodist Hospital, DeBakey Heart & Vascular Center, Houston, Texas.
| | - Pei-Ni Jone
- Lurie Children's Hospital, Northwestern University, Chicago, Illinois
| | | | - Tiffany Chen
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Milind Y Desai
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Paul Grayburn
- Baylor Scott & White Health, University of Texas Southwestern, Dallas, Texas
| | - Daniel W Groves
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Rebecca T Hahn
- Columbia University Irving Medical Center, New York, New York
| | - Stephen H Little
- Houston Methodist Hospital, DeBakey Heart & Vascular Center, Houston, Texas
| | - Eric Kruse
- University of Chicago Medical Center, Chicago, Illinois
| | | | - Sangeeta B Shah
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia
| | - Lissa Sugeng
- North Shore University Hospital, Manhasset, New York
| | - Madhav Swaminathan
- Cardiothoracic Anesthesiology and Critical Care Medicine, Duke University, Durham, North Carolina
| | | | | | - Wendy Tsang
- University of Toronto, Toronto, Ontario, Canada
| | | | - Edward Gill
- University of Colorado School of Medicine, Aurora, Colorado
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Chang WT, Lin CH, Lee WC, Kan WC, Lin YC, Hiremath P, Cheng S, Liao R, Chen ZC, Huang PS, Wu NC. Signal intensity coefficient as a detector of aortic stenosis-induced myocardial fibrosis and its correlation to the long term outcome. Int J Cardiol 2024; 394:131367. [PMID: 37726056 DOI: 10.1016/j.ijcard.2023.131367] [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: 05/26/2023] [Revised: 08/26/2023] [Accepted: 09/15/2023] [Indexed: 09/21/2023]
Abstract
OBJECTIVE Despite advanced aortic valve replacement techniques, aortic stenosis (AS)-induced irreversible myocardial fibrosis contributes to poorer outcomes. Therefore, in addition to early diagnosis of AS, detecting myocardial fibrosis is crucial for physicians to determine the timing of surgery. The Signal Intensity Coefficient (SIC) was used to detect subtle myocardial deformation. Hence, we aimed to investigate whether SIC correlated with myocardial dysfunction and fibrosis from both clinical and preclinical perspectives. METHODS We collected medical records and echocardiography images, including the SIC of patients who underwent surgical aortic valve replacement (AVR) for AS from 2010 to 2015. The endpoint of the study was mortality. Median follow-up period was 80 months. RESULTS Among 109 patients, 15 died due to cardiovascular causes. Although SIC decreased in all patients post-AVR, patients with an SIC ≥0.34 before surgeries presented with a higher probability of cardiovascular death. In contrast, changes in the left ventricular (LV) ejection fraction, LV mass index, and LV volume failed to predict outcomes. Similarly, SIC was obtained in mice undergoing aortic banding and debanding surgery for comparison with the degree of myocardial fibrosis. SIC was continuously elevated after aortic banding and declined gradually after debanding surgery in mice. Debanding surgery indicated the regression of aortic banding-induced myocardial fibrosis. CONCLUSION Pre-AVR SIC was associated with the risk of cardiovascular death and reflected the degree of myocardial fibrosis. Further investigations are required to study the clinical application of SIC in patients with AS.
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Affiliation(s)
- Wei-Ting Chang
- School of Medicine and Doctoral Program of Clinical and Experimental Medicine, College of Medicine and Center of Excellence for Metabolic Associated Fatty Liver Disease, National Sun Yat-Sen University, Kaohsiung, Taiwan; Division of Cardiology, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Chih-Hsien Lin
- Division of Cardiology, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan; School of Medicine, College of Medicine, National Sun Yat-Sen University, Kaohsiung, Taiwan
| | - Wei-Chieh Lee
- School of Medicine and Doctoral Program of Clinical and Experimental Medicine, College of Medicine and Center of Excellence for Metabolic Associated Fatty Liver Disease, National Sun Yat-Sen University, Kaohsiung, Taiwan; Division of Cardiology, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Wei-Chih Kan
- Division of Nephrology, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan; Department of Medical Laboratory Science and Biotechnology, Chung Hwa University of Medical Technology, Tainan, Taiwan
| | - You-Cheng Lin
- Division of Plastic Surgery, Department of Surgery, Chi-Mei Medical Center, Tainan, Taiwan
| | | | - Susan Cheng
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Ronglih Liao
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA; Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, MA, USA
| | - Zhih-Cherng Chen
- Division of Cardiology, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan; School of Medicine, College of Medicine, National Sun Yat-Sen University, Kaohsiung, Taiwan
| | - Po-Sen Huang
- Division of Cardiology, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan.
| | - Nan-Chun Wu
- Division of Cardiovascular Surgery, Department of Surgery, Chi Mei Medical Center, Tainan, Taiwan; Department of Hospital and Health Care Administration, Chia Nan University of Pharmacy and Science, Tainan, Taiwan.
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Meredith T, Roy D, Hayward C, Feneley M, Kovacic J, Muller D, Namasivayam M. Strain Assessment in Aortic Stenosis: Pathophysiology and Clinical Utility. J Am Soc Echocardiogr 2024; 37:64-76. [PMID: 37805144 DOI: 10.1016/j.echo.2023.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 09/26/2023] [Accepted: 10/01/2023] [Indexed: 10/09/2023]
Abstract
Contemporary echocardiographic criteria for grading aortic stenosis severity have remained relatively unchanged, despite significant advances in noninvasive imaging techniques over the last 2 decades. More recently, attention has shifted to the ventricular response to aortic stenosis and how this might be quantified. Global longitudinal strain, semiautomatically calculated from standard two-dimensional echocardiographic images, has been the focus of extensive research. Global longitudinal strain is a sensitive marker of subtle hypertrophy-related impairment in left ventricular function and has shown promise as a relatively robust prognostic marker, both independently and when added to severity classification systems. Herein we review the pathophysiological basis underpinning the potential utility of global longitudinal strain in the assessment of aortic stenosis, as well as its potential role in quantifying myocardial recovery and prognostic discrimination following aortic valve replacement.
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Affiliation(s)
- Thomas Meredith
- Department of Cardiology, St. Vincent's Hospital, Sydney, New South Wales, Australia; Victor Chang Cardiac Research Institute, Sydney, New South Wales, Australia; Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
| | - David Roy
- Department of Cardiology, St. Vincent's Hospital, Sydney, New South Wales, Australia; Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Christopher Hayward
- Department of Cardiology, St. Vincent's Hospital, Sydney, New South Wales, Australia; Victor Chang Cardiac Research Institute, Sydney, New South Wales, Australia; Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Michael Feneley
- Department of Cardiology, St. Vincent's Hospital, Sydney, New South Wales, Australia; Victor Chang Cardiac Research Institute, Sydney, New South Wales, Australia; Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Jason Kovacic
- Department of Cardiology, St. Vincent's Hospital, Sydney, New South Wales, Australia; Victor Chang Cardiac Research Institute, Sydney, New South Wales, Australia; Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
| | - David Muller
- Department of Cardiology, St. Vincent's Hospital, Sydney, New South Wales, Australia; Victor Chang Cardiac Research Institute, Sydney, New South Wales, Australia; Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Mayooran Namasivayam
- Department of Cardiology, St. Vincent's Hospital, Sydney, New South Wales, Australia; Victor Chang Cardiac Research Institute, Sydney, New South Wales, Australia; Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia.
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Zhong Y, Long Q, Zeng M, Wu L, Guo L, Wang G. Feature-Tracking-Derived Strain Analysis for Identification of Subendocardium-Involved Late Gadolinium Enhancement in Load-Induced Left Ventricular Hypertrophy: A Multicenter Study of Cardiac Magnetic Resonance Data. J Clin Med 2023; 12:7543. [PMID: 38137612 PMCID: PMC10744239 DOI: 10.3390/jcm12247543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 11/14/2023] [Accepted: 11/29/2023] [Indexed: 12/24/2023] Open
Abstract
BACKGROUND Subendocardium-involved late gadolinium enhancement (SILGE) is a significant predictor of poor prognosis in patients with load-induced left ventricular hypertrophy (LVH). OBJECTIVES This multicenter study aimed to investigate whether the diagnostic performance of cardiac magnetic resonance feature-tracking (CMR-FT)-derived strain analysis for detecting subtle subendocardial injury would be influenced by its load dependence in patients with load-induced LVH. METHODS A total of 149 patients with load-induced LVH were recruited from three centers and underwent enhanced CMR imaging. The patients were divided into two groups based on the presence or absence of SILGE on CMR (SILGE+ group: n = 56; SILGE- group: n = 93). Clinical and CMR parameters were evaluated in both groups. RESULTS The LV systolic pressure (LVSP) and LV end-diastolic pressure (LVEDP) in the SILGE+ group were higher than those in the SILGE- group (each with p < 0.05), and LVSP and LVEDP were correlated with the LV global longitudinal strain (GLS) (each with p < 0.05) in research center 1. The LV strain parameters were significantly lower in the SILGE+ group than those in the SILGE- group (each with p < 0.05). Logistic regression analysis identified GLS (OR 1.325; 95% CI 1.180 to 1.487, p < 0.001) as a predictive factor of SILGE in the patients with load-induced LVH. The receiver operating characteristic (ROC) curve analysis results indicated that the areas under the curve (AUC) of global radial strain (GRS), global circumferential strain (GCS), and GLS were 0.68, 0.69, and 0.76, respectively. De Long's test results implied that GLS had the best diagnostic performance for SILGE (p = 0.04). CONCLUSION Despite the load dependency of CMR-FT-derived strain analysis, the GLS exhibits reasonable accuracy in the identification of SILGE and can potentially serve as a feasible alternative for detecting subendocardial involvement in patients with load-induced LVH who are contraindicated for LGE.
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Affiliation(s)
- Ying Zhong
- Department of Radiology, The First Hospital of China Medical University, Shenyang 110001, China;
| | - Qian Long
- Department of Radiology, The Second Xiangya Hospital, Central South University, Changsha 410011, China; (Q.L.); (M.Z.)
| | - Mu Zeng
- Department of Radiology, The Second Xiangya Hospital, Central South University, Changsha 410011, China; (Q.L.); (M.Z.)
- National Clinical Research Center for Metabolic Diseases, Department of Metabolism and Endocrinology, The Second Xiangya Hospital, Central South University, Changsha 410011, China
| | - Lianming Wu
- Department of Radiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200001, China
| | - Liang Guo
- Department of Cardiovascular Medicine, The First Hospital of China Medical University, Shenyang 110001, China
| | - Guan Wang
- Department of Radiology, The First Hospital of China Medical University, Shenyang 110001, China;
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Ni JR, Xin WL, Hu Y, Liu SD, Li JK, Wan ZH, Lei JQ. Prognostic Value of Cardiac Magnetic Resonance Imaging in Chronic Aortic Regurgitation: A Systematic Review and Meta-Analysis. Rev Cardiovasc Med 2023; 24:359. [PMID: 39077090 PMCID: PMC11262437 DOI: 10.31083/j.rcm2412359] [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: 05/02/2023] [Revised: 07/13/2023] [Accepted: 07/27/2023] [Indexed: 07/31/2024] Open
Abstract
Background Chronic aortic regurgitation (AR) is a common valvular disease characterized by an overload of left ventricular volume and pressure. Accurate assessment of the heart from all angles is crucial for effective clinical management and prognostic evaluation of AR patients. As an advanced imaging technique, cardiac magnetic resonance (CMR) has become the gold standard for assessing cardiac volume and function. Accordingly, this study aimed to evaluate the prognostic value of CMR in chronic AR. Methods EMBASE, Cochrane Library, PubMed, and Web of Science were searched for clinical studies published between inception and July 19, 2022. Only studies that used CMR to assess patients with chronic isolated AR and provided prognostic data were included. Results For our analysis, 11 studies, which involved 1702 subjects and follow-up periods of 0.6-9.7 years, were eligible. We identified 13 CMR-related parameters associated with AR prognosis. With aortic valve surgery as the outcome, we estimated the pooled hazard ratios (HRs) for four of these parameters: aortic regurgitation fraction (ARF), aortic regurgitation volume (ARV), left ventricle end-diastolic volume (LVEDV), and LV end-systolic volume (LVESV). The pooled HR for ARF was found to be 4.31 (95% confidence interval [CI]: 1.12-16.59, p = 0.034), while that for ARV was 3.88 (95% CI: 0.71-21.04, p = 0.116). Additionally, the combined HRs of LVEDV and LVESV were estimated to be 2.20 (95% CI: 1.04-4.67, p = 0.039) and 3.14 (95% CI: 1.22-8.07, p = 0.018), respectively. Conclusions The assessment of ARF, LVEDV, and LVESV via CMR has significant prognostic value in predicting the prognosis of AR patients with aortic valve surgery as an endpoint. It is recommended to consider using multi-parameter CMR in the clinical management of AR patients for timely interventions and effective prognostic evaluation.
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Affiliation(s)
- Jin-Rong Ni
- The First Hospital (First Clinical Medical School) of Lanzhou University, 730000 Lanzhou, Gansu, China
- Department of Cardiovascular Surgery, The First Hospital of Lanzhou University, 730000 Lanzhou, Gansu, China
- Intelligent Imaging Medical Engineering Research Center of Gansu Province, 730000 Lanzhou, Gansu, China
- Accurate Image and Collaborative Innovation International Scientific and Technological Cooperation Base of Gansu Province, 730000 Lanzhou, Gansu, China
- Gansu Province Clinical Research Center for Radiology Imaging, 730000 Lanzhou, Gansu, China
| | - Wen-Long Xin
- Intelligent Imaging Medical Engineering Research Center of Gansu Province, 730000 Lanzhou, Gansu, China
- Accurate Image and Collaborative Innovation International Scientific and Technological Cooperation Base of Gansu Province, 730000 Lanzhou, Gansu, China
- Gansu Province Clinical Research Center for Radiology Imaging, 730000 Lanzhou, Gansu, China
- Department of Radiology, The First Hospital of Lanzhou University, 730000 Lanzhou, Gansu, China
| | - Yuan Hu
- Department of Cardiovascular Surgery, The First Hospital of Lanzhou University, 730000 Lanzhou, Gansu, China
| | - Shi-Dong Liu
- Department of Cardiovascular Surgery, The First Hospital of Lanzhou University, 730000 Lanzhou, Gansu, China
| | - Jin-Kui Li
- Intelligent Imaging Medical Engineering Research Center of Gansu Province, 730000 Lanzhou, Gansu, China
- Accurate Image and Collaborative Innovation International Scientific and Technological Cooperation Base of Gansu Province, 730000 Lanzhou, Gansu, China
- Gansu Province Clinical Research Center for Radiology Imaging, 730000 Lanzhou, Gansu, China
- Department of Radiology, The First Hospital of Lanzhou University, 730000 Lanzhou, Gansu, China
| | - Zun-Hui Wan
- Department of Cardiovascular Surgery, The First Hospital of Lanzhou University, 730000 Lanzhou, Gansu, China
| | - Jun-Qiang Lei
- The First Hospital (First Clinical Medical School) of Lanzhou University, 730000 Lanzhou, Gansu, China
- Intelligent Imaging Medical Engineering Research Center of Gansu Province, 730000 Lanzhou, Gansu, China
- Accurate Image and Collaborative Innovation International Scientific and Technological Cooperation Base of Gansu Province, 730000 Lanzhou, Gansu, China
- Gansu Province Clinical Research Center for Radiology Imaging, 730000 Lanzhou, Gansu, China
- Department of Radiology, The First Hospital of Lanzhou University, 730000 Lanzhou, Gansu, China
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Drăgan A, Mateescu AD. Novel Biomarkers and Advanced Cardiac Imaging in Aortic Stenosis: Old and New. Biomolecules 2023; 13:1661. [PMID: 38002343 PMCID: PMC10669288 DOI: 10.3390/biom13111661] [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: 09/30/2023] [Revised: 11/12/2023] [Accepted: 11/15/2023] [Indexed: 11/26/2023] Open
Abstract
Currently, the symptomatic status and left ventricular ejection fraction (LVEF) play a crucial role in aortic stenosis (AS) assessment. However, the symptoms are often subjective, and LVEF is not a sensitive marker of left ventricle (LV) decompensation. Over the past years, the cardiac structure and function research on AS has increased due to advanced imaging modalities and potential therapies. New imaging parameters emerged as predictors of disease progression in AS. LV global longitudinal strain has proved useful for risk stratification in asymptomatic severe AS patients with preserved LVEF. The assessment of myocardial fibrosis by cardiac magnetic resonance is the most studied application and offers prognostic information on AS. Moreover, the usage of biomarkers in AS as objective measures of LV decompensation has recently gained more interest. The present review focuses on the transition from compensatory LV hypertrophy (H) to LV dysfunction and the biomarkers associated with myocardial wall stress, fibrosis, and myocyte death. Moreover, we discuss the potential impact of non-invasive imaging parameters for optimizing the timing of aortic valve replacement and provide insight into novel biomarkers for possible prognostic use in AS. However, data from randomized clinical trials are necessary to define their utility in daily practice.
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Affiliation(s)
- Anca Drăgan
- Department of Cardiovascular Anaesthesiology and Intensive Care, Emergency Institute for Cardiovascular Diseases “Prof Dr C C Iliescu”, 258 Fundeni Road, 022328 Bucharest, Romania
| | - Anca Doina Mateescu
- Department of Cardiology, Emergency Institute for Cardiovascular Diseases “Prof Dr C C Iliescu”, 258 Fundeni Road, 022328 Bucharest, Romania;
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Dweck MR, Loganath K, Bing R, Treibel TA, McCann GP, Newby DE, Leipsic J, Fraccaro C, Paolisso P, Cosyns B, Habib G, Cavalcante J, Donal E, Lancellotti P, Clavel MA, Otto CM, Pibarot P. Multi-modality imaging in aortic stenosis: an EACVI clinical consensus document. Eur Heart J Cardiovasc Imaging 2023; 24:1430-1443. [PMID: 37395329 DOI: 10.1093/ehjci/jead153] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 06/16/2023] [Indexed: 07/04/2023] Open
Abstract
In this EACVI clinical scientific update, we will explore the current use of multi-modality imaging in the diagnosis, risk stratification, and follow-up of patients with aortic stenosis, with a particular focus on recent developments and future directions. Echocardiography is and will likely remain the key method of diagnosis and surveillance of aortic stenosis providing detailed assessments of valve haemodynamics and the cardiac remodelling response. Computed tomography (CT) is already widely used in the planning of transcutaneous aortic valve implantation. We anticipate its increased use as an anatomical adjudicator to clarify disease severity in patients with discordant echocardiographic measurements. CT calcium scoring is currently used for this purpose; however, contrast CT techniques are emerging that allow identification of both calcific and fibrotic valve thickening. Additionally, improved assessments of myocardial decompensation with echocardiography, cardiac magnetic resonance, and CT will become more commonplace in our routine assessment of aortic stenosis. Underpinning all of this will be widespread application of artificial intelligence. In combination, we believe this new era of multi-modality imaging in aortic stenosis will improve the diagnosis, follow-up, and timing of intervention in aortic stenosis as well as potentially accelerate the development of the novel pharmacological treatments required for this disease.
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Affiliation(s)
- Marc R Dweck
- Centre for Cardiovascular Science, University of Edinburgh, Chancellors Building, Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Krithika Loganath
- Centre for Cardiovascular Science, University of Edinburgh, Chancellors Building, Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Rong Bing
- Centre for Cardiovascular Science, University of Edinburgh, Chancellors Building, Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Thomas A Treibel
- Barts Heart Centre, Bart's Health NHS Trust, W Smithfield, EC1A 7BE, London, UK
- University College London Institute of Cardiovascular Science, 62 Huntley St, WC1E 6DD, London, UK
| | - Gerry P McCann
- Department of Cardiovascular Sciences, University of Leicester, University Rd, Leicester LE1 7RH, UK
- The NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Groby Road, Leicester, LE3 9QP, UK
| | - David E Newby
- Centre for Cardiovascular Science, University of Edinburgh, Chancellors Building, Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Jonathon Leipsic
- Centre for Cardiovascular Innovation, St Paul's and Vancouver General Hospital, 1081 Burrard St Room 166, Vancouver, British Columbia V6Z 1Y6, Canada
| | - Chiara Fraccaro
- Department of Cardiac, Thoracic and Vascular Science and Public Health, Via Giustiniani, 2 - 35128, Padua, Italy
| | - Pasquale Paolisso
- Cardiovascular Center Aalst, OLV Clinic, Moorselbaan 164, 9300 Aalst, Belgium
- Department of Advanced Biomedical Sciences, University of Naples, Federico II, 80125 Naples, Italy
| | - Bernard Cosyns
- Department of Cardiology, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090 Jette, Belgium
| | - Gilbert Habib
- Cardiology Department, Hôpital La Timone, 264 Rue Saint-Pierre, 13005 Marseille, France
| | - João Cavalcante
- Allina Health Minneapolis Heart Institute, Abbott Northwestern Hospital, 800 E 28th St, Minneapolis, MN 55407, USA
| | - Erwan Donal
- Cardiology and CIC, Université Rennes, 2 Rue Henri Le Guilloux, 35033 Rennes, France
| | - Patrizio Lancellotti
- GIGA Cardiovascular Sciences, Department of Cardiology, University of Liège Hospital, CHU Sart Tilman, Liège, Belgium
- Gruppo Villa Maria Care and Research, Corso Giuseppe Garibaldi, 11, 48022 Lugo RA, Italy
| | - Marie-Annick Clavel
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, 2725 Ch Ste-Foy, Québec, QC G1V 4G5, Canada
- Faculté de Médecine-Département de Médecine, Université Laval, Ferdinand Vandry Pavillon, 1050 Av. de la Médecine, Québec City, Quebec G1V 0A6, Canada
| | - Catherine M Otto
- Division of Cardiology, Department of Medicine, University of Washington School of Medicine, 4333 Brooklyn Ave NE Box 359458, Seattle, WA 98195-9458, USA
| | - Phillipe Pibarot
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, 2725 Ch Ste-Foy, Québec, QC G1V 4G5, Canada
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Jex N, Greenwood JP, Cubbon RM, Rider OJ, Chowdhary A, Thirunavukarasu S, Kotha S, Giannoudi M, McGrane A, Maccannell A, Conning-Rowland M, Straw S, Procter H, Papaspyros S, Evans B, Javangula K, Ferrara A, Elmahdy W, Kaul P, Xue H, Swoboda P, Kellman P, Valkovič L, Roberts L, Beech D, Kearney MT, Plein S, Dweck MR, Levelt E. Association Between Type 2 Diabetes and Changes in Myocardial Structure, Contractile Function, Energetics, and Blood Flow Before and After Aortic Valve Replacement in Patients With Severe Aortic Stenosis. Circulation 2023; 148:1138-1153. [PMID: 37746744 PMCID: PMC10558154 DOI: 10.1161/circulationaha.122.063444] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 08/15/2023] [Indexed: 09/26/2023]
Abstract
BACKGROUND Type 2 diabetes (T2D) is associated with an increased risk of left ventricular dysfunction after aortic valve replacement (AVR) in patients with severe aortic stenosis (AS). Persistent impairments in myocardial energetics and myocardial blood flow (MBF) may underpin this observation. Using phosphorus magnetic resonance spectroscopy and cardiovascular magnetic resonance, this study tested the hypothesis that patients with severe AS and T2D (AS-T2D) would have impaired myocardial energetics as reflected by the phosphocreatine to ATP ratio (PCr/ATP) and vasodilator stress MBF compared with patients with AS without T2D (AS-noT2D), and that these differences would persist after AVR. METHODS Ninety-five patients with severe AS without coronary artery disease awaiting AVR (30 AS-T2D and 65 AS-noT2D) were recruited (mean, 71 years of age [95% CI, 69, 73]; 34 [37%] women). Thirty demographically matched healthy volunteers (HVs) and 30 patients with T2D without AS (T2D controls) were controls. One month before and 6 months after AVR, cardiac PCr/ATP, adenosine stress MBF, global longitudinal strain, NT-proBNP (N-terminal pro-B-type natriuretic peptide), and 6-minute walk distance were assessed in patients with AS. T2D controls underwent identical assessments at baseline and 6-month follow-up. HVs were assessed once and did not undergo 6-minute walk testing. RESULTS Compared with HVs, patients with AS (AS-T2D and AS-noT2D combined) showed impairment in PCr/ATP (mean [95% CI]; HVs, 2.15 [1.89, 2.34]; AS, 1.66 [1.56, 1.75]; P<0.0001) and vasodilator stress MBF (HVs, 2.11 mL min g [1.89, 2.34]; AS, 1.54 mL min g [1.41, 1.66]; P<0.0001) before AVR. Before AVR, within the AS group, patients with AS-T2D had worse PCr/ATP (AS-noT2D, 1.74 [1.62, 1.86]; AS-T2D, 1.44 [1.32, 1.56]; P=0.002) and vasodilator stress MBF (AS-noT2D, 1.67 mL min g [1.5, 1.84]; AS-T2D, 1.25 mL min g [1.22, 1.38]; P=0.001) compared with patients with AS-noT2D. Before AVR, patients with AS-T2D also had worse PCr/ATP (AS-T2D, 1.44 [1.30, 1.60]; T2D controls, 1.66 [1.56, 1.75]; P=0.04) and vasodilator stress MBF (AS-T2D, 1.25 mL min g [1.10, 1.41]; T2D controls, 1.54 mL min g [1.41, 1.66]; P=0.001) compared with T2D controls at baseline. After AVR, PCr/ATP normalized in patients with AS-noT2D, whereas patients with AS-T2D showed no improvements (AS-noT2D, 2.11 [1.79, 2.43]; AS-T2D, 1.30 [1.07, 1.53]; P=0.0006). Vasodilator stress MBF improved in both AS groups after AVR, but this remained lower in patients with AS-T2D (AS-noT2D, 1.80 mL min g [1.59, 2.0]; AS-T2D, 1.48 mL min g [1.29, 1.66]; P=0.03). There were no longer differences in PCr/ATP (AS-T2D, 1.44 [1.30, 1.60]; T2D controls, 1.51 [1.34, 1.53]; P=0.12) or vasodilator stress MBF (AS-T2D, 1.48 mL min g [1.29, 1.66]; T2D controls, 1.60 mL min g [1.34, 1.86]; P=0.82) between patients with AS-T2D after AVR and T2D controls at follow-up. Whereas global longitudinal strain, 6-minute walk distance, and NT-proBNP all improved after AVR in patients with AS-noT2D, no improvement in these assessments was observed in patients with AS-T2D. CONCLUSIONS Among patients with severe AS, those with T2D demonstrate persistent abnormalities in myocardial PCr/ATP, vasodilator stress MBF, and cardiac contractile function after AVR; AVR effectively normalizes myocardial PCr/ATP, vasodilator stress MBF, and cardiac contractile function in patients without T2D.
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Affiliation(s)
- Nicholas Jex
- University of Leeds, Multidisciplinary Cardiovascular Research Centre, and Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., A. McGrane, A. Maccannell, M.C.-R., S.S., H.P., P.S., L.R., D.B., M.T.K., S.P., E.L.)
- Leeds Teaching Hospitals NHS Trust, Department of Cardiology, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., S.S., H.P., S.P., B.E., K.J., A.F., W.E., P. Kaul, P.S., M.T.K., E.L.)
| | - John P. Greenwood
- University of Leeds, Multidisciplinary Cardiovascular Research Centre, and Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., A. McGrane, A. Maccannell, M.C.-R., S.S., H.P., P.S., L.R., D.B., M.T.K., S.P., E.L.)
- Leeds Teaching Hospitals NHS Trust, Department of Cardiology, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., S.S., H.P., S.P., B.E., K.J., A.F., W.E., P. Kaul, P.S., M.T.K., E.L.)
| | - Richard M. Cubbon
- University of Leeds, Multidisciplinary Cardiovascular Research Centre, and Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., A. McGrane, A. Maccannell, M.C.-R., S.S., H.P., P.S., L.R., D.B., M.T.K., S.P., E.L.)
- Leeds Teaching Hospitals NHS Trust, Department of Cardiology, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., S.S., H.P., S.P., B.E., K.J., A.F., W.E., P. Kaul, P.S., M.T.K., E.L.)
| | - Oliver J. Rider
- Oxford Centre for Clinical Magnetic Resonance Research (OCMR), RDM Cardiovascular Medicine, University of Oxford, UK (O.J.R., L.V.)
| | - Amrit Chowdhary
- University of Leeds, Multidisciplinary Cardiovascular Research Centre, and Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., A. McGrane, A. Maccannell, M.C.-R., S.S., H.P., P.S., L.R., D.B., M.T.K., S.P., E.L.)
- Leeds Teaching Hospitals NHS Trust, Department of Cardiology, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., S.S., H.P., S.P., B.E., K.J., A.F., W.E., P. Kaul, P.S., M.T.K., E.L.)
| | - Sharmaine Thirunavukarasu
- University of Leeds, Multidisciplinary Cardiovascular Research Centre, and Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., A. McGrane, A. Maccannell, M.C.-R., S.S., H.P., P.S., L.R., D.B., M.T.K., S.P., E.L.)
- Leeds Teaching Hospitals NHS Trust, Department of Cardiology, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., S.S., H.P., S.P., B.E., K.J., A.F., W.E., P. Kaul, P.S., M.T.K., E.L.)
| | - Sindhoora Kotha
- University of Leeds, Multidisciplinary Cardiovascular Research Centre, and Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., A. McGrane, A. Maccannell, M.C.-R., S.S., H.P., P.S., L.R., D.B., M.T.K., S.P., E.L.)
- Leeds Teaching Hospitals NHS Trust, Department of Cardiology, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., S.S., H.P., S.P., B.E., K.J., A.F., W.E., P. Kaul, P.S., M.T.K., E.L.)
| | - Marilena Giannoudi
- University of Leeds, Multidisciplinary Cardiovascular Research Centre, and Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., A. McGrane, A. Maccannell, M.C.-R., S.S., H.P., P.S., L.R., D.B., M.T.K., S.P., E.L.)
- Leeds Teaching Hospitals NHS Trust, Department of Cardiology, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., S.S., H.P., S.P., B.E., K.J., A.F., W.E., P. Kaul, P.S., M.T.K., E.L.)
| | - Anna McGrane
- University of Leeds, Multidisciplinary Cardiovascular Research Centre, and Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., A. McGrane, A. Maccannell, M.C.-R., S.S., H.P., P.S., L.R., D.B., M.T.K., S.P., E.L.)
| | - Amanda Maccannell
- University of Leeds, Multidisciplinary Cardiovascular Research Centre, and Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., A. McGrane, A. Maccannell, M.C.-R., S.S., H.P., P.S., L.R., D.B., M.T.K., S.P., E.L.)
| | - Marcella Conning-Rowland
- University of Leeds, Multidisciplinary Cardiovascular Research Centre, and Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., A. McGrane, A. Maccannell, M.C.-R., S.S., H.P., P.S., L.R., D.B., M.T.K., S.P., E.L.)
| | - Sam Straw
- University of Leeds, Multidisciplinary Cardiovascular Research Centre, and Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., A. McGrane, A. Maccannell, M.C.-R., S.S., H.P., P.S., L.R., D.B., M.T.K., S.P., E.L.)
- Leeds Teaching Hospitals NHS Trust, Department of Cardiology, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., S.S., H.P., S.P., B.E., K.J., A.F., W.E., P. Kaul, P.S., M.T.K., E.L.)
| | - Henry Procter
- University of Leeds, Multidisciplinary Cardiovascular Research Centre, and Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., A. McGrane, A. Maccannell, M.C.-R., S.S., H.P., P.S., L.R., D.B., M.T.K., S.P., E.L.)
- Leeds Teaching Hospitals NHS Trust, Department of Cardiology, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., S.S., H.P., S.P., B.E., K.J., A.F., W.E., P. Kaul, P.S., M.T.K., E.L.)
| | - Sotiris Papaspyros
- University of Leeds, Multidisciplinary Cardiovascular Research Centre, and Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., A. McGrane, A. Maccannell, M.C.-R., S.S., H.P., P.S., L.R., D.B., M.T.K., S.P., E.L.)
| | - Betsy Evans
- Leeds Teaching Hospitals NHS Trust, Department of Cardiology, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., S.S., H.P., S.P., B.E., K.J., A.F., W.E., P. Kaul, P.S., M.T.K., E.L.)
| | - Kalyana Javangula
- Leeds Teaching Hospitals NHS Trust, Department of Cardiology, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., S.S., H.P., S.P., B.E., K.J., A.F., W.E., P. Kaul, P.S., M.T.K., E.L.)
| | - Antonella Ferrara
- Leeds Teaching Hospitals NHS Trust, Department of Cardiology, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., S.S., H.P., S.P., B.E., K.J., A.F., W.E., P. Kaul, P.S., M.T.K., E.L.)
| | - Walid Elmahdy
- Leeds Teaching Hospitals NHS Trust, Department of Cardiology, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., S.S., H.P., S.P., B.E., K.J., A.F., W.E., P. Kaul, P.S., M.T.K., E.L.)
| | - Pankaj Kaul
- Leeds Teaching Hospitals NHS Trust, Department of Cardiology, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., S.S., H.P., S.P., B.E., K.J., A.F., W.E., P. Kaul, P.S., M.T.K., E.L.)
| | - Hui Xue
- National Heart, Lung, and Blood Institute, National Institutes of Health, Department of Health and Human Services, Bethesda, MD (H.X., P. Kellman)
| | - Peter Swoboda
- University of Leeds, Multidisciplinary Cardiovascular Research Centre, and Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., A. McGrane, A. Maccannell, M.C.-R., S.S., H.P., P.S., L.R., D.B., M.T.K., S.P., E.L.)
- Leeds Teaching Hospitals NHS Trust, Department of Cardiology, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., S.S., H.P., S.P., B.E., K.J., A.F., W.E., P. Kaul, P.S., M.T.K., E.L.)
| | - Peter Kellman
- National Heart, Lung, and Blood Institute, National Institutes of Health, Department of Health and Human Services, Bethesda, MD (H.X., P. Kellman)
| | - Ladislav Valkovič
- Oxford Centre for Clinical Magnetic Resonance Research (OCMR), RDM Cardiovascular Medicine, University of Oxford, UK (O.J.R., L.V.)
- Department of Imaging Methods, Institute of Measurement Science, Slovak Academy of Sciences, Bratislava, Slovakia (L.V.)
| | - Lee Roberts
- University of Leeds, Multidisciplinary Cardiovascular Research Centre, and Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., A. McGrane, A. Maccannell, M.C.-R., S.S., H.P., P.S., L.R., D.B., M.T.K., S.P., E.L.)
| | - David Beech
- University of Leeds, Multidisciplinary Cardiovascular Research Centre, and Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., A. McGrane, A. Maccannell, M.C.-R., S.S., H.P., P.S., L.R., D.B., M.T.K., S.P., E.L.)
| | - Mark T. Kearney
- University of Leeds, Multidisciplinary Cardiovascular Research Centre, and Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., A. McGrane, A. Maccannell, M.C.-R., S.S., H.P., P.S., L.R., D.B., M.T.K., S.P., E.L.)
- Leeds Teaching Hospitals NHS Trust, Department of Cardiology, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., S.S., H.P., S.P., B.E., K.J., A.F., W.E., P. Kaul, P.S., M.T.K., E.L.)
| | - Sven Plein
- Leeds Teaching Hospitals NHS Trust, Department of Cardiology, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., S.S., H.P., S.P., B.E., K.J., A.F., W.E., P. Kaul, P.S., M.T.K., E.L.)
| | - Marc R. Dweck
- University of Edinburgh/BHF Centre for Cardiovascular Science, Edinburgh, UK (M.R.D.)
| | - Eylem Levelt
- University of Leeds, Multidisciplinary Cardiovascular Research Centre, and Biomedical Imaging Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., A. McGrane, A. Maccannell, M.C.-R., S.S., H.P., P.S., L.R., D.B., M.T.K., S.P., E.L.)
- Leeds Teaching Hospitals NHS Trust, Department of Cardiology, Leeds, UK (N.J., J.P.G., R.M.C., A.C., S.T., S.K., M.G., S.S., H.P., S.P., B.E., K.J., A.F., W.E., P. Kaul, P.S., M.T.K., E.L.)
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Ravassa S, López B, Treibel TA, San José G, Losada-Fuentenebro B, Tapia L, Bayés-Genís A, Díez J, González A. Cardiac Fibrosis in heart failure: Focus on non-invasive diagnosis and emerging therapeutic strategies. Mol Aspects Med 2023; 93:101194. [PMID: 37384998 DOI: 10.1016/j.mam.2023.101194] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 06/09/2023] [Accepted: 06/14/2023] [Indexed: 07/01/2023]
Abstract
Heart failure is a leading cause of mortality and hospitalization worldwide. Cardiac fibrosis, resulting from the excessive deposition of collagen fibers, is a common feature across the spectrum of conditions converging in heart failure. Eventually, either reparative or reactive in nature, in the long-term cardiac fibrosis contributes to heart failure development and progression and is associated with poor clinical outcomes. Despite this, specific cardiac antifibrotic therapies are lacking, making cardiac fibrosis an urgent unmet medical need. In this context, a better patient phenotyping is needed to characterize the heterogenous features of cardiac fibrosis to advance toward its personalized management. In this review, we will describe the different phenotypes associated with cardiac fibrosis in heart failure and we will focus on the potential usefulness of imaging techniques and circulating biomarkers for the non-invasive characterization and phenotyping of this condition and for tracking its clinical impact. We will also recapitulate the cardiac antifibrotic effects of existing heart failure and non-heart failure drugs and we will discuss potential strategies under preclinical development targeting the activation of cardiac fibroblasts at different levels, as well as targeting additional extracardiac processes.
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Affiliation(s)
- Susana Ravassa
- Program of Cardiovascular Diseases, CIMA Universidad de Navarra and IdiSNA, Pamplona, Spain; CIBERCV, Carlos III Institute of Health, Madrid, Spain
| | - Begoña López
- Program of Cardiovascular Diseases, CIMA Universidad de Navarra and IdiSNA, Pamplona, Spain; CIBERCV, Carlos III Institute of Health, Madrid, Spain
| | - Thomas A Treibel
- Institute of Cardiovascular Science, University College London, UK; Barts Heart Centre, St Bartholomew's Hospital, London, UK
| | - Gorka San José
- Program of Cardiovascular Diseases, CIMA Universidad de Navarra and IdiSNA, Pamplona, Spain; CIBERCV, Carlos III Institute of Health, Madrid, Spain
| | - Blanca Losada-Fuentenebro
- Program of Cardiovascular Diseases, CIMA Universidad de Navarra and IdiSNA, Pamplona, Spain; CIBERCV, Carlos III Institute of Health, Madrid, Spain
| | - Leire Tapia
- Program of Cardiovascular Diseases, CIMA Universidad de Navarra and IdiSNA, Pamplona, Spain; CIBERCV, Carlos III Institute of Health, Madrid, Spain
| | - Antoni Bayés-Genís
- CIBERCV, Carlos III Institute of Health, Madrid, Spain; Servei de Cardiologia i Unitat d'Insuficiència Cardíaca, Hospital Universitari Germans Trias i Pujol, Badalona, Spain; Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain; ICREC Research Program, Germans Trias i Pujol Health Science Research Institute, Badalona, Spain
| | - Javier Díez
- Program of Cardiovascular Diseases, CIMA Universidad de Navarra and IdiSNA, Pamplona, Spain; CIBERCV, Carlos III Institute of Health, Madrid, Spain.
| | - Arantxa González
- Program of Cardiovascular Diseases, CIMA Universidad de Navarra and IdiSNA, Pamplona, Spain; CIBERCV, Carlos III Institute of Health, Madrid, Spain.
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Abdullah SM. First-Phase Ejection Fraction: Can Assessment of Early Ejection Fraction Guide Early Aortic Valve Replacement Referral? Am J Cardiol 2023; 203:498-499. [PMID: 37532640 DOI: 10.1016/j.amjcard.2023.06.122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 06/29/2023] [Indexed: 08/04/2023]
Affiliation(s)
- Shuaib M Abdullah
- Department of Internal Medicine, University of Texas-Southwestern Medical Center and Veteran's Affairs North Texas Medical Center, Dallas, Texas.
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Prendergast BD, Patterson T, Redwood S. Transcatheter aortic valve implantation in patients with severe aortic stenosis and cardiogenic shock: an important step forward. Eur Heart J 2023; 44:3196-3198. [PMID: 37559255 DOI: 10.1093/eurheartj/ehad471] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/11/2023] Open
Affiliation(s)
- Bernard D Prendergast
- Cleveland Clinic London, London, UK
- Department of Cardiology, St Thomas' Hospital, Westminster Bridge Road, London SE1 7EH, UK
| | - Tiffany Patterson
- Department of Cardiology, St Thomas' Hospital, Westminster Bridge Road, London SE1 7EH, UK
| | - Simon Redwood
- Cleveland Clinic London, London, UK
- Department of Cardiology, St Thomas' Hospital, Westminster Bridge Road, London SE1 7EH, UK
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Nikolaidou C, Ormerod JO, Ziakas A, Neubauer S, Karamitsos TD. The Role of Cardiovascular Magnetic Resonance Imaging in Patients with Cardiac Arrhythmias. Rev Cardiovasc Med 2023; 24:252. [PMID: 39076394 PMCID: PMC11262447 DOI: 10.31083/j.rcm2409252] [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: 05/11/2023] [Revised: 06/05/2023] [Accepted: 06/12/2023] [Indexed: 07/31/2024] Open
Abstract
Cardiac arrhythmias are associated with significant morbidity, mortality and poor quality of life. Cardiovascular magnetic resonance (CMR) imaging, with its unsurpassed capability of non-invasive tissue characterisation, high accuracy, and reproducibility of measurements, plays an integral role in determining the underlying aetiology of cardiac arrhytmias. CMR can reliably diagnose previous myocardial infarction, non-ischemic cardiomyopathy, characterise congenital heart disease and valvular pathologies, and also detect the underlying substrate concealed on conventional investigations in a significant proportion of patients with arrhythmias. Determining the underlying substrate of arrhythmia is of paramount importance for treatment planning and prognosis. However, CMR imaging in patients with irregular heart rates can be problematic. Understanding the different ways to overcome the limitations of CMR in arrhythmia is essential for providing high-quality imaging, comprehensive information, and definitive answers in this diverse group of patients.
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Affiliation(s)
- Chrysovalantou Nikolaidou
- Oxford Centre for Clinical Magnetic Resonance Research, University of
Oxford, John Radcliffe Hospital, Headington, OX3 9DU Oxford, UK
| | - Julian O.M. Ormerod
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine,
University of Oxford, John Radcliffe Hospital, Headington, OX3 9DU
Oxford, UK
| | - Antonios Ziakas
- First Department of Cardiology, AHEPA Hospital, School of Medicine,
Faculty of Health Sciences, Aristotle University of Thessaloniki, 54636
Thessaloniki, Greece
| | - Stefan Neubauer
- Oxford Centre for Clinical Magnetic Resonance Research, University of
Oxford, John Radcliffe Hospital, Headington, OX3 9DU Oxford, UK
| | - Theodoros D. Karamitsos
- Oxford Centre for Clinical Magnetic Resonance Research, University of
Oxford, John Radcliffe Hospital, Headington, OX3 9DU Oxford, UK
- First Department of Cardiology, AHEPA Hospital, School of Medicine,
Faculty of Health Sciences, Aristotle University of Thessaloniki, 54636
Thessaloniki, Greece
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Banovic M, Iung B, Wojakowski W, Van Mieghem N, Bartunek J. Asymptomatic Severe and Moderate Aortic Stenosis: Time for Appraisal of Treatment Indications. STRUCTURAL HEART : THE JOURNAL OF THE HEART TEAM 2023; 7:100201. [PMID: 37745683 PMCID: PMC10512009 DOI: 10.1016/j.shj.2023.100201] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 04/11/2023] [Accepted: 04/13/2023] [Indexed: 09/26/2023]
Abstract
Over the last decades, we have witnessed considerable improvements in diagnostics and risk stratification of patients with significant aortic stenosis (AS), paralleled by advances in operative and anesthetic techniques. In addition, accumulating evidence points to the potential benefit of early valve replacement in such patients prior to the onset of symptoms. In parallel, interventional randomized trials have proven the benefit of transcatheter aortic valve replacement in comparison to a surgical approach to valve replacement over a broad risk spectrum in symptomatic patients with AS. This article reviews contemporary management approaches and scrutinizes open questions regarding timing and mode of intervention in asymptomatic patients with severe AS. We also discuss the challenges surrounding the management of symptomatic patients with moderate AS as well as emerging dilemmas related to the concept of a life-long treatment strategy for patients with AS.
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Affiliation(s)
- Marko Banovic
- Belgrade Medical Faculty, University of Belgrade, Belgrade, Serbia
- Cardiology Department, University Clinical Center of Serbia, Belgrade, Serbia
| | - Bernard Iung
- University of Paris, Paris, France
- Department of Cardiology, Assistance Publique-Hôpitaux de Paris (AP-HP), Bichat Hospital, Paris, France
| | - Wojtek Wojakowski
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | | | - Jozef Bartunek
- Cardiovascular Center Aalst, OLV Hospital, Aalst, Belgium
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Iung B, Pierard L, Magne J, Messika-Zeitoun D, Pibarot P, Baumgartner H. Great debate: all patients with asymptomatic severe aortic stenosis need valve replacement. Eur Heart J 2023; 44:3136-3148. [PMID: 37503668 DOI: 10.1093/eurheartj/ehad355] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/29/2023] Open
Affiliation(s)
- Bernard Iung
- Cardiology Department, Bichat Hospital, APHP, Université Paris Cité, 46 rue Henri Huchard, 75018 Paris, France
| | - Luc Pierard
- Department of Cardiology, University of Liege, Avenue de l´Hopital, 11, B-4000 Liege, Belgium
| | - Julien Magne
- Inserm U1094, IRD U270, University Limoges, CHU Limoges, EpiMaCT-Epidemiology of chronic diseases in tropical zone, Institute of Epidemiology and Tropical Neurology, Omega Health, 2 rue du Dr Marcland, 87025 Limoges, France
- CHU Limoges, Centre of Research and Clinical Data, 2 rue Martin Luther King, 87402 Limoges, France
| | - David Messika-Zeitoun
- Division of Cardiology, University of Ottawa Heart Institute, 40, Rue Ruskin Street, Ottawa, Ontario K1Y 4W7, Canada
| | - Philippe Pibarot
- Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart & Lung Institute, Laval University, 2725, Chemin Saite-Foy, Quebec City, Quebec G1V 4G5, Canada
| | - Helmut Baumgartner
- Department of Cardiology III-Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building A1, 48149 Muenster, Germany
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Balčiūnaitė G, Rudinskaitė I, Palionis D, Besusparis J, Žurauskas E, Janušauskas V, Zorinas A, Valevičienė N, Ručinskas K, Sogaard P, Glaveckaitė S. Electrocardiographic Markers of Adverse Left Ventricular Remodeling and Myocardial Fibrosis in Severe Aortic Stenosis. J Clin Med 2023; 12:5588. [PMID: 37685655 PMCID: PMC10488170 DOI: 10.3390/jcm12175588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 08/22/2023] [Accepted: 08/24/2023] [Indexed: 09/10/2023] Open
Abstract
The optimal timing for aortic valve replacement (AVR) in aortic stenosis (AS) is still controversial and may be guided by markers of adverse left ventricular (LV) remodeling. We aim to assess electrocardiographic (ECG) strain in relation to LV remodeling and myocardial fibrosis. 83 severe AS patients underwent surgical AVR, with preoperative 12-lead ECG, cardiovascular magnetic resonance with T1 mapping and echocardiography with global longitudinal strain analysis. Collagen volume fraction (CVF) was measured in myocardial biopsies sampled during AVR. Patients with ECG strain had more severe AS, more advanced LV remodeling and evidence of heart failure. Patients with ECG strain had more diffuse fibrosis, as evident by higher mean native T1 values (974.8 ± 34 ms vs. 946.5 ± 28 ms, p < 0.001). ECG strain was the only predictor of increased LV mass index on multivariate regression analysis (OR = 7.10, 95% CI 1.46-34.48, p = 0.02). Patients with persistent ECG strain at 1 year following AVR had more advanced LV remodeling and more histological fibrosis (CVF 12.5% vs. 7.3%, p = 0.009) at baseline assessment. Therefore, ECG strain is a marker of adverse LV remodeling and interstitial myocardial fibrosis. Lack of improvement in ECG strain following AVR indicates more advanced baseline LV injury and higher levels of myocardial fibrosis.
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Affiliation(s)
- Giedrė Balčiūnaitė
- Clinic of Cardiovascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, LT-08661 Vilnius, Lithuania; (V.J.); (A.Z.); (K.R.); (S.G.)
| | - Ieva Rudinskaitė
- Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania;
| | - Darius Palionis
- Department of Radiology, Nuclear Medicine and Medical Physics, Institute of Biomedical Sciences, Faculty of Medicine, Vilnius University, LT-08661 Vilnius, Lithuania; (D.P.); (N.V.)
| | - Justinas Besusparis
- Department of Pathology, Forensic Medicine and Pharmacology, Institute of Biomedical Sciences, Faculty of Medicine, Vilnius University, LT-08406 Vilnius, Lithuania; (J.B.)
| | - Edvardas Žurauskas
- Department of Pathology, Forensic Medicine and Pharmacology, Institute of Biomedical Sciences, Faculty of Medicine, Vilnius University, LT-08406 Vilnius, Lithuania; (J.B.)
| | - Vilius Janušauskas
- Clinic of Cardiovascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, LT-08661 Vilnius, Lithuania; (V.J.); (A.Z.); (K.R.); (S.G.)
| | - Aleksejus Zorinas
- Clinic of Cardiovascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, LT-08661 Vilnius, Lithuania; (V.J.); (A.Z.); (K.R.); (S.G.)
| | - Nomeda Valevičienė
- Department of Radiology, Nuclear Medicine and Medical Physics, Institute of Biomedical Sciences, Faculty of Medicine, Vilnius University, LT-08661 Vilnius, Lithuania; (D.P.); (N.V.)
| | - Kęstutis Ručinskas
- Clinic of Cardiovascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, LT-08661 Vilnius, Lithuania; (V.J.); (A.Z.); (K.R.); (S.G.)
| | - Peter Sogaard
- Clinic of Cardiovascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, LT-08661 Vilnius, Lithuania; (V.J.); (A.Z.); (K.R.); (S.G.)
- Clinical Institute of Aalborg University, Aalborg University Hospital, Hobrovej 18-22, 9100 Aalborg, Denmark
| | - Sigita Glaveckaitė
- Clinic of Cardiovascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, LT-08661 Vilnius, Lithuania; (V.J.); (A.Z.); (K.R.); (S.G.)
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