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Silent coronary artery disease in asymptomatic patients with severe aortic stenosis and normal exercise testing. Coron Artery Dis 2021; 31:166-173. [PMID: 31577622 DOI: 10.1097/mca.0000000000000801] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE There are no data about the prevalence of silent coronary artery disease in asymptomatic severe aortic stenosis patients with normal exercise testing. Importantly, unmasking significant coronary artery disease in patients with aortic stenosis could influence the choice/timing of treatment in these patients. METHOD Exercise testing was performed on semi-supine ergobicycle. Cardiopulmonary analysis during exercise testing, echocardiography, and laboratory analysis at rest was done. Standard clinical/electrocardiography criteria were assessed for symptoms/signs of ischemia during/after exercise testing. In patients with normal exercise testing coronary angiography was performed using standard femoral/radial percutaneous approach. Coronary stenosis was considered significant if >70% of vessel diameter or 50%-70% with fractional flow reserve ≤0.8. RESULTS Total of 96 patients with normal exercise testing were included (67.6 years, 50.6% males). No patient had any complication or adverse event. The Pmean was 52.7 mmHg, mean indexed aortic valve area was 0.36 cm/m and left ventricular ejection fraction, 69.5%. 19/96 patients (19.8%) had significant coronary artery disease on coronary angiography. Multivariate logistic regression analysis revealed brain natriuretic peptide and blood glucose as independent predictors of silent coronary artery disease. Brain natriuretic peptide value of 118 pg/ml had sensitivity/specificity of 63%/73% for predicting coronary artery disease (area under the curve 0.727, P = 0.006). CONCLUSION Our results are the first to show that in patients with severe aortic stenosis, normal left ventricular ejection fraction,, and normal exercise testing, significant coronary artery disease is present in as many as 1/5 patients. In such patients, further prospective studies are warranted to address the diagnostic value of brain natriuretic peptide in detecting silent coronary artery disease.
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Pathophysiology, Diagnosis, and Treatment of Patients with Concomitant Severe Aortic Stenosis and Coronary Artery Disease: A Closer Look to the Unresolved Perplexity. J Clin Med 2021; 10:jcm10081617. [PMID: 33920349 PMCID: PMC8070187 DOI: 10.3390/jcm10081617] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 04/01/2021] [Accepted: 04/08/2021] [Indexed: 01/09/2023] Open
Abstract
Degenerative aortic stenosis (AS) and coronary artery disease (CAD) are the most prevalent cardiovascular diseases in developed countries, and they coexist in up to 50% of patients. The pathophysiological rationale behind concomitant AS and CAD is discussed in detail in this review, together with prognostic implications. Detecting CAD in patients with AS may be challenging, as AS may mask the existence and symptoms of CAD. The safety and reliability of invasive and non-invasive physiological assessment for epicardial coronary disease are also a matter of debate. Finally, the selection and timing of optimal treatment of CAD in patients with severe AS are still unclear. Given the aging of the population, the increase in the prevalence of AS, and the ongoing paradigm shift in its treatment, controversies in the diagnosis and treatment of CAD in the setting of AS are deemed to grow in importance. In this paper, we present contemporary issues in the diagnosis and management of CAD in patients with severe AS who are transcatheter aortic valve implantation (TAVI) candidates and provide perspective on the treatment approach.
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Abstract
Aortic stenosis is a heterogeneous disorder. Variations in the pathological and physiological responses to pressure overload are incompletely understood and generate a range of flow and pressure gradient patterns, which ultimately cause varying microvascular effects. The impact of cardiac-coronary coupling depends on these pressure and flow effects. In this article, we explore important concepts concerning cardiac physiology and the coronary microcirculation in aortic stenosis and their impact on myocardial remodeling, aortic valve flow patterns, and clinical progression.
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Affiliation(s)
- Hannah Z.R. McConkey
- Cardiovascular Division, King’s College London British Heart Foundation Centre of Excellence, The Rayne Institute, St. Thomas’ Hospital Campus, London, United Kingdom (H.Z.R.M., M.M., A.C., S.R.R., B.D.P.)
| | - Michael Marber
- Cardiovascular Division, King’s College London British Heart Foundation Centre of Excellence, The Rayne Institute, St. Thomas’ Hospital Campus, London, United Kingdom (H.Z.R.M., M.M., A.C., S.R.R., B.D.P.)
| | - Amedeo Chiribiri
- Cardiovascular Division, King’s College London British Heart Foundation Centre of Excellence, The Rayne Institute, St. Thomas’ Hospital Campus, London, United Kingdom (H.Z.R.M., M.M., A.C., S.R.R., B.D.P.)
| | - Philippe Pibarot
- Department of Medicine, Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, Québec, Canada (P.P.)
| | - Simon R. Redwood
- Cardiovascular Division, King’s College London British Heart Foundation Centre of Excellence, The Rayne Institute, St. Thomas’ Hospital Campus, London, United Kingdom (H.Z.R.M., M.M., A.C., S.R.R., B.D.P.)
| | - Bernard D. Prendergast
- Cardiovascular Division, King’s College London British Heart Foundation Centre of Excellence, The Rayne Institute, St. Thomas’ Hospital Campus, London, United Kingdom (H.Z.R.M., M.M., A.C., S.R.R., B.D.P.)
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Abstract
Aortic stenosis and diabetes mellitus are both progressive diseases which, if left untreated, result in significant morbidity and mortality. There is evidence that the prevalence of diabetes is substantially increased in patients with aortic stenosis and those with diabetes have increased rates of progression from mild to severe aortic stenosis. There are good data supporting the hypothesis that aortic stenosis and diabetes mellitus are associated with diabetes mellitus being detrimental towards the quality of life and survival of patients. Thus, a thorough understanding of the pathogenesis of both of these disease processes and the relationship between them aids in designing appropriate preventive and therapeutic approaches. This review aims to give a comprehensive and up-to-date insight into the influence of diabetes mellitus on patients with degenerative aortic stenosis, as well as the prognosis and therapeutic approach to these patients.
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Affiliation(s)
- Marko Banovic
- 1 Cardiology Clinic, University Clinical Center of Serbia, Belgrade, Serbia
- 2 Belgrade Medical School, University of Belgrade, Belgrade, Serbia
| | - Lavanya Athithan
- 3 Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- 4 The NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Gerry P McCann
- 3 Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- 4 The NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
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Banovic M, DaCosta M. Degenerative Mitral Stenosis: From Pathophysiology to Challenging Interventional Treatment. Curr Probl Cardiol 2018; 44:10-35. [PMID: 29731112 DOI: 10.1016/j.cpcardiol.2018.03.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 03/22/2018] [Indexed: 01/01/2023]
Abstract
Mitral stenosis (MS) is characterized by obstruction of left ventricular inflow as a result of narrowing of the mitral valve orifice. Although its prevalence has declined over the last decade, especially in developed countries, it remains an important cause of morbidity and mortality. The most often cause of MS worldwide is still postrheumatic mitral valve disease. However, in developed countries, degenerative or calcific changes cause MS in a siginificant proportion of patients. Although the range of treatment for mitral valve disease has grown over the years in parallel with transcatheter therapies for aortic valve disease, these improvements in mitral valve disease therapy have experienced slower development. This is mainly due to the more complex anatomy of the mitral valve and entire mitral apparatus, and the interplay of the mitral valve with the left ventricle which hinders the development of effective implantable mitral valve devices. This is especially the case with degenerative MS where percutaneous or surgical comissurotomy is rarely employed due to the presence of extensive annular calcification and at the base of leaflets, without associated commissural fusion. However, the last few years have witnessed innovations in transcatheter interventional procedures for degenerative MS which consequently hinted that in the future, transcatheter mitral valve replacement could be the treatment of choice for these patients.
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Banovic MD, Nikolic SD. Treatment Strategies in Symptomatic Intermediate, Low-Risk, and Asymptomatic Patients With Severe Aortic Stenosis. Curr Probl Cardiol 2017; 43:335-354. [PMID: 29290389 DOI: 10.1016/j.cpcardiol.2017.12.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Survival of symptomatic patients with severe aortic stenosis (AS) is very poor, with an average mortality reaching up to 2% per month. Approach to diagnosis and treatment of patients with AS was conservative; patients were referred to surgery only if the AS-induced symptoms become apparent and significantly limit the quality of patient' life. In the past 15 years, the novel treatment strategy in subgroups of symptomatic patients with AS have been the subject of extensive research, starting from introduction of transcatheter aortic valve implant (TAVI) in inoperable symptomatic patients with severe AS and continuing further to patients with very high and high operative risk. In the past few years, the focus has further shifted toward the patients with lower operative risk, as well as to asymptomatic patients with severe AS. In the former group, the question relates to whether TAVI is beneficial when compared to SAVR in intermediate- to low-risk patients with symptomatic AS. In the latter group, the main issue is if and when the SAVR should be performed. This article analyzes current status and evidences regarding treatment strategies in symptomatic high, intermediate, low-risk, and asymptomatic patients with isolated severe AS.
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Banovic MD. NT-proBNP in patients with asymptomatic severe aortic stenosis: relation to coronary microvascular function. Biomark Med 2017. [DOI: 10.2217/bmm-2017-0083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Marko D Banovic
- Department of Non-Invasive Cardiology, Cardiology Clinic, University Clinical Centre of Serbia; Belgrade Medical School, Belgrade, Serbia
- Belgrade Medical School, University of Belgrade, Serbia
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Banovic MD. Changing concept in treatment of asymptomatic severe aortic stenosis and normal ejection fraction: time for biomarkers reappraisal. Biomark Med 2017; 11:369-376. [PMID: 28290210 DOI: 10.2217/bmm-2016-0369] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The uncertainty of whether/how to treat asymptomatic patients with isolated severe aortic stenosis and normal left ventricular ejection fraction is one of the most topical in cardiovascular medicine. Recently, the AVATAR trial: first ever randomized trial in the setting of aortic stenosis has been started in an attempt to adequately address this 'burning issue'. In light of this fact it is important to identify biomarkers which might help in risk stratification of these patients, not only in the referring physician's office during a routine exam, but also for preoperative patients scheduled for surgical replacement/transcatheter aortic valve implantation. This report is focusing on novel laboratory parameters which might be helpful in this risk stratification.
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Affiliation(s)
- Marko D Banovic
- Cardiology Department, University Clinical Center of Serbia, Belgrade, Serbia.,Belgrade Medical School, University of Belgrade, Belgrade, Serbia
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Banovic M, Brkovic V, Nedeljkovic I, Nedeljkovic M, Popovic D, Djordjevic-Dikic A, Ristic A, Nikolic S, Beleslin B. Diabetes mellitus and coronary microvascular function in asymptomatic patients with severe aortic stenosis and nonobstructed coronary arteries. Diab Vasc Dis Res 2016; 13:220-7. [PMID: 26993497 DOI: 10.1177/1479164115627107] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND AND AIM Coronary flow reserve is impaired in asymptomatic patients with aortic stenosis and has a prognostic value. We investigated whether the type II diabetes mellitus additionally impairs microvascular circulation assessed by coronary flow reserve in patients with asymptomatic severe aortic stenosis, normal left ventricular ejection fraction and nonobstructed coronary arteries. METHODS A total of 128 patients, mean age of 66.35 ± 10.51 (58.6% males), with severe aortic stenosis and normal left ventricular ejection fraction were enrolled in this study. Patients with diabetes mellitus, those who were treated for diabetes mellitus or had documentation confirming the diagnosis of diabetes mellitus, were considered. All patients underwent coronary angiography and had no obstructive coronary disease (defined as having no stenosis >50% in diameter), standard transthoracic Doppler-echocardiographic study and adenosine stress transthoracic echocardiography for coronary flow reserve measurement. RESULTS Diabetes mellitus was present in 26 patients (20.31%). There was no significant difference in aortic stenosis severity between diabetic and non-diabetic patients [aortic valve area (0.81 ± 0.18 vs 0.85 ± 0.15 cm(2)) and Vmax (4.20 ± 0.57 vs 4.21 ± 0.48 m/s)]. Mean coronary flow reserve in diabetic patients was 1.98 ± 0.48, while mean coronary flow reserve in non-diabetic patients was 2.64 ± 0.54 (p < 0.01). Diabetes mellitus was independent predictor of coronary flow reserve [B = -0.636, 95% confidence interval (-0.916 to -0.368), p < 0.001]. CONCLUSION Diabetes mellitus additionally impairs coronary microvascular function in asymptomatic patients with severe aortic stenosis and nonobstructed coronary arteries.
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Affiliation(s)
- Marko Banovic
- Departments of Non-Invasive Cardiology and Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia Belgrade Medical School, University of Belgrade, Belgrade, Serbia
| | - Voin Brkovic
- Departments of Non-Invasive Cardiology and Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia
| | - Ivana Nedeljkovic
- Departments of Non-Invasive Cardiology and Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia Belgrade Medical School, University of Belgrade, Belgrade, Serbia
| | - Milan Nedeljkovic
- Departments of Non-Invasive Cardiology and Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia Belgrade Medical School, University of Belgrade, Belgrade, Serbia
| | - Dejana Popovic
- Departments of Non-Invasive Cardiology and Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia
| | - Ana Djordjevic-Dikic
- Departments of Non-Invasive Cardiology and Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia Belgrade Medical School, University of Belgrade, Belgrade, Serbia
| | - Arsen Ristic
- Departments of Non-Invasive Cardiology and Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia Belgrade Medical School, University of Belgrade, Belgrade, Serbia
| | | | - Branko Beleslin
- Departments of Non-Invasive Cardiology and Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia Belgrade Medical School, University of Belgrade, Belgrade, Serbia
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Cho EJ, Park SJ, Yun HR, Jeong DS, Lee SC, Park SW, Park PW. Predicting Left Ventricular Dysfunction after Surgery in Patients with Chronic Mitral Regurgitation: Assessment of Myocardial Deformation by 2-Dimensional Multilayer Speckle Tracking Echocardiography. Korean Circ J 2016; 46:213-21. [PMID: 27014352 PMCID: PMC4805566 DOI: 10.4070/kcj.2016.46.2.213] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Revised: 07/11/2015] [Accepted: 07/21/2015] [Indexed: 11/28/2022] Open
Abstract
Background and Objectives The development of postoperative left ventricular (LV) dysfunction is a frequent complication in patients with chronic severe mitral valve regurgitation (MR) and portends a poor prognosis. Assessment of myocardial deformation enables myocardial contractility to be accurately estimated. The aim of the present study was to evaluate the predictive value of preoperative regional LV contractile function assessment using two-dimensional multilayer speckle-tracking echocardiography (2D MSTE) analysis in patients with chronic severe MR with preserved LV systolic function. Subjects and Methods Forty-three consecutive patients with chronic severe MR with preserved LV systolic function scheduled for mitral valve replacement (MVR) or MV repair were prospectively enrolled. Serial echocardiographic studies were performed before surgery, at 7 days follow-up, and at least 3 months follow-up postoperatively. The conventional echocardiographic parameters were analyzed. Global longitudinal strain (GLS) was obtained quantitatively by 2D MSTE. Results The mean age of patients was 51.7±14.3 years and 25 (58.1%) were male. In receiver-operating characteristic curve analysis, the most useful cutoff value for discriminating postoperative LV remodeling in severe MR with normal LV systolic function was -20.5% of 2D mid-layer GLS. Patients were divided into two groups by the baseline GLS -20.5%. Preoperative GLS values strongly predicted postoperative LV remodeling or LV dysfunction. The postoperative degree of decrease in LV end-diastolic dimension might be an additive predictive factor. Conclusion STE can be used to predict a decrease in LV function after MVR in patients with chronic severe MR. This promising method could be of use in the clinic when trying to decide upon the optimum time to schedule surgery for such patients.
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Affiliation(s)
- Eun Jeong Cho
- Division of Cardiology, Department of Internal Medicine, Cardiovascular Imaging Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.; Division of Cardiology, Department of Internal Medicine, Cardiology Clinic, National Cancer Center, Goyang, Korea
| | - Sung-Ji Park
- Division of Cardiology, Department of Internal Medicine, Cardiovascular Imaging Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hye Rim Yun
- Division of Cardiology, Department of Internal Medicine, Cardiovascular Imaging Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong Seop Jeong
- Department of Thorax Surgery, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sang-Chol Lee
- Division of Cardiology, Department of Internal Medicine, Cardiovascular Imaging Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung Woo Park
- Division of Cardiology, Department of Internal Medicine, Cardiovascular Imaging Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Pyo Won Park
- Department of Thorax Surgery, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Meimoun P, Czitrom D. [Coronary microvascular dysfunction and aortic stenosis: an update]. Ann Cardiol Angeiol (Paris) 2014; 63:353-361. [PMID: 25261167 DOI: 10.1016/j.ancard.2014.08.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Accepted: 08/24/2014] [Indexed: 06/03/2023]
Abstract
The coronary microcirculatory impairment is a key feature of the pathophysiology of aortic stenosis (AS), the most operated valvular disease over the world. Several studies showed this coronary microcirculatory impairment in AS, using different tools and protocols, in various patient population of AS. This article will review the impairment of the coronary microcirculation in AS underlining its multifactorial origin, its functional part related to the hemodynamic consequences of AS, its complex relationship with left ventricular hypertrophy, and its potential diagnostic and prognostic value.
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Affiliation(s)
- P Meimoun
- Service de cardiologie-USIC, centre hospitalier de Compiègne, 8, rue Henri-Adnot, 60200 Compiègne, France.
| | - D Czitrom
- Service de cardiologie, institut mutualiste Montsouris, 75014 Paris, France
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Banovic M, Bosiljka VT, Voin B, Milan P, Ivana N, Dejana P, Danijela T, Serjan N. Prognostic Value of Coronary Flow Reserve in Asymptomatic Moderate or Severe Aortic Stenosis with Preserved Ejection Fraction and Nonobstructed Coronary Arteries. Echocardiography 2013; 31:428-33. [DOI: 10.1111/echo.12404] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Marko Banovic
- Department of Cardiology; University Clinical Center of Serbia; Belgrade Serbia
- Medical School; University of Belgrade; Belgrade Serbia
| | - Vujisic-Tesic Bosiljka
- Department of Cardiology; University Clinical Center of Serbia; Belgrade Serbia
- Medical School; University of Belgrade; Belgrade Serbia
| | - Brkovic Voin
- Medical School; University of Belgrade; Belgrade Serbia
| | - Petrovic Milan
- Department of Cardiology; University Clinical Center of Serbia; Belgrade Serbia
- Medical School; University of Belgrade; Belgrade Serbia
| | - Nedeljkovic Ivana
- Department of Cardiology; University Clinical Center of Serbia; Belgrade Serbia
- Medical School; University of Belgrade; Belgrade Serbia
| | - Popovic Dejana
- Department of Cardiology; University Clinical Center of Serbia; Belgrade Serbia
- Medical School; University of Belgrade; Belgrade Serbia
| | - Trifunovic Danijela
- Department of Cardiology; University Clinical Center of Serbia; Belgrade Serbia
- Medical School; University of Belgrade; Belgrade Serbia
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