Aortic regurgitation (AR) is a common valvular heart disease, but the optimal timing of surgical intervention remains controversial. In the natural history of chronic severe AR, sudden death is rare, ...and the annual mortality rate is comparatively low. Considering the hemodynamic features of combined volume and pressure overload and long-term compensation in patients with chronic AR, symptoms related to AR do not frequently occur. Therefore, the progression of left ventricular (LV) dysfunction is a key factor in determining the timing of surgical intervention in patients with severe chronic AR. In addition to symptoms, an ejection fraction <50% and an LV endsystolic diameter (LVESD) >45 mm are appropriate cutoff values for surgical intervention in Japanese patients, whereas LV end-diastolic diameter is not a good indicator. An LVESD index of 25 mm/m2is controversial, because adjusting for body size may cause overcorrection in Japanese patients who have a small body size compared with Westerners. Accumulation of data from the Japanese population is indispensable for establishing guidelines on optimal management of patients with chronic AR.
•Atrial fibrillation-related tricuspid regurgitation (TR) and TR late after mitral surgery are main etiologies of isolated TR.•Isolated functional TR has been undertreated because of high mortality ...of surgery.•Right ventricular function is a key factor in determining indication of isolated tricuspid valve (TV) surgery.•Next target of transcatheter intervention may be TR.•We should reconsider the indication and optimal timing of isolated TV surgery.
The tricuspid valve has been called a “forgotten” valve; however, it is receiving increasing attention, since tricuspid regurgitation (TR) may be the next target of transcatheter intervention. Atrial fibrillation-related TR and TR that develops late after left-sided valve surgery are the main etiologies of isolated functional TR, in both of which annular dilatation is the main mechanism of TR.
Isolated functional TR has been undertreated because of the high mortality rate of isolated tricuspid valve surgery. Furthermore, a recent study showed that surgery does not improve survival as long as it is performed at the late timing as is common in the current clinical settings. Right ventricular function is a key factor in determining the indication for isolated tricuspid valve surgery and in predicting early and late outcomes. However, none of them have been validated as predictors of prognosis for patients with severe functional TR. Liver function and renal function are also important predictors, but the cut-off values of these parameters for improved outcomes of isolated tricuspid valve surgery should be determined by large-scale data analysis.
Now is a good time to reconsider the indications and the optimal timing of isolated tricuspid valve surgery in light of the upcoming transcatheter interventions.
Optimal management for asymptomatic severe aortic stenosis (AS) remains controversial. Considering the increase in elderly patients, improved surgical outcomes and the introduction of transcatheter ...aortic valve implantation, we must reconsider the optimal management of asymptomatic severe AS. In this article, previous studies regarding the natural history of asymptomatic severe AS were reviewed to obtain a clinical perspective of AS in the growing elderly patient population. The incidence of sudden death in asymptomatic severe AS varies among studies from 0.25% to 1.7% per year, with differences related to study design and patient background. Except for very severe AS, sudden death or AS-related cardiac death without preceding symptoms is uncommon if ‘watchful’ waiting strategy is possible. Therefore, early operation is reasonable in very severe AS, but it is not recommended for all patients with severe AS. Using exercise tests, plasma levels of natriuretic peptides and other parameters, risk stratification of asymptomatic severe AS is needed to select patients who may have greater benefit following early operation. On the other hand, ‘watchful’ waiting is not always possible in real world of our practice. Patient education and periodic echocardiography are essential in ‘watchful’ waiting, which is not simply waiting strategy without careful monitoring. Individualised discussion regarding the indication for early operation is necessary, considering age, clinical background, predicted natural history and operative risk in each patient.
Background: To determine the normal range of left ventricular (LV) 2- dimensional (2-D) strain and vendor-specific differences, a multicenter prospective 2-D strain study endorsed by the Japanese ...Society of Echocardiography was conducted. Methods and Results: 2-D speckle tracking analysis was performed on 817 healthy subjects (age range, 0–88 years); the images included 3 LV short axis and 3 apical views using an ultrasound system from 1 of the 3 different vendors (V1, n=333; V2, n=330; V3, n=337). With the 2-D speckle tracking software from each vendor, radial, circumferential and longitudinal strain were measured using an 18-segment model. Inter-vendor variability was also assessed in a subset of subjects. The feasibility for 2-D strain measurements was different among the 3 vendors (V1, 83%; V2, 70%; V3, 88%, P<0.01). The global radial (V1, 54.6±12.6%; V2, 36.3±8.2%; V3, 51.4±8.0%), circumferential (V1, –22.8±2.9%; V2, –22.2±3.2%; V3, –30.5±3.8%), and longitudinal (V1, –21.3±2.1%; V2, –18.9±2.5%; V3, –19.9±2.4%) strain measurements were significantly different for each of the vendors. Segmental strain was also different between the 3 vendors. On inter-vendor analysis, vendor agreement ranged from mild to moderate. Conclusions: Reference values are provided for normal 2-D strain for 3 different ultrasound vendors. Due to a low inter-vendor agreement, 2-D strain data are not interchangeable when conducting a longitudinal follow-up or a cross-sectional assessment of LV function. (Circ J 2012; 76: 2623–2632)
Background:Transaortic transcatheter aortic valve replacement (TAo-TAVR) is an alternative to peripheral or transapical TAVR. The procedural feasibility, safety, and midterm outcomes of TAo-TAVR were ...investigated in this study.Methods and Results:Eighty-four consecutive patients underwent TAo-TAVR from 2011 to 2021. Their median age was 83 years (interquartile range, 80–87 years). The Edwards SAPIEN and Medtronic CoreValve devices were used in 45 (53.6%) and 38 (45.2%) patients, respectively. The surgical approach was a right mini-thoracotomy in 43 patients (51.2%) and partial sternotomy in 4 patients (4.8%). The remaining 37 patients (44.0%) underwent full sternotomy because of concomitant off-pump coronary artery bypass grafting. VARC-3 device success was achieved in 77 patients (91.7%). Valve migration occurred in 3 patients (3.6%) using a first-generation CoreValve device, necessitating implantation of a second valve. No aortic annulus rupture, aortic dissection, or coronary orifice occlusion occurred. Conversion to surgery was required for 1 patient because of uncontrollable bleeding. Only 1 in-hospital death occurred. New pacemaker implantation was required in 6 patients (7.1%). Echocardiography at discharge showed no or trivial paravalvular leak (PVL) in 58 patients (69.0%), mild PVL in 23 (27.4%), and mild to moderate PVL in 2 (2.4%) patients. The 1- and 3-year incidence of cardiovascular death was 1.6% and 4.8%, respectively, with no structural valve deterioration.Conclusions:TAo-TAVR is feasible and safe with satisfactory midterm outcomes using both currently available devices.
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