The prevalence of calcific aortic stenosis (AS) and of cardiac amyloidosis (CA) increases with age, and their association is not uncommon in the elderly. The identification of CA is particularly ...challenging in patients with AS because these 2 conditions share several features. It is estimated that ≤15% of the AS population and ≤30% of the subset with low-flow, low-gradient pattern may have CA. In patients with AS, CA is associated with increased risk of heart failure, mortality, and treatment futility with aortic valve replacement. In case of suspicion of CA, it is thus crucial to confirm the diagnosis to guide therapeutic management of AS and eventually implement recently developed pharmacological treatment dedicated to transthyretin amyloidosis. Given the high surgical risk of patients with AS and concomitant CA, transcatheter aortic valve replacement may be preferred to surgery in these patients.
Aortic Stenosis and Cardiac Amyloidosis Ternacle, Julien; Krapf, Laura; Mohty, Dania ...
Journal of the American College of Cardiology,
11/2019, Volume:
74, Issue:
21
Journal Article
Peer reviewed
Open access
The prevalence of calcific aortic stenosis (AS) and of cardiac amyloidosis (CA) increases with age, and their association is not uncommon in the elderly. The identification of CA is particularly ...challenging in patients with AS because these 2 conditions share several features. It is estimated that ≤15% of the AS population and ≤30% of the subset with low-flow, low-gradient pattern may have CA. In patients with AS, CA is associated with increased risk of heart failure, mortality, and treatment futility with aortic valve replacement. In case of suspicion of CA, it is thus crucial to confirm the diagnosis to guide therapeutic management of AS and eventually implement recently developed pharmacological treatment dedicated to transthyretin amyloidosis. Given the high surgical risk of patients with AS and concomitant CA, transcatheter aortic valve replacement may be preferred to surgery in these patients.
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•CA may be present in ≤15% of patients with AS.•Clinical and imaging “red flags” for CA should be systematically searched in patients with AS.•Transcatheter rather than surgical AVR may be preferred in patients with CA.•Recently developed pharmacological treatment for transthyretin CA should be instituted as soon as diagnosis is confirmed.
Valvular heart calcification is common in patients with chronic kidney disease (CKD), especially in those receiving hemodialysis therapy, and it is associated with poor prognosis. Furthermore, ...progression of valvular heart disease (VHD) and structural valve deterioration of bioprosthetic valves are faster in these patients. Mechanisms involved in the pathophysiology of VHD are similar between patients with and without impaired kidney function, but CKD is associated with a bone metabolism dysregulation, which might lead to a procalcifying phenotype within vessels and heart valves. CKD is also associated with left ventricular remodelling and dysfunction, which might contribute to increase the risk of heart failure and death in patients with VHD. Even if promising pharmacotherapeutic avenues are in development, no medical treatment can prevent or reduce the valvular calcific process. Patients with advanced CKD should undergo transthoracic echocardiography for detection of VHD, and if present, follow-up should be more frequent than what is recommended in the guidelines. Transcatheter valve replacement might be preferred over surgical replacement in patients with CKD and severe aortic valve stenosis.
Les calcifications valvulaires sont fréquentes chez les atteints d’ isufisance rénale chronique, surtout en cas d’hémodialyse, et leur présence est associée à un mauvais pronostic. De plus, la progression des valvulopathies et la détérioration des bioprothèses sont accélérées dans cette population. Les mécanismes physiopathologiques impliqués dans le développement des valvulopathies sont similaires entre les patients avec et sans insuffisance rénale, cependant la dérégulation du métabolisme osseux est plus prononcée en cas de néphropathie, d’où un phénotype pro-calcifiant. L’insuffisance rénale entraine également un remodelage et une altération de la fonction du ventricule gauche, ce qui contribue à augmenter le risque d’insuffisance cardiaque et de décès en cas de valvulopathie. Même si des pistes thérapeutiques sont en développement, il n’existe aucun traitement médical permettant de prévenir ou de faire régresser les calcifications valvulaires. Chez les patients atteints d’ insuffisance rénale avancée, il est important d’effectuer une échocardiographie pour le dépistage des maladies valvulaires et d’effectuer un suivi plus rapproché que ce qui est recommandé dans les lignes directrices. Le remplacement valvulaire par cathéter semble être préférable au remplacement chirurgical chez les patients atteints d’ insuffisance rénale et de sténose aortique grave.
Optimal management, including timing of surgery, remains debated in Marfan syndrome because of a lack of data on aortic risk associated with this disease.
We used our database to evaluate aortic risk ...associated with standardized care. Patients who fulfilled the international criteria, had not had previous aortic surgery or dissection, and came to our center at least twice were included. Aortic measurements were made with echocardiography (every 2 years); patients were given systematic β-blockade and advice about sports activities. Prophylactic aortic surgery was proposed when the maximal aortic diameter reached 50 mm. Seven hundred thirty-two patients with Marfan syndrome were followed up for a mean of 6.6 years. Five deaths and 2 dissections of the ascending aorta occurred during follow-up. Event rate (death/aortic dissection) was 0.17%/y. Risk rose with increasing aortic diameter measured within 2 years of the event: from 0.09%/y per year (95% confidence interval, 0.00-0.20) when the aortic diameter was <40 mm to 0.3% (95% confidence interval, 0.00-0.71) with diameters of 45 to 49 mm and 1.33% (95% confidence interval, 0.00-3.93) with diameters of 50 to 54 mm. The risk increased 4 times at diameters ≥50 mm. The annual risk dropped below 0.05% when the aortic diameter was <50 mm after exclusion of a neonatal patient, a woman who became pregnant against our recommendation, and a 72-year-old woman with previous myocardial infarction.
Risk of sudden death or aortic dissection remains low in patients with Marfan syndrome and aortic diameter between 45 and 49 mm. Aortic diameter of 50 mm appears to be a reasonable threshold for prophylactic surgery.
Current guidelines recommend use of heart valve centres (HVCs) to deliver optimal quality of care for patients with valve disease but there is no evidence to support this. The hypothesis of this ...study is that patient care with severe aortic stenosis (AS) will differ in HVCs compared with satellite centres. We aimed to compare the treatment of patients with AS at HVCs (tertiary care hospitals with full access to AS interventions) to satellites (hospitals without such access).
is a European, observational, prospective registry enrolling consecutive patients with newly diagnosed severe AS at four HVCs and 10 satellites. Clinical characteristics, interventions performed and outcomes up to 1 year by site-type were examined.
Among 790 patients, 594 were recruited in HVCs and 196 in satellites. At baseline, patients in HVCs had more severe valve disease (higher peak aortic velocity (4.3 vs 4.1 m/s; p=0.008)) and greater comorbidity (coronary artery disease (CAD) (44% vs 27%; p<0.001) prior myocardial infarction (MI) (11% vs 5.1%; p=0.011) and chronic pulmonary disease (17% vs 8.9%; p=0.007)) than those presenting in satellites. An aortic valve replacement was performed more often by month 3 in HVCs than satellites in the overall population (52.6% of vs 31.3%; p<0.001) and in symptomatic patients (66.7% vs 43.2%, p<0.001). One-year survival rate was higher for patients in HVCs than satellites (HR2.19; 95% CI 1.28 to 3.73 total population and 2.89 (95%CI 1.64 to 5.11) for symptomatic patients.
Our data support the implementation of referral pathways that direct patients to HVCs performing both surgery and transcatheter interventions.
NCT03112629.
Rate control and rhythm control are accepted management strategies for atrial fibrillation (AF).
RealiseAF aimed to describe the success of either strategy and the impact of control on symptomatic ...status of patients with AF.
This international, observational, cross-sectional survey of patients with any history of AF in the previous year, recorded AF characteristics, management and frequency of control (defined as sinus rhythm or AF with resting heart rate ≤80 bpm).
Overall, 9665 patients were evaluable for AF control, with 59.0% controlled (sinus rhythm 26.5%, AF ≤80 bpm 32.5%) and 41.0% uncontrolled. Symptom prevalence in the previous week was lower in controlled than uncontrolled AF (55.7% vs 68.4%; p<0.001) and similar for patients in sinus rhythm versus AF ≤80 bpm (54.8% vs 56.4%; p=0.23). At the visit, AF-related functional impairment (EHRA class >I) was seen in 67.4% of patients with controlled AF and 82.1% of patients with uncontrolled AF (p<0.001). Quality-of-life (QoL, measured using EQ-5D) was better for patients with controlled versus uncontrolled AF using the Visual Analogue Scale (mean (SD) score 67.1 (18.4) vs 63.2 (18.9); p<0.001), single index utility score (median 0.78 vs 0.73; p<0.001), or five dimensions of well-being (all p<0.001). Irrespective of AF control, cardiovascular events had led to hospitalisation in the past year in 28.1%.
AF control is not optimal. Control appears to be associated with fewer symptoms and better QoL, but even patients with controlled AF have frequent symptoms, functional impairment, altered QoL and cardiovascular events. New treatments are needed to improve control and minimise the functional and QoL burden of AF.
Evaluation of left and right ventricular longitudinal systolic function may enhance risk stratification following aortic valve replacement (AVR). The study objective was to evaluate the changes in ...left and right ventricular longitudinal systolic function and RV-pulmonary artery (RV-PA) coupling from baseline to 30-days and 1-year after aortic valve replacement (AVR).
LV longitudinal strain (LS), tricuspid annulus plane systolic excursion (TAPSE), and RV-PA coupling were evaluated in patients from the PARTNER-2A surgical AVR (SAVR) arm (n=985) and from the PARTNER-2 SAPIEN-3 registry (n=719). TAPSE and RV-PA coupling decreased significantly following SAVR, but remained stable following TAVR. Lower LV LS, TAPSE, or RV-PA coupling at baseline were associated with increased risk of the composite of death, hospitalization, and stroke at 5-years (Adjusted-HRs for LV LS<15%: 1.24 95%CI 1.05-1.45, p=0.001; TAPSE<14mm: 1.44 95%CI 1.21-1.73, p<0.001; RV/PA coupling<0.55mm/mmHg: 1.32 95% CI 1.07-1.63, p=0.011). Reduced TAPSE at baseline was the most powerful predictor of the composite endpoint at 5-years. Patients with LV ejection fraction <50% at baseline had increased risk of the primary endpoint with SAVR (HR: 1.34, 95%CI 1.08-1.68, p=0.009) but not with TAVR (HR: 1.12, 95%CI 0.88-1.42). Lower RV-PA coupling at 30-days showed the strongest association with cardiac mortality.
SAVR but not TAVR was associated with a marked deterioration in RV longitudinal systolic function and RV-PA coupling. Lower TAPSE and RV-PA coupling at 30-days were associated with inferior clinical outcomes at 5-years. In patients with LVEF<50%, TAVR was associated with superior 5-year outcomes.
En el marco del proceso de insertar el Emprendedorismo y la Innovación Científica y Tecnológica en la enseñanza universitaria, se han realizado encuestas a profesores, alumnos y graduados de las ...carreras de Ingeniería Civil, Eléctrica y Mecánica de la Facultad de Ingeniería de la WF y a empresarios relacionados con la Facultad. Previamente se realizaron entrevistas a los responsables de cada carrera. El proceso de encuestas fue por correo electrónico y se llegaron a conclusiones que son de vital importancia para obtener la inserción de la temática en la currícula, excepto en el caso de los alumnos que fue presencial. La antigüedad de los profesores en la docencia fue muy importante para determinar su afinidad con el emprendedorismo, al igual que la metodología de las clases determina la capacidad creativa de los alumnos. Y la opinión de graduados y empresarios resulto fundamental para confirmar la importancia de esta temática.
Summary Although mitral stenosis is mostly due to rheumatic fever, other etiologies, such as degenerative, congenital, drug- or radiotherapy-induced mitral stenosis, are emerging and need to be ...recognized in order to decide the best therapeutic options. This pictorial review describes the echocardiographic features of these different anatomical types and the additional value of three-dimensional echocardiography.
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