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1
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Mohapatra SR, Rama E, Werner MP, Call T, Loewenberg T, Loewen A, Apel C, Kiessling F, Jockenhoevel S. Novel Bioreactor Design for Non-invasive Longitudinal Monitoring of Tissue-Engineered Heart Valves in 7T MRI and Ultrasound. Ann Biomed Eng 2025; 53:383-397. [PMID: 39438348 PMCID: PMC11805768 DOI: 10.1007/s10439-024-03632-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Accepted: 10/02/2024] [Indexed: 10/25/2024]
Abstract
The development of cardiovascular implants is abundant, yet their clinical adoption remains a significant challenge in the treatment of valvular diseases. Tissue-engineered heart valves (TEHV) have emerged as a promising solution due to their remodeling capabilities, which have been extensively studied in recent years. However, ensuring reproducible production and clinical translation of TEHV requires robust longitudinal monitoring methods.Cardiovascular magnetic resonance imaging (MRI) is a non-invasive, radiation-free technique providing detailed valvular imaging and functional assessment. To facilitate this, we designed a state-of-the-art metal-free bioreactor enabling dynamic MRI and ultrasound imaging. Our compact bioreactor, tailored to fit a 72 mm bore 7 T MRI coil, features an integrated backflow design ensuring MRI compatibility. A pneumatic drive system operates the bioreactor, minimizing potential MRI interference. The bioreactor was digitally designed and constructed using polymethyl methacrylate, utilizing only polyether ether ketone screws for secure fastening. Our biohybrid TEHV incorporates a non-degradable polyethylene terephthalate textile scaffold with fibrin matrix hydrogel and human arterial smooth muscle cells.As a result, the bioreactor was successfully proven to be MRI compatible, with no blooming artifacts detected. The dynamic movement of the TEHVs was observed using gated MRI motion artifact compensation and ultrasound imaging techniques. In addition, the conditioning of TEHVs in the bioreactor enhanced ECM production. Immunohistology demonstrated abundant collagen, α-smooth muscle actin, and a monolayer of endothelial cells throughout the valve cusp. Our innovative methodology provides a physiologically relevant environment for TEHV conditioning and development, enabling accurate monitoring and assessment of functionality, thus accelerating clinical acceptance.
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Affiliation(s)
- Saurav Ranjan Mohapatra
- Department of Biohybrid & Medical Textile (BioTex), Center for Biohybrid Medical Systems (CBMS), Institute for Applied Medical Engineering, RWTH Aachen University, Forckenbeckstr. 55, 52074, Aachen, Germany
| | - Elena Rama
- Institute for Experimental Molecular Imaging, RWTH Aachen University, Forckenbeckstr. 55, 52074, Aachen, Germany
| | - Maximillian P Werner
- Department of Biohybrid & Medical Textile (BioTex), Center for Biohybrid Medical Systems (CBMS), Institute for Applied Medical Engineering, RWTH Aachen University, Forckenbeckstr. 55, 52074, Aachen, Germany
| | - Tobias Call
- Department of Biohybrid & Medical Textile (BioTex), Center for Biohybrid Medical Systems (CBMS), Institute for Applied Medical Engineering, RWTH Aachen University, Forckenbeckstr. 55, 52074, Aachen, Germany
| | - Tanja Loewenberg
- Department of Biohybrid & Medical Textile (BioTex), Center for Biohybrid Medical Systems (CBMS), Institute for Applied Medical Engineering, RWTH Aachen University, Forckenbeckstr. 55, 52074, Aachen, Germany
| | - Alexander Loewen
- Department of Biohybrid & Medical Textile (BioTex), Center for Biohybrid Medical Systems (CBMS), Institute for Applied Medical Engineering, RWTH Aachen University, Forckenbeckstr. 55, 52074, Aachen, Germany
| | - Christian Apel
- Department of Biohybrid & Medical Textile (BioTex), Center for Biohybrid Medical Systems (CBMS), Institute for Applied Medical Engineering, RWTH Aachen University, Forckenbeckstr. 55, 52074, Aachen, Germany
| | - Fabian Kiessling
- Institute for Experimental Molecular Imaging, RWTH Aachen University, Forckenbeckstr. 55, 52074, Aachen, Germany
| | - Stefan Jockenhoevel
- Department of Biohybrid & Medical Textile (BioTex), Center for Biohybrid Medical Systems (CBMS), Institute for Applied Medical Engineering, RWTH Aachen University, Forckenbeckstr. 55, 52074, Aachen, Germany.
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Hoeijmakers MJMM, Morgenthaler V, Rutten MCM, van de Vosse FN. Scale-Resolving Simulations of Steady and Pulsatile Flow Through Healthy and Stenotic Heart Valves. J Biomech Eng 2022; 144:1119643. [PMID: 34529056 DOI: 10.1115/1.4052459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Indexed: 11/08/2022]
Abstract
Blood-flow downstream of stenotic and healthy aortic valves exhibits intermittent random fluctuations in the velocity field which are associated with turbulence. Such flows warrant the use of computationally demanding scale-resolving models. The aim of this work was to compute and quantify this turbulent flow in healthy and stenotic heart valves for steady and pulsatile flow conditions. Large eddy simulations (LESs) and Reynolds-averaged Navier-Stokes (RANS) simulations were used to compute the flow field at inlet Reynolds numbers of 2700 and 5400 for valves with an opening area of 70 mm2 and 175 mm2 and their projected orifice-plate type counterparts. Power spectra and turbulent kinetic energy were quantified on the centerline. Projected geometries exhibited an increased pressure-drop (>90%) and elevated turbulent kinetic energy levels (>147%). Turbulence production was an order of magnitude higher in stenotic heart valves compared to healthy valves. Pulsatile flow stabilizes flow in the acceleration phase, whereas onset of deceleration triggered (healthy valve) or amplified (stenotic valve) turbulence. Simplification of the aortic valve by projecting the orifice area should be avoided in computational fluid dynamics (CFD). RANS simulations may be used to predict the transvalvular pressure-drop, but scale-resolving models are recommended when detailed information of the flow field is required.
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Affiliation(s)
- M J M M Hoeijmakers
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven 5600 MB The Netherlands; Ansys Inc., Villeurbanne 69100, France
| | | | - M C M Rutten
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven 5600 MB, The Netherlands
| | - F N van de Vosse
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven 5600 MB, The Netherlands
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Pontone G, Marano R, Agricola E, Alushi B, Bartorelli A, Cameli M, Carrabba N, Esposito A, Faletti R, Francone M, Galea N, Golino P, Guglielmo M, Palmisano A, Petronio S, Petullà M, Pradella S, Ribichini F, Romeo F, Russo V, Scandura S, Schicchi N, Spaccarotella C, Tomai F, Centonze M, indolfi C. Recommendations in pre-procedural imaging assessment for transcatheter aortic valve implantation intervention. J Cardiovasc Med (Hagerstown) 2022; 23:216-227. [DOI: 10.2459/jcm.0000000000001293] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Corazza I, Zecchi M, Zannoli R. Evaluation of low gradient severe aortic stenosis: should we change our outlook in the analysis of clinical data? Open Heart 2021; 8:openhrt-2021-001746. [PMID: 34635576 PMCID: PMC8506845 DOI: 10.1136/openhrt-2021-001746] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/22/2021] [Indexed: 11/16/2022] Open
Abstract
Nowadays, technological progress has equipped clinicians with new useful devices for the collection, analysis and presentation of data. As a consequence, many diseases and pathological conditions have been studied in a more detailed way, sometimes with remarkable results. In fact, they are not always validated by the old physiological models. In this respect, we present the case of low gradient severe aortic stenosis, a condition characterised by a small aortic valve area and a low-pressure gradient. According to the mathematical and physical assumptions these readings are contradictory whereas the Doppler-echocardiography shows clearly the existence of such a situation. In this work, we have described the physiological base of this phenomenon and discussed the limitations of the technology used. In this work, we are going to analyse some conditions commonly observed in daily clinical practice in order to prompt a critical outlook in both clinicians and technicians about the instrumentations used and the methods applied.
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Affiliation(s)
- Ivan Corazza
- Department of Experimental Diagnostic and Specialty Medicine, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Margherita Zecchi
- Department of Experimental Diagnostic and Specialty Medicine, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Romano Zannoli
- Department of Experimental Diagnostic and Specialty Medicine, Alma Mater Studiorum University of Bologna, Bologna, Italy
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Shirazi S, Golmohammadi F, Tavoosi A, Salehi M, Larti F, Sardari A, Geraiely B, Rahmanian M, Saberi K, Sattarzadeh Badkoubeh R. Quantification of aortic valve area: comparison of different methods of echocardiography with 3-D scan of the excised valve. Int J Cardiovasc Imaging 2020; 37:529-538. [PMID: 33001325 DOI: 10.1007/s10554-020-02035-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 09/18/2020] [Indexed: 12/31/2022]
Abstract
Accurate determination of severity of aortic valve stenosis (AS) by aortic valve area (AVA) is essential for choosing the best treatment strategy. We compared AVA quantified by 4 different in vivo echocardiographic methods with AVA measured by 3D ex vivo scanning of the excised AV. The data on 38 patients who underwent aortic valve replacement were assessed. The AVA was determined by 4 echocardiographic methods of planimetry in 2D transesophageal echocardiography [planimetry (2D-TEE)], plainemetry by multiplanar reconstruction approach in 3D transesophageal echocardiography [MPR (3D-TEE)], and two continuity equation (CE) approaches; conventional CE (2D-TTE) in which left ventricular outflow tract [LVOT] area derived by LVOT diameter obtained in 2D transthoracic echocardiography and CE (3D-TEE) in which LVOT area obtained by 3D MPR. After the surgical removal of the AV, AVA was determined by 3D ex vivo scanning. Lowest AVA mean difference with 3D ex vivo scanning was found between CE (2D-TTE), followed by CE (3D-TEE). Planimetry (2D-TEE) in male patients as well as severely and non-severely calcified valves revealed a significant higher AVA mean difference with 3D ex vivo scanning than CE (2D-TTE) and CE (3D-TEE) methods. However, with a nonsignificant effect, CE (2D-TTE) and planimetry (2D-TEE) had the least mean difference with 3D ex vivo scanning possibly due to less frequent bicuspid AV in females. CE (2D-TTE) was more accurate than other methods of AVA calculation. Moreover, CE (3D-TEE) and MPR (3D-TEE) methods had acceptable accuracy in comparison with planimetry (2D-TEE) for definition of AS severity.
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Affiliation(s)
- Samira Shirazi
- Cardiology Department, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Keshavarz Boulevard, P.O.Box: 1419733141, Tehran, Iran
| | - Fatemeh Golmohammadi
- Cardiology Department, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Keshavarz Boulevard, P.O.Box: 1419733141, Tehran, Iran
| | - Anahita Tavoosi
- Cardiology Department, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Keshavarz Boulevard, P.O.Box: 1419733141, Tehran, Iran
| | - Mehrdad Salehi
- Cardiac Surgery Department, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Farnoosh Larti
- Cardiology Department, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Keshavarz Boulevard, P.O.Box: 1419733141, Tehran, Iran
| | - Akram Sardari
- Cardiology Department, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Keshavarz Boulevard, P.O.Box: 1419733141, Tehran, Iran
| | - Babak Geraiely
- Cardiology Department, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Keshavarz Boulevard, P.O.Box: 1419733141, Tehran, Iran
| | - Mehrzad Rahmanian
- Cardiac Surgery Department, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Kianoush Saberi
- Department of Anesthesiology, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Roya Sattarzadeh Badkoubeh
- Cardiology Department, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Keshavarz Boulevard, P.O.Box: 1419733141, Tehran, Iran.
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Hourai R, Ozawa H, Sohmiya K, Hirose Y, Katsumata T, Daimon M, Ishizaka N. IgG4-Positive Plasmacytic Infiltration in Aortic Wall and Aortic Valve Surgical Samples and Its Relation to Preoperative Serum IgG4 Levels. Int Heart J 2019; 60:688-694. [DOI: 10.1536/ihj.18-490] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
| | - Hideki Ozawa
- Department of Thoracic and Cardiovascular Surgery, Osaka Medical College
| | | | | | - Takahiro Katsumata
- Department of Thoracic and Cardiovascular Surgery, Osaka Medical College
| | - Masahiro Daimon
- Department of Thoracic and Cardiovascular Surgery, Osaka Medical College
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Hahn RT, Nicoara A, Kapadia S, Svensson L, Martin R. Echocardiographic Imaging for Transcatheter Aortic Valve Replacement. J Am Soc Echocardiogr 2018; 31:405-433. [DOI: 10.1016/j.echo.2017.10.022] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Indexed: 02/06/2023]
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Baumgartner H, Hung J, Bermejo J, Chambers JB, Edvardsen T, Goldstein S, Lancellotti P, LeFevre M, Miller F, Otto CM. Recommendations on the echocardiographic assessment of aortic valve stenosis: a focused update from the European Association of Cardiovascular Imaging and the American Society of Echocardiography. Eur Heart J Cardiovasc Imaging 2018; 18:254-275. [PMID: 28363204 DOI: 10.1093/ehjci/jew335] [Citation(s) in RCA: 504] [Impact Index Per Article: 72.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 12/23/2016] [Indexed: 02/07/2023] Open
Abstract
Echocardiography is the key tool for the diagnosis and evaluation of aortic stenosis. Because clinical decision-making is based on the echocardiographic assessment of its severity, it is essential that standards are adopted to maintain accuracy and consistency across echocardiographic laboratories. Detailed recommendations for the echocardiographic assessment of valve stenosis were published by the European Association of Echocardiography and the American Society of Echocardiography in 2009. In the meantime, numerous new studies on aortic stenosis have been published with particular new insights into the difficult subgroup of low gradient aortic stenosis making an update of recommendations necessary. The document focuses in particular on the optimization of left ventricular outflow tract assessment, low flow, low gradient aortic stenosis with preserved ejection fraction, a new classification of aortic stenosis by gradient, flow and ejection fraction, and a grading algorithm for an integrated and stepwise approach of artic stenosis assessment in clinical practice.
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Affiliation(s)
- Helmut Baumgartner
- Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster, Muenster, Germany
| | - Judy Hung
- Division of Cardiology, Massachusetts General Hospital, Boston, MA, USA
| | - Javier Bermejo
- Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense de Madrid and CIBERCV, Madrid, Spain
| | | | - Thor Edvardsen
- Department of Cardiology and Center for Cardiological Innovation, Oslo University Hospital, Oslo and University of Oslo, Oslo, Norway
| | | | - Patrizio Lancellotti
- Universtiy of Liège Hospital, GIGA Cardiovascular Science, Heart Valve Clinic, Imaging Cardiology, Liège, Belgium and Gruppo Villa Maria Care and Research, Anthea Hospital, Bari, Italy
| | | | | | - Catherine M Otto
- Division of Cardiology, University of Washington School of Medicine, Seattle, WA, USA
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9
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Recommendations on the Echocardiographic Assessment of Aortic Valve Stenosis: A Focused Update from the European Association of Cardiovascular Imaging and the American Society of Echocardiography. J Am Soc Echocardiogr 2017; 30:372-392. [DOI: 10.1016/j.echo.2017.02.009] [Citation(s) in RCA: 763] [Impact Index Per Article: 95.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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10
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Katayama M, Chaliki HP. Diagnosis and management of patients with asymptomatic severe aortic stenosis. World J Cardiol 2016; 8:192-200. [PMID: 26981214 PMCID: PMC4766269 DOI: 10.4330/wjc.v8.i2.192] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2015] [Revised: 10/31/2015] [Accepted: 12/02/2015] [Indexed: 02/06/2023] Open
Abstract
Aortic stenosis (AS) is a disease that progresses slowly for years without symptoms, so patients need to be carefully managed with appropriate follow up and referred for aortic valve replacement in a timely manner. Development of symptoms is a clear indication for aortic valve intervention in patients with severe AS. The decision for early surgery in patients with asymptomatic severe AS is more complex. In this review, we discuss how to identify high-risk patients with asymptomatic severe AS who may benefit from early surgery.
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11
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Quader N, Wilansky S, Click RL, Katayama M, Chaliki HP. Visual Estimation of the Severity of Aortic Stenosis and the Calcium Burden by 2-Dimensional Echocardiography: Is It Reliable? JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2015; 34:1711-1717. [PMID: 26307124 DOI: 10.7863/ultra.15.14.11045] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Accepted: 12/16/2014] [Indexed: 06/04/2023]
Abstract
OBJECTIVES Guidelines have recommended aortic valve surgery in asymptomatic patients with severe aortic stenosis and a large aortic valve calcium burden. The purpose of this study was to determine whether visual assessment of aortic valve calcium and stenosis severity are reliable based on 2-dimensional echocardiography alone. METHODS We prospectively enrolled 68 patients with aortic stenosis and compared them with 30 control participants without aortic stenosis. All had aortic valve calcium score assessment by computed tomography. In a random order, 2-dimensional images without hemodynamic data were independently reviewed by 2 level 3-trained echocardiographers, who then classified these patients into categories based on aortic valve calcium and stenosis severity. RESULTS The 68 patients (mean age ± SD, 74 ± 10 years) were classified as having mild (n = 28), moderate (n = 22), and severe (n = 18) aortic stenosis. When the observers were asked to grade the degree of valve calcification, the agreement between them was poor (κ = 0.33-0.39). The visual ability to determine stenosis severity compared with Doppler echocardiography had high specificity (81% and 88% for observers 1 and 2). However, sensitivity was unacceptably low (56%-67%), and the positive predictive value was poor (44%-50%). Agreement was fair (κ= 0.58-0.69) between the observers for determining severe stenosis. CONCLUSIONS Our results suggest that visual assessment of aortic valve calcium has high interobserver variability; the visual ability to determine severe aortic stenosis has low sensitivity but high specificity. Our results may have important implications for treatment of patients with aortic stenosis and guiding the use of handheld echocardiography. Further research with larger cohorts is needed to validate the variability, sensitivity, and specificity reported in our study.
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Affiliation(s)
- Nishath Quader
- Division of Cardiovascular Diseases, Mayo Clinic, Scottsdale, Arizona USA (N.Q., S.W., M.K., H.P.C.); and Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota USA (R.L.C.)
| | - Susan Wilansky
- Division of Cardiovascular Diseases, Mayo Clinic, Scottsdale, Arizona USA (N.Q., S.W., M.K., H.P.C.); and Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota USA (R.L.C.)
| | - Roger L Click
- Division of Cardiovascular Diseases, Mayo Clinic, Scottsdale, Arizona USA (N.Q., S.W., M.K., H.P.C.); and Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota USA (R.L.C.)
| | - Minako Katayama
- Division of Cardiovascular Diseases, Mayo Clinic, Scottsdale, Arizona USA (N.Q., S.W., M.K., H.P.C.); and Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota USA (R.L.C.)
| | - Hari P Chaliki
- Division of Cardiovascular Diseases, Mayo Clinic, Scottsdale, Arizona USA (N.Q., S.W., M.K., H.P.C.); and Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota USA (R.L.C.).
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12
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Alzahrani H, Woo MY, Johnson C, Pageau P, Millington S, Thiruganasambandamoorthy V. Can severe aortic stenosis be identified by emergency physicians when interpreting a simplified two-view echocardiogram obtained by trained echocardiographers? Crit Ultrasound J 2015; 7:5. [PMID: 25932319 PMCID: PMC4409610 DOI: 10.1186/s13089-015-0022-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Accepted: 03/26/2015] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Aortic stenosis (AS) is a common valve problem that causes significant morbidity and mortality. The goal of this study was to determine whether an emergency physician (EP) could determine severe AS by reviewing only two B-mode echocardiographic views (parasternal long axis (PSLA) and parasternal short axis (PSSA)) obtained by trained echocardiographers. METHODS A convenience sample of 60 patients with no AS, mild/moderate AS or severe AS was selected for health record and echocardiogram review. The echocardiograms were performed in an accredited echocardiography laboratory. An EP blinded to the cardiologist's final report reviewed the PSLA and PSSA views after the cases were randomly sorted. Severe AS was defined as no cusp movement seen by the EP reviewers. A second EP independently reviewed 25% of randomly selected patients for inter-rater reliability. Collected data included patient demographics, EP interpretation and details of each echo view (quality, the number of cusps visualized, presence of calcification) and compared to final cardiology reports. Analyses included descriptive statistics, test characteristics for severe AS and kappa for agreement. RESULTS The mean age was 75.3 years (range 18 to 90) with 36.7% females. The cardiologist's diagnosis was as follows: 38.3% severe AS, 28.3% mild/moderate AS and 33.3% no AS. The PSSA view was poorer in quality compared with the PSLA (33.3% vs. 13.3%, p = 0.02), but the PSSA view was better than PSLA to visualize all three cusps (83.3% vs. 0%, p = 0.001). There was no difference in the presence of calcification between the mild/moderate and severe AS groups (94.1% vs. 100.0%, p = 0.46). The sensitivity and specificity for EP diagnosis of severe AS was 75.0% (95% CI 56.7% to 85.4%) and 92.5% (83.3% to 97.7%). The kappa for severe AS was 0.69 (0.41 to 0.85), and there was no significant difference between observers in the quality of the view, presence of aortic calcification and the number of cusps visible. CONCLUSIONS PSLA and PSSA views obtained by trained echocardiographers can be interpreted by an EP with appropriate training to identify severe AS with good specificity. Further larger prospective studies are required before widespread use by EPs.
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Affiliation(s)
- Hasan Alzahrani
- Department of Emergency Medicine, University of Ottawa, 1053 Carling Avenue, Ottawa, ON K1Y 4E9 Canada
| | - Michael Y Woo
- Department of Emergency Medicine, University of Ottawa, 1053 Carling Avenue, Ottawa, ON K1Y 4E9 Canada ; The Ottawa Hospital Research Institute, 40 Ruskin Street, Ottawa, Ontario K1Y 4W7 Canada
| | - Chris Johnson
- Division of Cardiology, University of Ottawa, 40 Ruskin Street, Ottawa, Ontario K1Y 4W7 Canada ; The Ottawa Hospital Research Institute, 40 Ruskin Street, Ottawa, Ontario K1Y 4W7 Canada
| | - Paul Pageau
- Department of Emergency Medicine, University of Ottawa, 1053 Carling Avenue, Ottawa, ON K1Y 4E9 Canada ; The Ottawa Hospital Research Institute, 40 Ruskin Street, Ottawa, Ontario K1Y 4W7 Canada
| | - Scott Millington
- Division of Critical Care, University of Ottawa, 1053 Carling Avenue, Ottawa, ON K1Y 4E9 Canada ; The Ottawa Hospital Research Institute, 40 Ruskin Street, Ottawa, Ontario K1Y 4W7 Canada
| | - Venkatesh Thiruganasambandamoorthy
- Department of Emergency Medicine, University of Ottawa, 1053 Carling Avenue, Ottawa, ON K1Y 4E9 Canada ; Department of Epidemiology and Community Medicine, University of Ottawa, 451 Smyth Road, Ottawa, Ontario K1H 8M5 Canada ; The Ottawa Hospital Research Institute, 40 Ruskin Street, Ottawa, Ontario K1Y 4W7 Canada
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Machida T, Izumo M, Suzuki K, Yoneyama K, Kamijima R, Mizukoshi K, Takai M, Kobayashi Y, Harada T, Miyake F, Ohtaki E, Nobuoka S, Matsumoto N, Akashi YJ. Value of anatomical aortic valve area using real-time three-dimensional transoesophageal echocardiography in patients with aortic stenosis: a comparison between tricuspid and bicuspid aortic valves. Eur Heart J Cardiovasc Imaging 2015; 16:1120-8. [DOI: 10.1093/ehjci/jev056] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 02/18/2015] [Indexed: 11/12/2022] Open
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Ramineni R, Almomani A, Kumar A, Ahmad M. Role of Multimodality Imaging in Transcatheter Aortic Valve Replacement. Echocardiography 2014; 32:677-98. [DOI: 10.1111/echo.12854] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Affiliation(s)
- Rajesh Ramineni
- Division of Cardiology; University of Texas Medical Branch; Galveston Texas
| | - Ahmed Almomani
- Department of Internal Medicine; University of Texas Medical Branch; Galveston Texas
| | - Arnav Kumar
- Department of Internal Medicine; University of Texas Medical Branch; Galveston Texas
| | - Masood Ahmad
- Division of Cardiology; University of Texas Medical Branch; Galveston Texas
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15
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Schoenhagen P, Hill A. Transcatheter aortic valve implantation and potential role of 3D imaging. Expert Rev Med Devices 2014; 6:411-21. [DOI: 10.1586/erd.09.18] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Koyama T, Okura H, Kume T, Fukuhara K, Imai K, Hayashida A, Neishi Y, Kawamoto T, Tanemoto K, Yoshida K. Impact of energy loss index on left ventricular mass regression after aortic valve replacement. J Echocardiogr 2013; 12:51-8. [PMID: 24955015 PMCID: PMC4042008 DOI: 10.1007/s12574-013-0196-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Revised: 10/15/2013] [Accepted: 10/28/2013] [Indexed: 01/20/2023]
Abstract
Background Recently, the energy loss index (ELI) has been proposed as a new functional index to assess the severity of aortic stenosis (AS). The aim of this study was to investigate the impact of the ELI on left ventricular mass (LVM) regression in patients after aortic valve replacement (AVR) with mechanical valves. Methods A total of 30 patients with severe AS who underwent AVR with mechanical valves was studied. Echocardiography was performed to measure the LVM before AVR (pre-LVM) (n = 30) and repeated 12 months later (post-LVM) (n = 19). The ELI was calculated as [effective orifice area (EOA) × aortic cross sectional area]/(aortic cross sectional area − EOA) divided by the body surface area. The LVM regression rate (%) was calculated as 100 × (post-LVM − pre-LVM)/(pre-LVM). A cardiac event was defined as a composite of cardiac death and heart failure requiring hospitalization. Results LVM regressed significantly (245.1 ± 84.3 to 173.4 ± 62.6 g, P < 0.01) at 12 months after AVR. The LVM regression rate negatively correlated with the ELI (R = −0.67, P < 0.01). By receiver operating characteristic (ROC) curve analysis, ELI <1.12 cm2/m2 predicted smaller (<−30.0 %) LVM regression rates (area under the curve = 0.825; P = 0.030). Patients with ELI <1.12 cm2/m2 had significantly lower cardiac event-free survival. Conclusion The ELI as well as the EOA index (EOAI) could predict LVM regression after AVR with mechanical valves. Whether the ELI is a stronger predictor of clinical events than EOAI is still unclear, and further large-scale study is necessary to elucidate the clinical impact of the ELI in patients with AVR.
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Affiliation(s)
- Terumasa Koyama
- Division of Cardiology, Kawasaki Medical School, 577 Matsushima, Kurashiki, 701-0192 Japan
| | - Hiroyuki Okura
- Division of Cardiology, Kawasaki Medical School, 577 Matsushima, Kurashiki, 701-0192 Japan
| | - Teruyoshi Kume
- Division of Cardiology, Kawasaki Medical School, 577 Matsushima, Kurashiki, 701-0192 Japan
| | - Kenzo Fukuhara
- Division of Cardiology, Kawasaki Medical School, 577 Matsushima, Kurashiki, 701-0192 Japan
| | - Koichiro Imai
- Division of Cardiology, Kawasaki Medical School, 577 Matsushima, Kurashiki, 701-0192 Japan
| | - Akihiro Hayashida
- Division of Cardiology, Kawasaki Medical School, 577 Matsushima, Kurashiki, 701-0192 Japan
| | - Yoji Neishi
- Division of Cardiology, Kawasaki Medical School, 577 Matsushima, Kurashiki, 701-0192 Japan
| | - Takahiro Kawamoto
- Division of Cardiology, Kawasaki Medical School, 577 Matsushima, Kurashiki, 701-0192 Japan
| | - Kazuo Tanemoto
- Division of Cardiovascular Surgery, Kawasaki Medical School, Kurashiki, Japan
| | - Kiyoshi Yoshida
- Division of Cardiology, Kawasaki Medical School, 577 Matsushima, Kurashiki, 701-0192 Japan
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O'Brien B, Schoenhagen P, Kapadia SR, Svensson LG, Rodriguez L, Griffin BP, Tuzcu EM, Desai MY. Integration of 3D Imaging Data in the Assessment of Aortic Stenosis. Circ Cardiovasc Imaging 2011; 4:566-73. [DOI: 10.1161/circimaging.111.964916] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Bridget O'Brien
- From the Heart and Vascular Institute (B.O., P.S., S.R.K., L.G.S., L.R., B.P.G., E.M.T., M.Y.D.) and Imaging Institute (P.S., L.R., M.Y.D.), the Cleveland Clinic, Cleveland, OH
| | - Paul Schoenhagen
- From the Heart and Vascular Institute (B.O., P.S., S.R.K., L.G.S., L.R., B.P.G., E.M.T., M.Y.D.) and Imaging Institute (P.S., L.R., M.Y.D.), the Cleveland Clinic, Cleveland, OH
| | - Samir R. Kapadia
- From the Heart and Vascular Institute (B.O., P.S., S.R.K., L.G.S., L.R., B.P.G., E.M.T., M.Y.D.) and Imaging Institute (P.S., L.R., M.Y.D.), the Cleveland Clinic, Cleveland, OH
| | - Lars G. Svensson
- From the Heart and Vascular Institute (B.O., P.S., S.R.K., L.G.S., L.R., B.P.G., E.M.T., M.Y.D.) and Imaging Institute (P.S., L.R., M.Y.D.), the Cleveland Clinic, Cleveland, OH
| | - Leonardo Rodriguez
- From the Heart and Vascular Institute (B.O., P.S., S.R.K., L.G.S., L.R., B.P.G., E.M.T., M.Y.D.) and Imaging Institute (P.S., L.R., M.Y.D.), the Cleveland Clinic, Cleveland, OH
| | - Brian P. Griffin
- From the Heart and Vascular Institute (B.O., P.S., S.R.K., L.G.S., L.R., B.P.G., E.M.T., M.Y.D.) and Imaging Institute (P.S., L.R., M.Y.D.), the Cleveland Clinic, Cleveland, OH
| | - E. Murat Tuzcu
- From the Heart and Vascular Institute (B.O., P.S., S.R.K., L.G.S., L.R., B.P.G., E.M.T., M.Y.D.) and Imaging Institute (P.S., L.R., M.Y.D.), the Cleveland Clinic, Cleveland, OH
| | - Milind Y. Desai
- From the Heart and Vascular Institute (B.O., P.S., S.R.K., L.G.S., L.R., B.P.G., E.M.T., M.Y.D.) and Imaging Institute (P.S., L.R., M.Y.D.), the Cleveland Clinic, Cleveland, OH
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Schoenhagen P, Hill A, Kelley T, Popovic Z, Halliburton SS. In Vivo Imaging and Computational Analysis of the Aortic Root. Application in Clinical Research and Design of Transcatheter Aortic Valve Systems. J Cardiovasc Transl Res 2011; 4:459-469. [DOI: 10.1007/s12265-011-9277-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2011] [Accepted: 03/30/2011] [Indexed: 10/18/2022]
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Abstract
Ultrasound applications in perioperative medicine have expanded enormously over the past decade. Transoesophageal echocardiography has been performed by anaesthetists during cardiac surgery for over 20 years. With the increasing availability of portable ultrasound systems, the use of ultrasound to assist in vascular cannulation and regional anaesthesia has been well described. Portable ultrasound systems come with a range of probes for different applications, including transthoracic echocardiography. While transthoracic echocardiography has traditionally been the domain of cardiologists, its use has been increasing in critical care, the emergency room and, recently, by anaesthetists in the perioperative period. Unlike formal cardiology-based transthoracic echocardiography, focused, goal-directed transthoracic echocardiography is often more appropriate in the perioperative period to address a particular question and can be performed in just a few minutes. Transthoracic echocardiography allows rapid, noninvasive, point-of-care assessment of ventricular function, valvular integrity, volume status and fluid responsiveness. It can help distinguish undifferentiated systolic murmurs preoperatively, give valuable information on the aetiology of unexplained hypotension and cardiovascular collapse and assess response to therapeutic interventions such as vasoactive drugs and volume resuscitation. Focused transthoracic echocardiography should include qualitative assessment of left and right ventricular function, an estimate of aortic valve gradient, right ventricular systolic pressure and intravascular volume status as minimum requirements. Transthoracic echocardiography is a valuable tool in the perioperative period and ideally the equipment and expertise should be available in all operating rooms.
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Affiliation(s)
- B. S. Cowie
- Department of Anaesthesia, St. Vincent's Hospital, Melbourne, Victoria, Australia
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20
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Puymirat E, Chassaing S, Trinquart L, Barbey C, Chaudeurge A, Bar O, Blanchard D. Hakki's formula for measurement of aortic valve area by magnetic resonance imaging. Am J Cardiol 2010; 106:249-54. [PMID: 20599011 DOI: 10.1016/j.amjcard.2010.03.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2009] [Revised: 03/02/2010] [Accepted: 03/02/2010] [Indexed: 11/18/2022]
Abstract
Hakki's formula (simplified Gorlin formula) can be used during cardiac catheterization to calculate the stenosed cardiac valve areas and can also be adapted to magnetic resonance imaging (MRI) to measure the stenosed cardiac valve areas. We evaluated the reliability of this approach to determine the severity of aortic stenosis compared to the continuity equation using transthoracic echocardiography and planimetry using MRI. We included all eligible symptomatic patients with known aortic stenosis referred to our department during a 1-year period. The aortic valve area (AVA) was estimated using Hakki's formula (MRI), planimetry (MRI), and the continuity equation (transthoracic echocardiography). The agreement among the measurement methods was analyzed using the Bland-Altman method. A total of 63 patients were included (mean age 72 +/- 10 years, 35 men [56%]). The mean AVA was 0.70 +/- 0.21 cm(2) using the continuity equation (transthoracic echocardiography), 0.67 +/- 0.18 cm(2) using planimetry (MRI), and 0.64 +/- 0.21 cm(2) using Hakki's formula (MRI). The mean difference was 0.03 cm(2) (95% limits of agreement -0.32 to 0.25) between planimetry and the continuity equation, 0.05 cm(2) (95% limits of agreement -0.40 to 0.29) between Hakki's formula and the continuity equation, 0.02 cm(2) (95% limits of agreement -0.20 to 0.25) between Hakki's formula and planimetry. The inter- and intraobserver reproducibility using Hakki's formula was excellent. In conclusion, measurement of the AVA using Hakki's formula yielded similar results to those obtained using planimetry and slightly different ones from those obtained using the continuity equation. However, Hakki's formula has the advantage of being easy to use, fast, and reproducible and can be used regardless of the status of the valve (in contrast to planimetry).
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de la Morena G, Saura D, Oliva MJ, Soria F, Gonzalez J, Garcia M, Moreno V, Bonaque JC, Valdes M. Real-time three-dimensional transoesophageal echocardiography in the assessment of aortic valve stenosis. EUROPEAN JOURNAL OF ECHOCARDIOGRAPHY 2009; 11:9-13. [DOI: 10.1093/ejechocard/jep154] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Schoenhagen P, Tuzcu EM, Kapadia SR, Desai MY, Svensson LG. Three-dimensional imaging of the aortic valve and aortic root with computed tomography: new standards in an era of transcatheter valve repair/implantation. Eur Heart J 2009; 30:2079-2086. [DOI: 10.1093/eurheartj/ehp260] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/29/2023] Open
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23
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Leye M, Brochet E, Lepage L, Cueff C, Boutron I, Detaint D, Hyafil F, Iung B, Vahanian A, Messika-Zeitoun D. Size-adjusted left ventricular outflow tract diameter reference values: a safeguard for the evaluation of the severity of aortic stenosis. J Am Soc Echocardiogr 2009; 22:445-51. [PMID: 19307102 DOI: 10.1016/j.echo.2009.02.007] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2008] [Indexed: 12/21/2022]
Abstract
OBJECTIVE We sought to evaluate the relationship among left ventricular outflow tract diameter (LVOTd), gender, and body surface area (BSA) and to evaluate the usefulness of size-adjusted LVOTd reference values in patients with aortic stenosis (AS). AS grading is based on the echocardiographic calculation of the aortic valve area (AVA) and requires LVOTd measurements, one main potential source of error. Transesophageal echocardiography (TEE) is reputed to be more accurate than transthoracic echocardiography (TTE), but validation studies are rare. A safeguard for LVOTd measurements is thus desirable. METHODS Since January 2006, 3 subsets of patients have been prospectively and concurrently enrolled: 1) TEE group: In 120 patients with and without AS, we prospectively measured LVOTd during both TTE and TEE. 2) Validation set: In 382 patients without aortic valve or ascending aorta diseases, we evaluated the relationship among LVOTd, gender, and BSA. 3) Testing set: In 173 patients with AS, we compared the AVA obtained using measured LVOTd (AVA(MEAS)) and calculated LVOTd derived from a regression determined in the validation set (AVA(CALC)). RESULTS TTE did not differ from and correlated well with TEE measurements overall (23 +/- 2 mm vs 23 +/- 2 mm, P = .26; r = 0.95, P < .0001) and in patients with AS (N = 43) (24 +/- 2 mm vs 24 +/- 3 mm, P = .15; r = 0.92, P < .0001). LVOTd was linearly correlated to BSA independently of gender (LVOTd = 5.7 * BSA+12.1; r = 0.55, P < .0001). In the testing set, AVA(CALC) did not differ from and correlated well with AVA(MEAS) (1.20 +/- 0.42 cm2 vs 1.23 +/- 0.40 cm2; P = .08; r = 0.89; P < .0001). CONCLUSION TTE and TEE measurements of the LVOTd provided similar results. LVOTd was significantly associated to BSA and LVOTd, derived from a linear regression linked to BSA independently of gender, provided an acceptable approximation of the AVA. Thus, although accurate measurement of LVOTd is a crucial part of the echocardiographic evaluation of AS severity, the present equation may be used as a safeguard when this measurement is difficult or not possible with TTE.
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Affiliation(s)
- Mohamed Leye
- AP-HP, Cardiology Department, Bichat Hospital, Paris, France
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24
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Leborgne L, Choplin Y, Renard C, Claeys M, Levy F, Jarry G, Rey JL, Remond A, Quiret JC, Tribouilloy C. Quantification of aortic valve area with ECG-gated multi-detector spiral computed tomography in patients with aortic stenosis and comparison of two image analysis methods. Int J Cardiol 2009; 135:266-9. [DOI: 10.1016/j.ijcard.2008.03.095] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2007] [Accepted: 03/07/2008] [Indexed: 10/21/2022]
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Shah RG, Novaro GM, Blandon RJ, Whiteman MS, Asher CR, Kirsch J. Aortic valve area: meta-analysis of diagnostic performance of multi-detector computed tomography for aortic valve area measurements as compared to transthoracic echocardiography. Int J Cardiovasc Imaging 2009; 25:601-9. [DOI: 10.1007/s10554-009-9464-z] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2009] [Accepted: 04/22/2009] [Indexed: 11/24/2022]
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Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice. J Am Soc Echocardiogr 2009; 22:1-23; quiz 101-2. [PMID: 19130998 DOI: 10.1016/j.echo.2008.11.029] [Citation(s) in RCA: 1362] [Impact Index Per Article: 85.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Baumgartner H, Hung J, Bermejo J, Chambers JB, Evangelista A, Griffin BP, Iung B, Otto CM, Pellikka PA, Quiñones M. Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice. EUROPEAN JOURNAL OF ECHOCARDIOGRAPHY 2008; 10:1-25. [PMID: 19065003 DOI: 10.1093/ejechocard/jen303] [Citation(s) in RCA: 727] [Impact Index Per Article: 42.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Imai K, Okura H, Kume T, Yamada R, Miyamoto Y, Kawamoto T, Watanabe N, Neishi Y, Toyota E, Yoshida K. C-Reactive protein predicts severity, progression, and prognosis of asymptomatic aortic valve stenosis. Am Heart J 2008; 156:713-8. [PMID: 18926152 DOI: 10.1016/j.ahj.2008.04.011] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2008] [Accepted: 04/14/2008] [Indexed: 02/08/2023]
Abstract
BACKGROUND C-Reactive protein (CRP) has been shown to play a pivotal role in the pathogenesis of atherosclerosis progression. The aim of this study was to assess whether CRP predicts severity, progression, and prognosis of aortic valve stenosis (AS). METHODS One hundred and thirty-five patients with asymptomatic AS were studied. Patients were diagnosed as mild (n = 18, aortic valve area [AVA] > or =1.5 cm(2)), moderate (n = 57, AVA 1.0-1.49 cm(2)), or severe AS (n = 60, AVA <1.0 cm(2)) by Doppler echocardiography. Patients with serial (baseline and at 1 year) echocardiographic examination (n = 47) were grouped as either slow (n = 22, DeltaAVA <-0.15 cm(2)/y) or rapid progression group (n = 25, DeltaAVA > or =-0.15 cm(2)/y). In addition, long-term prognosis was compared between patients with low CRP (n = 68, CRP <0.15 mg/dL) and those with high CRP (n = 67, CRP > or =0.15 mg/dL). RESULTS Baseline CRP was significantly higher in patients with severe AS than in those with mild or moderate AS (mild AS 0.17 +/- 0.43, moderate AS 0.22 +/- 0.28, severe AS 0.53 +/- 0.66 mg/dL, P = .001). By multivariate logistic regression analysis, CRP was an independent predictor of severe AS (odds ratio 3.51, P = .015). Similarly, CRP was significantly higher in the rapid progression group than in the slow progression group (0.56 +/- 0.76 vs 0.19 +/- 0.25 mg/dL, P = .004). Furthermore, long-term survival was significantly lower in the high CRP group than in the low CRP group (log rank: P < .001). CONCLUSION C-Reactive protein predicts severity, progression, and prognosis in patients with asymptomatic AS.
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Tanaka H, Shimada K, Yoshida K, Jissho S, Yoshikawa J, Yoshiyama M. The Simultaneous Assessment of Aortic Valve Area and Coronary Artery Stenosis Using 16-Slice Multidetector-Row Computed Tomography in Patients With Aortic StenosisComparison With Echocardiography. Circ J 2007; 71:1593-8. [PMID: 17895557 DOI: 10.1253/circj.71.1593] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Recent advancements in 16-slice multidetector-row computed tomography (16-slice MDCT) provide for non-invasive assessment of not only coronary artery disease (CAD), but also myocardial properties and the anatomy of the whole heart. The purpose of the present study was to investigate whether the aortic valve area (AVA) in patients with aortic stenosis (AS) assessed by 16-slice MDCT corresponds to echocardiographic assessment and to evaluate simultaneously the clinical accuracy in detecting CAD with 16-slice MDCT. METHODS AND RESULTS The AVA of 29 consecutive AS patients with transthoracic echocardiography (TTE) and 16-slice MDCT were analyzed. The AVA was estimated by means of the continuity equation method in 2-dimensional echocardiography (DE) and the quantitative planimetric method after multi-planar reformation in 16-slice MDCT. Concomitantly, the severity of the coronary artery stenosis was assessed by 16-slice MDCT. In the present study, the AVA assessed by TTE and 16-slice MDCT was 1.34+/-0.32 cm(2) and 1.38+/-0.32 cm(2), respectively. Regression analysis showed that the AVA in patients with AS determined by 16-slice MDCT correlated well with those determined by 2-DE (r=0.96, p<0.001). Significant coronary artery stenosis of more than 50% diameter reduction was present in 48% of the study population. CONCLUSIONS In patients with AS, the analysis of the severity of the AVA by 16-slice MDCT provides a feasible and accurate estimation with the concomitant evaluation of CAD.
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Affiliation(s)
- Hidemasa Tanaka
- The Division of Cardiovascular Medicine, Osaka Ekisaikai Hospital, 2-1-10 Honden, Nishi-ku, Osaka 550-0022, Japan.
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Feuchtner GM, Dichtl W, Friedrich GJ, Frick M, Alber H, Schachner T, Bonatti J, Mallouhi A, Frede T, Pachinger O, zur Nedden D, Müller S. Multislice Computed Tomography for Detection of Patients With Aortic Valve Stenosis and Quantification of Severity. J Am Coll Cardiol 2006; 47:1410-7. [PMID: 16580530 DOI: 10.1016/j.jacc.2005.11.056] [Citation(s) in RCA: 110] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2005] [Revised: 11/02/2005] [Accepted: 11/15/2005] [Indexed: 10/24/2022]
Abstract
OBJECTIVES The purpose of this study was to evaluate whether multislice computed tomography (MSCT) provides a reliable, noninvasive imaging modality for identification of patients with degenerative aortic valve stenosis (AS) by quantifying the aortic valve area (AVA) in comparison to the accepted diagnostic standard transthoracic echocardiography (TTE). BACKGROUND Management of patients with degenerative AS is based on the severity of disease. The severity of AS in clinical practice is assessed by TTE and classified as mild, moderate, or severe according to the AVA. METHODS Forty-six patients were examined with contrast-enhanced, electrocardiogram-gated, 16-row MSCT for the evaluation of the diagnostic accuracy. In 30 patients, quantification of the AVA with MSCT was compared to TTE using the continuity equation with Doppler velocity-time integral for calculation of the AVA. RESULTS Sensitivity of MSCT for the identification of patients with degenerative AS was 100%, and the specificity was 93.7%. Thirty of 46 patients had AS determined by TTE. Quantification of AVA by MSCT (mean AVA = 0.94 cm2) in patients with AS showed a good correlation to TTE (r = 0.89; p < 0.001). Bland-Altman plot illustrated good intermodality agreement between the two methods (limits of agreement, 0.20; 0.29). CONCLUSIONS Multislice computed tomography may provide an accurate, noninvasive imaging technique for detection of patients with AS and quantification of AVA.
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Affiliation(s)
- Gudrun M Feuchtner
- Clinical Department of Radiology II, Innsbruck Medical University, Innsbruck, Austria.
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Smith LA, Cowell SJ, White AC, Boon NA, Newby DE, Northridge DB. Contrast agent increases doppler velocities and improves reproducibility of aortic valve area measurements in patients with aortic stenosis. J Am Soc Echocardiogr 2004; 17:247-52. [PMID: 14981423 DOI: 10.1016/j.echo.2003.11.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Observer variability may limit assessment of aortic stenosis by Doppler echocardiography. This study aimed to assess whether echocardiographic contrast agent improves reproducibility of aortic valve area (AVA) measurements for patients with aortic stenosis. In all, 20 patients with aortic stenosis (67 +/- 10 years old) underwent noncontrast and contrast Doppler echocardiography on 2 occasions, 3 weeks apart. Intraobserver and interobserver coefficients of reproducibility were 0.36 and 0.20 cm for left ventricular outflow tract (LVOT) diameter, and 0.38 and 0.24 cm(2) for AVA, respectively. Although intraobserver reproducibility was unaffected, contrast improved interobserver reproducibility for LVOT diameter (mean of differences -0.02 +/- 0.07 cm vs 0.01 +/- 0.10 cm, P <.05) and AVA (mean of differences 0.02 +/- 0.10 cm(2) vs 0.07 +/- 0.12 cm(2), P <.05). Prevalve and postvalve velocities were increased with contrast compared with noncontrast imaging (prevalve, 1.07 +/- 0.20 vs 0.94 +/- 0.19 m/s, P <.01; postvalve, 3.76 +/- 0.87 vs 3.47 +/- 0.78 m/s, P <.01). We conclude that contrast significantly increases Doppler velocities and produces modest improvements in reproducibility of LVOT diameter and AVA. We suggest that, when assessing patients with aortic stenosis, contrast agents should be considered in patients who are difficult to image with poor baseline LVOT images or Doppler studies, or where there is poor interobserver reproducibility.
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Affiliation(s)
- Lindsay A Smith
- Cardiovascular Research, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh EH16 4SB, Scotland, UK.
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Dumont Y, Arsenault M. An alternative to standard continuity equation for the calculation of aortic valve area by echocardiography. J Am Soc Echocardiogr 2003; 16:1309-15. [PMID: 14652611 DOI: 10.1067/j.echo.2003.07.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Calculation of aortic valve area by echocardiography is sometimes technically difficult. We tested a modified continuity equation to help measure valve area in those difficult cases. The studies of 105 patients with aortic stenosis were analyzed retrospectively. We calculated aortic valve area by standard continuity equation and by the modified method where Doppler-derived stroke volume was replaced by the difference between diastolic and systolic volume according to Simpson's biplane method of disks. The correlation between the 2 methods was excellent. For patients with left ventricular outflow tract acceleration, modified continuity equation correlated better than standard continuity equation with invasively measured aortic valve area by Gorlin equation. We conclude that the modified method is accurate and becomes an attractive alternative to the conventional continuity equation especially for patients in whom stroke volume calculation by Doppler may be unreliable for technical reasons.
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Affiliation(s)
- Yannick Dumont
- Groupe de Recherche en Valvulopathies, Hôpital Laval Research Center, Quebec Heart Institute, Hôpital Laval, Laval University, Ste-Foy, Quebec, Canada
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Brasch AV, Luo H, Khan SS, Mirocha JM, DeRobertis M, Naqvi TZ, Jeon DS, Siegel RJ. Effect of harmonic imaging for planimetry on transthoracic echocardiography on visualization of the aortic valve. Am J Cardiol 2001; 88:1047-9. [PMID: 11704010 DOI: 10.1016/s0002-9149(01)01991-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- A V Brasch
- Division of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Maslow AD, Mashikian J, Haering JM, Heindel S, Douglas P, Levine R. Transesophageal echocardiographic evaluation of native aortic valve area: utility of the double-envelope technique. J Cardiothorac Vasc Anesth 2001; 15:293-9. [PMID: 11426358 DOI: 10.1053/jcan.2001.23272] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To assess the accuracy of aortic valve area (AVA) calculations using the continuity equation with data obtained from the double envelope (DE) (simultaneously obtained left ventricular outflow tract [V1]) and aortic valve [V2] velocities) during intraoperative transesophageal echocardiography (TEE). DESIGN Prospective study; measurements were performed on-line. SETTING University hospital. PARTICIPANTS Cardiac and noncardiac surgical patients (n = 75) with recent aortic valve assessment (<3 months) undergoing general anesthesia or endotracheal intubation. INTERVENTIONS Intraoperative AVA was measured by the continuity equation using the DE technique (DE/TEE) and by planimetry (PL/TEE). Left ventricular outflow tract diameter was obtained from midesophageal views, whereas subvalvular (V1) and valvular (V2) velocities were obtained simultaneously using continuous-wave Doppler from transgastric views. V1 was also obtained using pulsed-wave Doppler. Measurements were compared with AVA obtained preoperatively by the Gorlin equation during cardiac catheterization (G/CATH) or by transthoracic echocardiography using the traditional continuity equation (C/TTE) (nonsimultaneously obtained V1 and V2). MEASUREMENTS AND MAIN RESULTS A DE was obtained in 73 of 75 patients (97%). Four patients had atrial fibrillation at the time of the examination, whereas the rest were in sinus rhythm. PL/TEE was performed in 54 of 71 patients with sinus rhythm (76%). Agreement was good between DE/TEE and G/CATH (mean bias, 0.02 cm(2) [SD, 0.24 cm(2)]), and C/TTE (mean bias, -0.05 cm(2) [SD, 0.16 cm(2)]). Agreement was not as good between PL/TEE and G/CATH (mean bias, -0.07 cm(2) [SD, 0.28 cm(2)]) and C/TTE (mean bias, -0.13 cm(2) [SD, 0.30 cm(2)]). V1 obtained by pulsed-wave Doppler and with DE closely agreed (mean bias, 0.01 m/sec [SD, 0.05 m/sec]). CONCLUSION TEE evaluation of native AVA using the DE technique is feasible and in good agreement with that obtained by C/TTE and G/CATH. Compared with DE/TEE, PL/TEE did not agree as well. Use of DE/TEE should simplify the continuity equation and may minimize errors resulting from beat-to-beat variability in stroke volume.
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Affiliation(s)
- A D Maslow
- Departments of Anesthesia and Cardiology, Beth Israel-Deaconess Medical Center, Boston, MA, USA
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Abstract
Surgical therapy for congestive heart failure can offer gratifying results in selected elderly patients. Several trials have shown a survival advantage for surgical revascularization compared with medical therapy in the treatment of ischemic cardiomyopathy. Aortic valve replacement is highly effective in treating elderly patients with heart failure caused by severe aortic stenosis, and stentless aortic valves seem to provide a survival advantage in elderly patients with low-gradient aortic stenosis. Mitral valve repair with or without coronary revascularization has been used successfully in patients with severe mitral regurgitation. Transplantation is a viable but rarely used option for elderly patients with congestive heart failure. Totally implantable ventricular assist devices are an exciting new option for elderly patients with congestive heart failure who are not heart transplantation candidates.
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Affiliation(s)
- M S Slaughter
- Mechanical Assist Device Program and Surgery for Congestive Heart Failure, Christ Hospital and Medical Center, Oak Lawn, Illinois, USA
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Bermejo J, García-Fernández MA, Antoranz JC, Moreno MM, Delcán JL. Stress Echocardiography in Aortic Stenosis: Insights into Valve Mechanics and Hemodynamics. Echocardiography 1999; 16:689-699. [PMID: 11175211 DOI: 10.1111/j.1540-8175.1999.tb00126.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Stress interventions have been classically combined with cardiac catheterization recordings to understand the hemodynamic principles of valvular stenosis. Indices of aortic stenosis such as pressure gradient and valve area were based on simple hydraulic principles and have proved to be clinically useful for patient management during a number of decades. With the advent of Doppler echocardiography, these hemodynamic indices can be readily obtained noninvasively. Abundant evidence obtained using exercise and pharmacological stress echocardiography has demonstrated that the assumptions of classic hemodynamic models of aortic stenosis were wrong. Consequently, it is recognized that conventional indices may be misleading indicators of aortic stenosis significance in particular clinical situations. To improve diagnostic accuracy, several alternative hemodynamic models have been developed in the past few years, including valve resistance and left ventricular stroke work loss, among others. Nevertheless, these more-accurate indices should be obtainable noninvasively and need to demonstrate greater diagnostic and prognostic power than conventional indices; preliminary data suggest such superiority. Stress echocardiography is well established as the tool of choice for testing hypothesis and physical models of cardiac valve function. Although the final role of alternative indices is not yet well established, the new insights into valvular hemodynamics provided by this technique may change the clinical assessment of aortic stenosis.
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Affiliation(s)
- Javier Bermejo
- Laboratory of Echocardiography, Department of Cardiology, Hospital General Universitario Gregorio Marañón, Dr. Esquerdo 46, 28007 Madrid, Spain
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Arsenault M, Masani N, Magni G, Yao J, Deras L, Pandian N. Variation of anatomic valve area during ejection in patients with valvular aortic stenosis evaluated by two-dimensional echocardiographic planimetry: comparison with traditional Doppler data. J Am Coll Cardiol 1998; 32:1931-7. [PMID: 9857874 DOI: 10.1016/s0735-1097(98)00460-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Flow variations can affect valve-area calculation in aortic stenosis and lead to inaccuracies in the evaluation of the stenosis. Knowing that transvalvular flow varies normally within one beat, we designed this study to assess the response of the valve to intrabeat variation of flow during systole. Results were compared with flow-derived measurements. BACKGROUND Technological improvements now allow us to evaluate aortic valve area directly by short axis planimetry. This offers the possibility to perform serial planimetries during one ejection phase and analyze the intrabeat dynamic behavior of the stenotic-aortic valve and compare these measurements with flow-derived measurements. METHODS Forty echocardiograms displaying different degrees of aortic stenosis were analyzed by frame-by-frame planimetry of the valve area from onset of opening to complete closure. Maximal-mean area, opening and closing rates and ejection times were obtained and compared with Doppler-derived data. RESULTS Valve area varied during ejection. Stenotic valves opened and closed more slowly than normals and remained maximally open for a shorter period. Mean area by Doppler data corresponded more closely to maximal than to mean-planimetered area. Duration of flow was shorter than valve opening in severely stenotic valves. Discrepancies between Doppler-derived and two-dimensional (2D) measurements decreased in less stenotic valves. CONCLUSIONS Our observations reveal striking differences between the dynamics of normal and stenotic valves. Surprisingly, Doppler-derived mean-valve area correlated better with maximal-anatomic area than with mean-anatomic area in patients with aortic stenosis. Discrepancies between duration of flow and valve opening could explain this phenomenon.
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Affiliation(s)
- M Arsenault
- Non-invasive Cardiac Imaging Laboratory, Tufts University, New England Medical Center, Boston, Massachusetts, USA.
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