2016 Vol. 13, No. 6
Background Whilst the majority of the patients with severe aortic stenosis can be directly addressed to surgical aortic valve replacement (AVR) or transcatheter aortic valve implantation (TAVI), in some instances additional information may be needed to complete the diagnostic workout. We evaluated the role of balloon aortic valvuloplasty (BAV) as a bridge-to-decision (BTD) in selected high-risk patients. Methods Between 2007 and 2012, the heart team in our Institution required BTD BAV in 202 patients. Very low left ventricular ejection fraction, mitral regurgitation grade ≥ 3, frailty, hemodynamic instability, serious comorbidity, or a combination of these factors were the main drivers for this strategy. We evaluated how BAV influenced the final treatment strategy in the whole patient group and in each specific subgroup. Results Mean logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) was 23.5% ± 15.3%, age 81 ± 7 years. In-hospital mortality was 4.5%, cerebrovascular accident 1% and overall vascular complications 4% (0.5% major; 3.5% minor). Of the 193 patients with BTD BAV who survived and received a second heart team evaluation, 72.6% were finally deemed eligible for definitive treatment (25.4% for AVR; 47.2% for TAVI): 96.7% of patients with left ventricular ejection fraction recovery; 70.5% of patients with mitral regurgitation reduction; 75.7% of patients who underwent BAV in clinical hemodynamic instability; 69.2% of frail patients and 68% of patients who presented serious comorbidities. Conclusions Balloon aortic valvuloplasty can be considered as bridge-to- decision in high-risk patients with severe aortic stenosis who cannot be immediate candidates for definitive transcatheter or surgical treatment.
Background Postprocedural aortic regurgitations following transcatheter aortic valve implantation (TAVI) procedures remain an issue. Benefit of oversizing strategies to prevent them isn’t well established. We compared different level of oversizing in our cohort of consecutive patients to address if severe oversizing compared to normal sizing had an impact on post-procedural outcomes. Methods From January 2010 to August 2013, consecutive patients were referred for TAVI with preoperative Multislice-CT (MSCT) and the procedures were achieved using Edwards Sapien? or Corevalve devices?. Retrospectively, according to pre-procedural MSCT and the valve size, patients were classified into three groups: normal, moderate and severe oversizing; depending on the ratio between the prosthesis area and the annulus area indexed and measured on MSCT. Main endpoint was mid-term mortality and secondary endpoints were the Valve Academic Research Consortium (VARC-2) endpoints. Results Two hundred and sixty eight patients had a MSCT and underwent TAVI procedure, with mainly Corevalve?. While all-cause and cardiovascular mortality rates were similar in all groups, post-procedural new pacemaker (PM) implantation rate was significantly higher in the severe oversizing group (P = 0.03), while we observed more in-hospital congestive heart-failure (P = 0.02) in the normal sizing group. There was a trend toward more moderate to severe aortic regurgitation (AR) in the normal sizing group (P = 0.07). Conclusions Despite a higher rate of PM implantation, oversizing based on this ratio reduces aortic leak with lower rates of post-procedural complications and a similar mid-term survival.
Aortic stenosis (AS) is a common valvular heart disease in the Western populations, with an estimated overall prevalence of 3% in adults over 75 years. To understand its patho-biological processes represents a priority. In elderly patients, AS usually involves trileaflet valves and is referred to as degenerative calcific processes. Scientific evidence suggests the involvement of an active “atherosclerosis-like” pathogenesis in the initiation phase of degenerative AS. To the contrary, the progression could be driven by different forces (such as me-chanical stress, genetic factors and interaction between inflammation and calcification). The improved understanding presents potentially new therapeutic targets for preventing and inhibiting the development and progression of the disease. Furthermore, in clinical practice the management of AS patients implies the evaluation of generalized atherosclerotic manifestations (i.e., in the coronary and carotid arteries) even for prognostic reasons. In counselling elderly patients, the risk stratification should address individual frailty beyond the generic risk scores. In these regard, the co-morbidities, and in particular those linked to the global atherosclerotic burden, should be carefully investigated in order to define the risk/benefit ratio for invasive treatment strategies. We present a detailed overview of insights in pathogenesis of AS with possible practical implications.
Aortic valve disease is a prevalent disorder that affects approximately 2% of the general adult population. Surgical aortic valve replacement is the gold standard treatment for symptomatic patients. This treatment has demonstrably proven to be both safe and effective. Over the last few decades, in an attempt to reduce surgical trauma, different minimally invasive approaches for aortic valve replacement have been developed and are now being increasingly utilized. A narrative review of the literature was carried out to describe the surgical techniques for minimally invasive aortic valve surgery and report the results from different experienced centers. Minimally invasive aortic valve replacement is associated with low perioperative morbidity, mortality and a low conversion rate to full sternotomy. Long-term survival appears to be at least comparable to that reported for conventional full sternotomy. Minimally invasive aortic valve surgery, either with a partial upper sternotomy or a right anterior minithoracotomy provides early- and long-term benefits. Given these benefits, it may be considered the standard of care for isolated aortic valve disease.
Aortic valve stenosis is the most common valve disease in the western world. Over the past few years the number of aortic valve re-placement (AVR) interventions has increased with outcomes that have been improved despite increasing age of patients and increasing burden of comorbidities. However, despite such excellent results and its well-established position, conventional AVR has undergone great development over the previous two decades. Such progress, by way of less invasive incisions and use of new technologies, including transcatheter aortic valve implantation and sutureless valve prostheses, is intended to reduce the traumatic impact of the surgical procedure, thus fulfilling lower risk patients’ expectations on the one hand, and extending the operability toward increasingly high-risk patients on the other. Sutureless and rapid deployment aortic valves are biological, pericardial prostheses that anchor within the aortic annulus with no more than three sutures. The sutureless prostheses, by avoiding the passage and the tying of the sutures, significantly reduce operative times and may improve outcomes. However, there is still a paucity of robust, evidence-based data on the role and performance of sutureless AVR. Therefore, strongest long-term data, randomized studies and registry data are required to adequately assess the durability and long-term outcomes of sutureless aortic valve replacement.
Aortic valve stenosis; Elderly patients; Minimally invasive surgery; Transcatheter aortic valve implantation
Both right and left ventricles are developed from two adjacent segments of the primary heart tube. Though they are different with re-gard to shape and power, they mirror each other in terms of behavior. This is the first level of symmetry in cardiac function assessment. Both cardiac muscle contraction and relaxation are active. This constructs the second level of symmetry in cardiac function assessment. Combination of the two levels will help to find some hidden indexes or approaches to evaluate cardiac function. In this article, four major indexes from echocardiography were analyzed under this principal, another seventeen indexes or measurement approaches came out of the shadow, which is very helpful in the assessment of cardiac function, especially for the right cardiac function and diastolic cardiac function.
Ischemic mitral regurgitation (IMR) is a common complication of acute myocardial infarction (AMI). Current evidences suggest that revascularization of the culprit vessels with percutaneous coronary artery intervention (PCI) or coronary artery bypass grafting can be beneficial for relieving IMR. A 2.5-year follow-up data of a 61-year-old male patient with ST-segment elevation AMI complicated with IMR showed that mitral regurgitation area increased five days after PCI, and decreased to lower steady level three months after PCI. This finding suggest that three months after PCI might be a suitable time point for evaluating the possibility of IMR recovery and the necessity of surgical intervention of the mitral valve for AMI patient.
Remote ECG monitoring systems are becoming commonplace medical devices for remote heart monitoring. In recent years, remote ECG monitoring systems have been applied in the monitoring of various kinds of heart diseases, and the quality of the transmission and reception of the ECG signals during remote process kept advancing. However, there remains accompanying challenges. This report focuses on the three components of the remote ECG monitoring system: patient (the end user), the doctor workstation, and the remote server, reviewing and evaluating the imminent challenges on the wearable systems, packet loss in remote transmission, portable ECG monitoring system, patient ECG data collection system, and ECG signals transmission including real-time processing ST segment, R wave, RR interval and QRS wave, etc. This paper tries to clarify the future developmental strategies of the ECG remote monitoring, which can be helpful in guiding the research and development of remote ECG monitoring.
Background Metabolic syndrome is known to be a prothrombotic state. We undertook this study to examine a hypothesis that aspirin resistance may be associated with metabolic syndrome, and to assess other potential determinants of aspirin resistance in patients with cardiovascular disease (CVD). Methods A total of 469 elderly patients with CVD were recruited. One hundred and seventy-two patients with metabolic syndrome and 297 without metabolic syndrome (control group) received daily aspirin therapy (≥ 75 mg) over one month. Platelet aggregation was measured by light transmission aggregometry (LTA). Aspirin resistance was defined as ≥ 20% arachidonic acid (AA)- and ≥ 70% adenosine diphosphate (ADP)-induced aggregation according to LTA. Aspirin semi-responders were defined as meeting one (but not both) of these criteria. Results By LTA, 38 of 469 (8.1%) patients were aspirin resistant. The prevalence of aspirin resistance was higher in the metabolic syndrome group compared with the control group [11.6 % vs. 6.6%, odds ratio (OR) = 2.039; 95% confidence interval (CI): 1.047–3.973]. In the multivariate logistic regression analysis, metabolic syndrome (OR = 4.951, 95% CI: 1.440–17.019, P = 0.011) was a significant risk factor for aspirin resistance. Conclusions A significant number of patients with CVD and metabolic syndrome are resistant to aspirin therapy. This might further increase the risk of cardiovascular morbidity and mortality in these patients.
Objective To investigate the relationship among serum vitamin D levels, physical performance impairment, and geriatric syndromes in elders with hypertension. Methods According to the concentration of vitamin D levels, a total of 143 elderly patients with hypertension were classified into vitamin D deficient group (vitamin D ≤ 20 ng/mL, n = 94) and vitamin D appropriate group (vitamin D > 20 ng/mL, n = 49). Geriatric syndromes and physical performance were assessed by using comprehensive geriatric assessment (CGA). Correlation among vitamin D levels, geriatric syndromes and physical performance was analyzed. Results No statistical differences were found in various aspects of geriatric syndromes between the two groups (P > 0.05). While correlation analysis indicated that vitamin D levels had a positive association with ADL score (r = 0.235, P r = –0.238, P P P P P Conclusions In elderly hypertensive patients, serum vitamin D deficient level is associated with physical performance impairment. However, no statistical significance was found between vitamin D and geriatric syndromes. Further study is required to investigate possible mechanisms for the association between vitamin D and physical performance
Background Elevated left ventricular filling pressure (LVFP) is an important cause of exercise intolerance in patients with atrial fibrillation (AF). Exercise stress echocardiography could assess LVFP during exercise. The objective of this study was to investigate the relationship between exercise induced elevation of LVFP and exercise capacity in patients with AF. Methods This study included 145 consecutive patients (81 men and 64 women; mean age 65.5 ± 8.0 years) with persistent non-valvular AF and normal left ventricular systolic function (left ventricular ejection fraction ≥ 50%). All patients underwent a symptom-limited cardiopulmonary exercise test (CPET). Doppler echocardiography was performed both at rest and immediately after exercise. Five consecutive measurements of early diastolic mitral inflow velocity (E) and early diastolic mitral annular velocity (e’) were taken and averaged. E/e’ ratio was calculated. Elevated LVFP was defined as E/e’ > 9, and patients with elevated LVFP at rest were excluded. Results Patients were classified into two groups according to LVFP estimated by E/e’ ratio after exercise: 39 (26.9%) with elevated LVFP after exercise and 106 (73.1%) with normal LVFP. As compared with patients with normal LVFP, the ones with elevated LVFP after exercise had significantly lower peak oxygen uptake (VO2 peak) (21.7 ± 2.3 vs. 26.4 ± 3.8 mL/min per kilogram, P vs. 26.0 ± 4.0 mL/min per kilogram, P vs. 7.0 ± 1.3 min, P 2 peak. Conclusion Elevated LVFP estimated by E/e’ ratio after exercise is independ?ently associated with reduced exercise capacity in AF patients.
Objectives. Erectile dysfunction (ED) is a recognized predictor of asymptomatic coronary artery disease (CAD) in diabetic patients and represents the most common sexual dysfunction in older men with or without diabetes. No study has evaluated whether ED is able to predict the presence of asymptomatic CAD in elderly diabetic patients. Therefore, the aim of the present study is to evaluate whether ED is associated with asymptomatic CAD in 66 years or older men with type 2 diabetes. Methods. We consecutively enrolled 328 men with type 2 diabetes: 213 subjects were 65 years old or younger (GROUP A) and 115 were older than 65 years (GROUP B). After a systematic screening for asymptomatic CAD, the two study groups were stratified by the presence/absence of documented angiographic CAD. Forty-five subjects in the GROUP A and 37 in the GROUP B had CAD. ED has been evaluated by the validated International Index of Erectile Function-5 (IIEF-5) questionnaire. Results. In the GROUP A the prevalence of subjects with ED was significantly higher among subjects with than in those without CAD (31.1% vs 16.6%; p=0.030), while no significant difference in ED prevalence was observed between patients with and without CAD among older men (48.6% vs 39.7%; p=0.364). The multivariate analysis found that ED was significantly associated with asymptomatic CAD in younger (OR: 1.87; 95%CI:1.02-7.31; p=0.046), but not in older men. Conclusions. Our study shows that ED seems to lose its powerful role of predictor of asymptomatic CAD in elderly type 2 diabetic patients.