The aorta stiffens with aging, a process that is accelerated by arterial hypertension. Decreased arterial compliance is one of the earliest detectable manifestations of adverse structural and ...functional changes within the vessel wall. The use of different imaging techniques optimized for assessment of vascular elasticity and quantification of luminal and vessel wall parameters allows for a comprehensive and detailed view of the vascular system. In addition, several studies have also documented the prognostic importance of arterial stiffness (AS) in various populations as an independent predictor of cardiovascular morbidity and all-cause mortality. Measurement of AS by applanation tonometry with pulse-wave velocity has been the gold-standard method and is well-validated in large populations as a strong predictor of adverse cardiovascular outcomes. Because aortic stiffness depends on the prevailing blood pressure, effective antihypertensive treatment is expected to reduce it in proportion to the blood pressure reduction. Nevertheless, drugs lowering blood pressure might differ in their effects on structure and function of the arterial walls. This review paper not only will discuss the current understanding and clinical significance of AS but also will review the effects of various pharmacological and nonpharmacological interventions that can be used to preserve the favorable profile of a more compliant and less stiff aorta.
Full text
Available for:
GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Aortic stenosis is characterized both by progressive valve narrowing and the left ventricular remodeling response that ensues. The only effective treatment is aortic valve replacement, which is ...usually recommended in patients with severe stenosis and evidence of left ventricular decompensation. At present, left ventricular decompensation is most frequently identified by the development of typical symptoms or a marked reduction in left ventricular ejection fraction <50%. However, there is growing interest in using the assessment of myocardial fibrosis as an earlier and more objective marker of left ventricular decompensation, particularly in asymptomatic patients, where guidelines currently rely on nonrandomized data and expert consensus. Myocardial fibrosis has major functional consequences, is the key pathological process driving left ventricular decompensation, and can be divided into 2 categories. Replacement fibrosis is irreversible and identified using late gadolinium enhancement on cardiac magnetic resonance, while diffuse fibrosis occurs earlier, is potentially reversible, and can be quantified with cardiac magnetic resonance T1 mapping techniques. There is a substantial body of observational data in this field, but there is now a need for randomized clinical trials of myocardial imaging in aortic stenosis to optimize patient management. This review will discuss the role that myocardial fibrosis plays in aortic stenosis, how it can be imaged, and how these approaches might be used to track myocardial health and improve the timing of aortic valve replacement.
Display omitted
Full text
Available for:
GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Assessing the severity of tricuspid regurgitation remains a challenging task, and although echocardiography is the test of choice, significant limitations of the current recommendations exist. Newer ...methods have been used in current trials of transcatheter devices and may improve our understanding of the disease process. Cardiac magnetic resonance imaging and computed tomography angiography may play significant roles as adjunctive imaging modalities. This paper reviews the imaging modalities currently used to quantify tricuspid regurgitation severity.
Display omitted
Full text
Available for:
GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Transcatheter interventions to treat mitral and tricuspid valve disease are becoming increasingly available because of the growing number of elderly patients with significant comorbidities or high ...operative risk. Thorough clinical and imaging evaluation in these patients is essential. The latter involves both characterization of the mechanism and severity of valvular disease as well as determining the hemodynamic consequences and extent of ventricular remodeling, which is an important predictor of future outcomes. Moreover, an assessment of the suitability and risk of complications associated with device-specific therapies is also an important component of the preprocedural evaluation in this cohort. Although echocardiography including 2-dimensional and 3-dimensional methods has an important role in the initial assessment and procedural guidance, cross-sectional imaging, including both computed tomographic imagning and cardiac magnetic resonance imaging, is increasingly being integrated into the evaluation of mitral and tricuspid valve disease. In this review, we discuss the role of cross-sectional imaging in mitral and tricuspid valve disease, primarily valvular regurgitation assessment, with an emphasis on the preprocedural evaluation and implications for transcatheter interventions.
Hypertensive disorders of pregnancy (HDP) are associated with short-term cardiac structure and function abnormalities, but later life changes are not well studied.
This study aimed to determine if ...HDP history is associated with echocardiographic differences 8 to 10 years after delivery, and if subgroups with placental maternal vascular malperfusion (MVM) lesions or current hypertension may be particularly affected.
Women with pregnancies delivered from 2008 to 2009 were selected from a clinical cohort with abstracted pregnancy and placental pathology data to undergo transthoracic echocardiography (2017 to 2020). Medical history, blood pressure, and weight were measured at the study visit.
The authors enrolled 132 women (10 ± 1 years post-delivery, age 38 ± 6 years): 102 with normotensive pregnancies and 30 with HDP: pre-eclampsia (n = 21) or gestational hypertension (n = 9). Compared with women with normotensive pregnancies, those with HDP history were more likely to have current hypertension (63% vs. 26%; p < 0.001). After adjusting for age, race, MVM lesions, body mass index, current hypertension, and hemoglobin A1c, women with HDP history had higher interventricular septal thickness (β = 0.08; p = 0.04) and relative wall thickness (β = 0.04; p = 0.04). In subgroup analyses, those with both HDP history and current hypertension had a higher proportion of left ventricular remodeling (79.0%) compared with all other groups (only HDP 36.4%; p = 0.01, only current hypertension 46.2%; p = 0.02, and neither HDP nor hypertension 38.2%; p < 0.001), and lower mitral inflow E/A and annular e'. Accounting for placental MVM lesions did not impact results.
Women with both HDP history and current hypertension have pronounced differences in left ventricular structure and function a decade after pregnancy, warranting continued surveillance and targeted therapies for cardiovascular disease prevention.
Full text
Available for:
GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Adverse cardiac remodelling is the main determinant of patient prognosis in degenerative valvular heart disease (VHD). However, to give an indication for valvular intervention, current guidelines ...include parameters of cardiac chamber dilatation or function which are subject to variability, do not directly reflect myocardial structural changes, and, more importantly, seem to be not sensitive enough in depicting early signs of myocardial dysfunction before irreversible myocardial damage has occurred. To avoid irreversible myocardial dysfunction, novel biomarkers are advocated to help refining indications for intervention and risk stratification. Advanced echocardiographic modalities, including strain analysis, and magnetic resonance imaging have shown to be promising in providing new tools to depict the important switch from adaptive to maladaptive myocardial changes in response to severe VHD. This review, therefore, summarizes the current available evidence on the role of these new imaging biomarkers in degenerative VHD, aiming at shifting the clinical perspective from a valve-centred to a myocardium-focused approach for patient management and therapeutic decision-making.
Abstract
Mitral valve prolapse (MVP) is the most frequent valve condition but remains a conundrum in many aspects, particularly in regard to the existence and frequency of an arrhythmic form (AMVP) ...and its link to sudden cardiac death. Furthermore, the presence, frequency, and significance of the anatomic functional feature called mitral annular disjunction (MAD) have remained widely disputed. Recent case series and cohorts have shattered the concept that MVP is most generally benign and have emphasized the various phenotypes associated with clinically significant ventricular arrhythmias, including AMVP. The definition, evaluation, follow-up, and management of AMVP represent the focus of the present review, strengthened by recent coherent studies defining an arrhythmic MVP phenotypic that would affect a small subset of patients with MVP at concentrated high risk. The role of MAD in this context is of particular importance, and this review highlights the characteristics of AMVP phenotypes and MAD, their clinical, multimodality imaging, and rhythmic evaluation. These seminal facts lead to proposing a risk stratification clinical pathway with consideration of medical, rhythmologic, and surgical management and have been objects of recent expert consensus statements and of proposals for new research directions.
Graphical Abstract
Graphical Abstract
Pathophysiology, risk stratification and management of arrhythmic mitral valve prolapse and mitral annular disjunction. (Left panel, from top-to-bottom) No/trivial, mild, moderate, and severe ventricular arrhythmia. (Middle panel) Risk stratification aiming at assessing the risk of ventricular arrhythmias and sudden cardiac death in patients with mitral valve prolapse, involving two phases based on the clinical and imaging context and the uncovered arrhythmia. In the absence of ventricular tachycardia, phenotypic risk features will trigger the intensity of screening for arrhythmia. Green boxes indicate green heart consensus statements, and yellow boxes indicate yellow heart consensus statements. High risk = sustained ventricular tachycardia, polymorphic non-sustained ventricular tachycardia, fast (>180 b.p.m.) non-sustained ventricular tachycardia, ventricular tachycardia/non-sustained ventricular tachycardia resulting in syncope. (Right panel, from top to bottom) The arrhythmic mitral valve prolapse imaging phenotype with bileaflet mitral valve prolapse and mitral annular disjunction, leaflet redundancy, mitral regurgitation severity, and late gadolinium enhancement. AAD, anti-arrhythmic drug; DMR, degenerative mitral regurgitation; ICD, implantable cardioverter-defibrillator; LA, left atrium; LGE, late gadolinium enhancement; LV-EF, left ventricular ejection fraction; MAD, mitral annular disjunction; MV, mitral valve; PVC, premature ventricular complex; TWI, T-wave inversion; VT, ventricular tachycardia. #Additional electrocardiogram monitoring method may be used such as loop recorders. Modified from Essayagh et al. and Sabbag et al.36,44
Although transcatheter aortic valve replacement (TAVR) therapy continues to grow, there have been concerns about the occurrence of hypoattenuating leaflet thickening (HALT), which may affect ...prosthesis function or durability. This study aimed to examine prosthesis frame factors and correlate their extent to the frequency of HALT and clinical outcomes.
We prospectively examined 565 patients with cardiac computed tomography screening for HALT at 30 days after balloon-expandable SAPIEN3 and self-expanding EVOLUT TAVR. Deformation of the TAVR prostheses, asymmetric prosthesis leaflet expansion, prosthesis sinus volumes, and commissural alignment were analyzed on the postprocedural computed tomography. For descriptive purposes, an index of prosthesis deformation was calculated, with values >1.00 representing relative midsegment underexpansion. A time-to-event model was performed to evaluate the association of HALT with the clinical outcome.
Overall, HALT was present in 21% of SAPIEN3 patients and in 16% of EVOLUT patients at 30 days after TAVR. The occurrence of HALT was directly associated with greater prosthesis frame deformation (
<0.001), worse asymmetry of the leaflets (
<0.001), and smaller TAVR neosinus volumes (
<0.001). These relations were present in both prosthetic types and in all of their size ranges (all
<0.05). In multivariable analyses that include clinical variables previously associated with HALT (eg, anticoagulant therapy), variables of TAVR prosthesis deformation remained predictive of HALT. Although HALT was not associated with changes in prosthetic hemodynamics, its presence was associated with the risk of mortality at 1 year, with respect to greater incidences of all-cause mortality (hazard ratio, 2.98 95% CI, 1.57-5.63;
=0.001), cardiac death (hazard ratio, 4.58 95% CI, 1.81-11.6;
=0.001), and a composite outcome of all-cause mortality and heart failure hospitalization (hazard ratio, 1.94 95% CI, 1.14-3.30;
=0.02) with adjustment for age, sex, and comorbidities.
Nonuniform expansion of TAVR prostheses resulting in frame deformation, asymmetric leaflet, and smaller neosinus volume is related to occurrence of HALT in patients who undergo TAVR. These data may have implications for both prosthesis valve design and deployment techniques to improve clinical outcomes for these patients.
PDF
