scholarly journals Size-adjusted aortic valve area: refining the definition of severe aortic stenosis

2020 ◽  
Author(s):  
Branka Vulesevic ◽  
Naozumi Kubota ◽  
Ian G Burwash ◽  
Claire Cimadevilla ◽  
Sarah Tubiana ◽  
...  
Keyword(s):  
Aortic Valve ◽  
Predictive Accuracy ◽  
Severe Aortic Stenosis ◽  
Aortic Valve Area ◽  
Obese Patients ◽  
Derivation Cohort ◽  
Wide Range ◽  
Definition Of ◽  
Diagnostic And Prognostic Value ◽  
Valve Area

Abstract Aims Severe aortic valve stenosis (AS) is defined by an aortic valve area (AVA) <1 cm2 or an AVA indexed to body surface area (BSA) <0.6 cm/m2, despite little evidence supporting the latter approach and important intrinsic limitations of BSA indexation. We hypothesized that AVA indexed to height (H) might be more applicable to a wide range of populations and body morphologies and might provide a better predictive accuracy. Methods and results In 1298 patients with degenerative AS and preserved ejection fraction from three different countries and continents (derivation cohort), we aimed to establish an AVA/H threshold that would be equivalent to 1.0 cm2 for defining severe AS. In a distinct prospective validation cohort of 395 patients, we compared the predictive accuracy of AVA/BSA and AVA/H. Correlations between AVA and AVA/BSA or AVA/H were excellent (all R2 > 0.79) but greater with AVA/H. Regressions lines were markedly different in obese and non-obese patients with AVA/BSA (P < 0.0001) but almost identical with AVA/H (P = 0.16). AVA/BSA values that corresponded to an AVA of 1.0 cm2 were markedly different in obese and non-obese patients (0.48 and 0.59 cm2/m2) but not with AVA/H (0.61 cm2/m for both). Agreement for the diagnosis of severe AS (AVA < 1 cm2) was significantly higher with AVA/H than with AVA/BSA (P < 0.05). Similar results were observed across the three countries. An AVA/H cut-off value of 0.6 cm2/m [HR = 8.2(5.6–12.1)] provided the best predictive value for the occurrence of AS-related events [absolute AVA of 1 cm2: HR = 7.3(5.0–10.7); AVA/BSA of 0.6 cm2/m2 HR = 6.7(4.4–10.0)]. Conclusion In a large multinational/multiracial cohort, AVA/H was better correlated with AVA than AVA/BSA and a cut-off value of 0.6 cm2/m provided a better diagnostic and prognostic value than 0.6 cm2/m2. Our results suggest that severe AS should be defined as an AVA < 1 cm2 or an AVA/H < 0.6 cm2/m rather than a BSA-indexed value of 0.6 cm2/m2.

scholarly journals P1692 The past returns after 20 years: a case report

2020 ◽  
Vol 21 (Supplement_1) ◽  
Author(s):  
S Habjan ◽  
D Cantisani ◽  
I S Scarfo` ◽  
M C Guarneri ◽  
G Semeraro ◽  
...  
Keyword(s):  
Heart Disease ◽  
Coronary Artery ◽  
Aortic Valve ◽  
Aortic Stenosis ◽  
Valvular Heart Disease ◽  
Radiation Treatment ◽  
Severe Aortic Stenosis ◽  
Aortic Valve Area ◽  
Radiation Induced ◽  
Valve Area

Abstract Introduction Radiation therapy is one of the cornerstones of treatment for many types of cancer. These patients can later in life develop cardiovascular complications associated with radiation treatment. Late cardiovascular effects of radiation treatment include coronary artery disease (CAD), valvular heart disease, congestive heart failure, pericardial disease and sudden death. The most common sign of radiation-induced valvular heart disease is the calcification of the intervalvular fibrosa between the aortic and mitral valve. Case presentation A 71-year-old male patient with a history of Non-Hodgkin lymphoma treated with radiotherapy and chemotherapy 20 years ago, CAD, arterial hypertension, diabetes type II, dyslipidemia, obesity and currently smoking presented in the emergency room in our medical facility with acute pulmonary edema. The patient had unstable angina pectoris in 2018, the coronary angiography showed two-vessel disease with a non-significant stenosis of the left main coronary artery (LMCA) and 70% stenosis of the left anterior descending artery (LAD), for which he refused the percutaneous coronary intervention. At the same time, a transthoracic echocardiography (TTE) showed severe aortic stenosis and moderately severe mitral stenosis, at that time the patient refused the operation. After the initial treatment for pulmonary edema, TTE and transesophageal echocardiography (TEE) were performed and showed a tricuspid aortic valve with calcification of the cusps and a very severe aortic stenosis (planimetric aortic valve area 0.74 cm², functional aortic valve area 0.55 cm², indexed functional aortic valve area 0.25 cm²/m², mean gradient 61 mmHg, peak gradient 100 mmHg, stroke volume (SV) 69 ml, stroke volume index (SVI) 31 ml/m², flow rate 221 ml/s, aortic annulus 20x26 mm). The left ventricle was severely dilated (end diastolic volume 268 ml) with diffuse hypokinesia and severe systolic dysfunction (ejection fraction 32%). We appreciated a calcification of the mitral-aortic intervalvular fibrosa and the mitral annulus, without mitral stenosis but with moderate mitral regurgitation. The calcification of the intervalvular fibrosa suggested our final diagnosis of radiation-induced valvular heart disease with a severe aortic stenosis in low-flow conditions. The patient was successfully treated with transcatheter aortic valve implantation (TAVI). Conclusion Radiation-induced heart disease is a common reality and is destinated to raise due to the increasing number of cancer survivors. Effects are seen also many years after the radiation treatment. The exact primary mechanism of radiation injury to the heart is still unknown. The treatment of radiation-induced valve disease is the same as the treatment of valve disease in the general population. Abstract P1692 Figure. Radiation-induced valvular heart disease

scholarly journals Percutaneous Balloon Aortic Valvuloplasty (Pbav) in a Child With Congenital Severe Aortic Stenosis –A Case Report

1970 ◽  
Vol 1 (2) ◽  
pp. 234-236
Author(s):  
AQM Reza ◽  
MSR Patwary ◽  
A Baqui
Keyword(s):  
Aortic Valve ◽  
Aortic Stenosis ◽  
Bicuspid Aortic Valve ◽  
Severe Aortic Stenosis ◽  
Systolic Pressure ◽  
Aortic Valve Area ◽  
Balloon Aortic Valvuloplasty ◽  
Percutaneous Balloon ◽  
Aortic Valvuloplasty ◽  
Valve Area

A 8 years old boy presented with shortness of breath, cough and palpitation and subsequently diagnosed as a case of severe aortic stenosis with bicuspid aortic valve. Percutaneous balloon aortic valvuloplasty (PBAV) was done and he became asymptomatic. Post procedure his aortic valve area and aortic systolic pressure increased, transaortic pressure gradient decreased. So good result, lower cost, elimination of drawbacks of thoracotomy and cardiopulmonary bypass suggest in children percutaneous balloon aortic valvuloplasty should be the treatment of choice for patients with severe aortic stenosis. Key Words: Percutaneous balloon aortic valvuloplasty, Severe aortic stenosis, Bicuspid aortic valve DOI: http://dx.doi.org/10.3329/cardio.v1i2.8241 Cardiovasc. j. 2009; 1(2): 234-236

Abstract 18065: Combining Echo Doppler and CT Derived LVOT Measurements Improve Accuracy of Continuity Equation Based Aortic Valve Area Determination

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Sami Alnasser ◽  
Asim Cheema ◽  
Vamshi Kotha ◽  
Djeven Deva ◽  
Jeremy Edwards ◽  
...  
Keyword(s):  
Aortic Valve ◽  
Aortic Stenosis ◽  
Correlation Coefficient ◽  
Continuity Equation ◽  
Severe Aortic Stenosis ◽  
Ventricular Outflow Tract ◽  
Left Ventricular ◽  
Aortic Valve Area ◽  
Left Ventricular Outflow ◽  
Valve Area

Background: Left ventricular outflow tract (LVOT) measurement by Echo falsely assumes circular LVOT with implications for aortic valve area (AVA) determined using continuity equation. In this study, we investigated the utility of combining Echo Doppler and computed tomography (CT) based LVOT area for precise AVA assessment. Methods: AVA-echo was calculated using continuity equation and standard echocardiography techniques. CT-LVOT area was measured by 3 independent readers. Blinded measurements were obtained in candidates for percutaneous aortic valve replacement. AVA-CT was calculated using CT-LVOT area and echo Doppler measurements. The inter-observer variability for CT-LVOT area and correlation between AVA-echo and AVA-CT was analyzed using intra-class (ICC) and Spearman correlation coefficient. Results: Complete data for 66 patients was analyzed. The ICC for CT derived LVOT measurement by three observers was 0.96 demonstrating excellent reliability. The LVOT area by echo was significantly smaller than that obtained by CT (3.43±0.8 vs. 4.45±1.2 cm2, p<0.0001) and showing moderate correlation (r=0.66, p=0.006). Similarly, the AVA-echo was significantly lower compared to AVA-CT (0.76±0.46 vs. 0.97±0.53 cm2, p<0.0001). The correlation coefficient for AVA-echo and AVA-CT was 0.7 (p < 0.0001), 0.4 (p=0.06) and 0.9 (p<0.0001) for AVA-echo of 0.8 cm2 respectively. The regression analysis showed that AVA-CT could be predicted by applying a correction factor to the AVA-echo as AVA-CT = AVA-echo x 1.1+0.14. Conclusion: CT provides accurate and reliable LVOT assessment. Combining CT-LVOT and echo Doppler measurements result in a larger AVA compared to AVA-echo representing a true anatomic measurement. These findings have important implications for grading of aortic stenosis and management of patients with moderate to severe aortic stenosis.

Abstract 4692: Impact of Pressure Recovery on Diagnosis of Severe Aortic Stenosis in Asymptomatic Patients. (A SEAS Substudy)

Circulation ◽  
2008 ◽  
Vol 118 (suppl_18) ◽  
Author(s):  
Edda Bahlmann ◽  
Dana Cramariuc ◽  
Eva Gerdts ◽  
Christa Gohlke-Baerwolf ◽  
Chritoph Nienaber ◽  
...  
Keyword(s):  
Aortic Valve ◽  
Aortic Stenosis ◽  
Energy Loss ◽  
Severe Aortic Stenosis ◽  
Pressure Recovery ◽  
Doppler Velocity ◽  
Aortic Valve Area ◽  
Total Study Population ◽  
Asymptomatic Patients ◽  
Valve Area

Background: Downstream pressure recovery (PR) in the aorta affects transvalvular pressure gradient measurement and calculation of aortic valve area by continuity equation in patients with aortic stenosis (AS). Methods: To assess the clinical importance of PR on evaluation of severity of AS, echocardiographic data in 1562 patients with asymptomatic aortic stenosis (mean age 67 ± 10, 39% women, 51% hypertensive) recruited in the Simvastatin Ezitimibe in Aortic Stenosis (SEAS) study was used. The inner diameter of the ascending aorta was measured at annulus and at sinutubular junction. The aortic valve area (AVAI) was calculated from annular diameter and velocity time integrals from sub- and transaortic flow by Doppler. PR and PR corrected AVAI assessed as energy loss index (ELI) were calculated by previously published equations. Severe aortic stenosis was defined as AVAI <0.60cm 2 /m 2 and ELI <0.55cm 2 /m 2 , respectively. Patients were grouped into tertiles of peak transaortic Doppler velocity (<2.79, 2.79 –3.32, ≥3.33 m/sec, respectively). Results: In the total study population, PR ranged from 1.22–16.75 mmHg (mean 5.9±2.3), AVAI from 0.20 –1.85 cm 2 /m 2 (mean 0.67±0.22) and ELI from 0.22–5.94 cm 2 /m 2 (mean 0.89±0.45). PR increased significantly with severity of AS (Table 1 ). Both AVAI and ELI decreased with increasing peak transaortic velocity, and the overestimation of AS severity by using unadjusted AVA was largest in the lowest tertile (Table 1 ). Conclusion: Severity of AS is often overestimated in milder degrees of asymptomatic AS if correction for pressure recovery is not performed. Adjustment of AVA for the effect of energy loss should be performed routinely, and this may be especially important for accuracy of severity assessment in patients with relatively low transvalvular velocities. Table 1

scholarly journals Evaluation of low gradient severe aortic stenosis: should we change our outlook in the analysis of clinical data?

Open Heart ◽  
2021 ◽  
Vol 8 (2) ◽  
pp. e001746
Author(s):  
Ivan Corazza ◽  
Margherita Zecchi ◽  
Romano Zannoli
Keyword(s):  
Clinical Practice ◽  
Aortic Valve ◽  
Aortic Stenosis ◽  
Doppler Echocardiography ◽  
Technological Progress ◽  
Severe Aortic Stenosis ◽  
Aortic Valve Area ◽  
Physiological Models ◽  
Pathological Conditions ◽  
Valve Area

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.

scholarly journals At what flow rate does aortic valve gradient become severely elevated? Implications for guideline recommendations on aortic valve area cutoffs

2021 ◽  
Author(s):  
Wilbert Aronow ◽  
Ayesha Salahuddin ◽  
Daniel Spevack
Keyword(s):  
Aortic Valve ◽  
Linear Regression ◽  
Aortic Stenosis ◽  
Flow Rate ◽  
Aortic Valve Area ◽  
Flow Rates ◽  
Wide Range ◽  
The Relationship ◽  
Valve Area

IntroductionSince many patients with AVA < 1.0 cm2 do not manifest a mAVG > 40 mmHg, we sought to determine the AVA at which mAVG tends to exceed 40 mmHg in a sample of subjects with varied transvalvular flow rates.Material and methodsWe selected 200 subjects with an AVA< 1.0 cm2. The sample was selected to include subjects with a varied mean systolic flow (MSF) rates. Linear regression was performed to determine the relationship between MSF and mAVG. Since this relationship varied by AVA, the regression was stratified by AVA (critical <0.6 cm2, severe 0.6-0.79 cm2 , moderately severe 0.8-0.99 cm2)ResultsThe study sample was 79 ± 12 years-old and was 60% female. The MSF rate at which mAVG tended to exceed 40 mmHg was 120 ml/s for critical AVA, 183 ml/s for severe AVA and 257 ml/s for moderately severe AVA. Those with moderately severe AVA rarely (8%) had a mAVG > 40 mmHg at a wide range of MSF. In contrast, those with severe AVA typically (75%) had mAVG > 40 mmHg when MSF was normal (>200 ml/s). Those with critical AVA frequently (44%) had mAVG > 40 mmHg, even when MSF was reduced.ConclusionsAVA > 0.8 cm2 was rarely associated with mAVG > 40 mmHg, even when transvalvular flow rate was normal. Consideration should therefore be given to either raising the cutoff AVA or lowering the mAVG at which aortic stenosis is considered severe.

Abstract 4290: Risk Factors and Prognostic Implications of Mitral Regurgitation in Severe Aortic Stenosis

Circulation ◽  
2008 ◽  
Vol 118 (suppl_18) ◽  
Author(s):  
Padmini Varadarajan ◽  
Ramdas G Pai
Keyword(s):  
Risk Factors ◽  
Aortic Valve ◽  
Mitral Regurgitation ◽  
Aortic Stenosis ◽  
Independent Predictor ◽  
Severe Aortic Stenosis ◽  
Aortic Valve Area ◽  
List Type ◽  
Prognostic Implications ◽  
Valve Area

Introduction: Mitral regurgitation (MR) is present in nearly half of the patients with severe aortic stenosis (AS). Risk factors for its development and its prognostic implications are not clear. Methods: Search of our echocardiographic database between 1993 to 2003 yielded 740 patients with severe AS defined as aortic valve area (AVA) ≤ 0.8cm2. Thorough chart reviews were conducted to collect clinical and pharmacological data. Mortality data was obtained from National death index. Results: Patient characteristics: age 74±13 years; females 60%, EF 54±20%, aortic valve area 0.67±0.17 cm2. MR grade ≥2+ were present in 339 (46%) patients: 2+ in 166 (22%), 3+ in 115 (16%) and 4+ in 58 (8%). There was a progressive decrease in survival with each grade of MR in the whole cohort as well as the surgically and medically treated subsets (p<0.0001, figure ). Presence of 3 and 4+ MR was associated with a larger LV (p<0.0001), lower EF (p<0.0001), greater age (p=0.0001), a smaller aortic valve area (p=0.001) and female gender (p=0.003). It remained an independent predictor of lower survival after adjusting for group differences using the Cox regression model. There was a lower AVR rate in those with 3 or 4+ MR compared to the rest (32 vs. 41%, p=0.03) despite a distinct independent survival advantage with AVR (RR 0.40, p<0.0001). Conclusion: Significant MR is present in nearly half of the patients with severe AS. The risk factors for its development include age, greater AS severity and LV dysfunction. It is an independent predictor of reduced survival.

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