Aortic valve stenosis—multimodality assessment with PET/CT and PET/MRI

Aortic valve disease is the most common form of heart valve disease in developed countries and a growing healthcare burden with an ageing population. Transthoracic and transoesophageal echocardiography remains central to the diagnosis and surveillance of patients with aortic stenosis, providing gold standard assessments of valve haemodynamics and myocardial performance. However, other multimodality imaging techniques are being explored for the assessment of aortic stenosis, including combined PET/CT and PET/MR. Both approaches provide unique information with respect to disease activity in the valve alongside more conventional anatomic assessments of the valve and myocardium in this condition. This review investigates the emerging use of PET/CT and PET/MR to assess patients with aortic stenosis, examining how the complementary data provided by each modality may be used for research applications and potentially in future clinical practice.

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The evaluation of aortic stenosis, how the new guidelines are implemented across Europe: a survey by EACVI

European Heart Journal - Cardiovascular Imaging ◽

10.1093/ehjci/jeaa009 ◽

2020 ◽

Vol 21 (4) ◽

pp. 357-362 ◽

Cited By ~ 9

Author(s):

Blazej Michalski ◽

Marc R Dweck ◽

Nina Ajmone Marsan ◽

Matteo Cameli ◽

Antonello D’Andrea ◽

...

Keyword(s):

Aortic Stenosis ◽

Heart Diseases ◽

Imaging Techniques ◽

Cardiac Computed Tomography ◽

Transoesophageal Echocardiography ◽

Developed Countries ◽

Ageing Population ◽

Patient Pathways ◽

Valvular Heart Diseases ◽

European Society Of Cardiology

Abstract Aortic stenosis (AS) is the most prevalent valvular disease in developed countries, with a prevalence that is set to expand further with an ageing population. The most recent guidelines on valvular heart disease published by the European Society of Cardiology and the European Association for Cardio-Thoracic Surgery, aim to standardize the diagnosis and management of valvular heart diseases. The imaging criteria of the current guidelines are mostly based on EACVI Recommendations, with an appropriate diagnostic workflow being of major importance, to ensure streamlined and efficient patient assessment and accurate diagnoses and decisions regarding the timing of surgery. The EACVI Scientific Initiatives Committee, therefore, created a survey on the imaging assessment of patient with AS to investigate the diagnostic patient pathways used in different centres across Europe. In particular, we conducted this survey to better understand the use and access of advanced imaging techniques in AS including 3D transthoracic echocardiography and 3D transoesophageal echocardiography, cardiac computed tomography, and cardiovascular magnetic resonance.

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Extracellular Matrix in Calcific Aortic Valve Disease: Architecture, Dynamic and Perspectives

International Journal of Molecular Sciences ◽

10.3390/ijms22020913 ◽

2021 ◽

Vol 22 (2) ◽

pp. 913

Author(s):

Anna Di Vito ◽

Annalidia Donato ◽

Ivan Presta ◽

Teresa Mancuso ◽

Francesco Saverio Brunetti ◽

...

Keyword(s):

Extracellular Matrix ◽

Aortic Valve ◽

Aortic Valve Disease ◽

Matrix Vesicles ◽

Developed Countries ◽

Valve Disease ◽

Ageing Population ◽

Calcific Aortic Valve Disease ◽

Molecular Alterations ◽

Active Processes

Calcific Aortic Valve Disease (CAVD) is the most common valvular heart disease in developed countries and in the ageing population. It is strongly correlated to median age, affecting up to 13% of the population over the age of 65. Pathophysiological analysis indicates CAVD as a result of an active and degenerative disease, starting with sclerosis and chronic inflammation and then leaflet calcification, which ultimately can account for aortic stenosis. Although CAVD has been firstly recognized as a passive event mostly resulting from a degenerative aging process, much evidences suggests that calcification arises from different active processes, involving both aortic valve-resident cells (valve endothelial cells, valve interstitial cells, mesenchymal stem cells, innate immunity cells) and circulating cells (circulating mesenchymal cells, immunity cells). Moreover, a role for the cell-derived “matrix vesicles” and extracellular matrix (ECM) components has also been recognized. The aim of this work is to review the cellular and molecular alterations occurring in aortic valve during CAVD pathogenesis, focusing on the role of ECM in the natural course of the disease.

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Diagnosis and Management of Aortic Valve Stenosis: The Role of Non-Invasive Imaging

Journal of Clinical Medicine ◽

10.3390/jcm10163745 ◽

2021 ◽

Vol 10 (16) ◽

pp. 3745

Author(s):

Gloria Santangelo ◽

Andrea Rossi ◽

Filippo Toriello ◽

Luigi Paolo Badano ◽

David Messika Zeitoun ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Stenosis ◽

Clinical Decision Making ◽

Left Ventricular Systolic Dysfunction ◽

Imaging Techniques ◽

Systolic Dysfunction ◽

Clinical Decision ◽

Left Ventricular ◽

Heart Valve Disease ◽

Optimal Timing

Aortic stenosis is the most common heart valve disease necessitating surgical or percutaneous intervention. Imaging has a central role for the initial diagnostic work-up, the follow-up and the selection of the optimal timing and type of intervention. Referral for aortic valve replacement is currently driven by the severity and by the presence of aortic stenosis-related symptoms or signs of left ventricular systolic dysfunction. This review aims to provide an update of the imaging techniques and seeks to highlight a practical approach to help clinical decision making.

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Multimodality Imaging for Discordant Low-Gradient Aortic Stenosis: Assessing the Valve and the Myocardium

Frontiers in Cardiovascular Medicine ◽

10.3389/fcvm.2020.570689 ◽

2020 ◽

Vol 7 ◽

Author(s):

Ezequiel Guzzetti ◽

Mohamed-Salah Annabi ◽

Philippe Pibarot ◽

Marie-Annick Clavel

Keyword(s):

Aortic Valve ◽

Aortic Stenosis ◽

Clinical Decision Making ◽

Multimodality Imaging ◽

Imaging Techniques ◽

Significant Proportion ◽

Clinical Decision ◽

Myocardial Remodeling ◽

Positron Emission ◽

Detailed Assessment

Aortic stenosis (AS) is a disease of the valve and the myocardium. A correct assessment of the valve disease severity is key to define the need for aortic valve replacement (AVR), but a better understanding of the myocardial consequences of the increased afterload is paramount to optimize the timing of the intervention. Transthoracic echocardiography remains the cornerstone of AS assessment, as it is universally available, and it allows a comprehensive structural and hemodynamic evaluation of both the aortic valve and the rest of the heart. However, it may not be sufficient as a significant proportion of patients with severe AS presents with discordant grading (i.e., an AVA ≤ 1 cm2 and a mean gradient <40 mmHg) which raises uncertainty about the true severity of AS and the need for AVR. Several imaging modalities (transesophageal or stress echocardiography, computed tomography, cardiovascular magnetic resonance, positron emission tomography) exist that allow a detailed assessment of the stenotic aortic valve and the myocardial remodeling response. This review aims to provide an updated overview of these multimodality imaging techniques and seeks to highlight a practical approach to help clinical decision making in the challenging group of patients with discordant low-gradient AS.

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Heart valve disease (aortic valve disease): aortic regurgitation

10.1093/med/9780198726012.003.0033 ◽

2016 ◽

Author(s):

Christophe Tribouilloy ◽

Patrizio Lancellotti ◽

Ferande Peters ◽

José Juan Gómez de Diego ◽

Luc A. Pierard

Keyword(s):

Aortic Valve ◽

Aortic Regurgitation ◽

Transoesophageal Echocardiography ◽

Left Ventricular ◽

Valve Disease ◽

Doppler Imaging ◽

Heart Valve Disease ◽

Associated Lesions ◽

2D Echocardiography ◽

Asymptomatic Patients

Echocardiography is the cornerstone examination for the assessment of aortic regurgitation (AR): it provides reliable evaluation of the aortic valve and allows diagnosis and identification of the mechanism of regurgitation. The specific aetiology of the disease can be identified in the majority of cases. A combination of quantitative and quantitative Doppler and two-dimensional (2D) echocardiographic parameters allows the evaluation of the severity of AR and determination of the haemodynamic and left ventricular function repercussions. Echocardiography allows the detection of associated lesions of the aortic root or other valves. In symptomatic patients, echocardiography is essential to confirm the severity of AR. In asymptomatic patients with moderate or severe AR, echocardiography is essential for regular follow-up, by providing precise and reproducible measurements of LV dimensions and function, and for identifying patients who should be considered for elective surgical intervention. In most cases, transthoracic echocardiography (TTE) provides all of the necessary information and transoesophageal echocardiography in usually not required. Real-time three-dimensional (3D) TTE can be complementary to 2D echocardiography for the assessment of the mechanism and quantification of AR by increasing the level of confidence, especially when 2D echocardiographic data are inconclusive or discordant with clinical findings. Tissue Doppler imaging and especially the speckle tracking method are promising approaches to detect early LV dysfunction in patients with asymptomatic severe AR. Echocardiography is therefore the key examination for the assessment of AR and at the centre of the strategic discussion concerning the indications and timing of surgery.

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Heart valve disease (aortic valve disease): aortic stenosis

10.1093/med/9780198726012.003.0032 ◽

2016 ◽

Author(s):

Helmut Baumgartner ◽

Stefan Orwat ◽

Elif Sade ◽

Javier Bermejo

Keyword(s):

Aortic Valve ◽

Aortic Stenosis ◽

Systolic Function ◽

Integrated Approach ◽

Left Ventricular ◽

Valve Disease ◽

Low Flow ◽

Heart Valve Disease ◽

Lv Function ◽

Diagnostic Challenge

Echocardiography has become the gold standard for the assessment of patients with aortic stenosis (AS). It allows morphological assessment of the aortic valve and provides information on the aetiology of the disease. The quantification of AS includes primarily the measurement of transaortic jet velocities and gradients as well as the calculation of the valve area, thus combining flow-dependent and relatively flow-independent variables. Awareness of potential pitfalls is fundamental when assessing these variables. Haemodynamic consequences of AS on left ventricular (LV) size, wall thickness, and function as well as associated valve lesions and estimates of pulmonary artery pressure are required for the comprehensive evaluation of the disease. In the setting of classical low-flow–low-gradient AS with reduced LV systolic function, low-dose dobutamine echocardiography is of particular diagnostic and prognostic importance. The entity of severe low-flow–low-gradient AS in the presence of preserved LV function remains a particular diagnostic challenge. For accurate differentiation from pseudo-severe AS or misclassified moderate AS, an integrated approach including additional variables such as the extent of valve calcification by computed tomography may be required. In addition to the assessment of AS aetiology and quantification of its severity, echocardiography can provide predictors of outcome that may have a major impact on the decision for intervention.

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Advances in Transcatheter Aortic Valve Therapy in Bicuspid Aortic Valve Disease: Insight into Patient Selection, Management, and Future Directions

Surgical Technology Online ◽

10.52198/21.sti.39.cv1468 ◽

2021 ◽

Vol 39 ◽

Author(s):

Valeria Cammalleri ◽

◽

Gianpaolo Ussia ◽

Mario Lusini ◽

Ciro Mastroianni ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Stenosis ◽

Aortic Valve Replacement ◽

Valve Replacement ◽

Bicuspid Aortic Valve ◽

Aortic Valve Disease ◽

Multimodality Imaging ◽

Valve Disease ◽

Transcatheter Aortic Valve ◽

Transcatheter Valve

Bicuspid aortic valve (BAV) disease is the most common congenital abnormality and is characterized by a risk of premature aortic valve disease, predominantly aortic stenosis. Surgery remains the treatment of choice for patients with symptomatic BAV disease, but, in patients who are unsuitable for surgical aortic valve replacement, transcatheter aortic valve replacement (TAVR) is currently used as an alternative to surgery, although there is no official recommendation for their management, since BAV patients with severe aortic stenosis have been excluded from the major TAVR randomized clinical trials. Patients with BAV stenosis present anatomic challenges for treatment with TAVR. The BAV annulus often has an elliptical shape and is larger than the tricuspid valve, and is more likely to exhibit severe eccentric calcification. In addition, BAV is often associated with a dilated, horizontal ascending aorta, and effaced sinuses. The calcified raphe may also place differential stress on the expansion of the transcatheter valve, increasing the risk of suboptimal positioning and consequently the risk of paravalvular leakage, new pacemaker implantation, new-onset left bundle branch block, and annular rupture. Moreover, coronary obstruction may occur when leaflet fusion results in a longer leaflet. Although some of these challenges have been successfully overcome using new-generation devices, the complication rate is still relatively high and requires a deeper understanding of the patient’s specific complex and variable anatomy. Selection of the type and size of the transcatheter valve according to the patient’s individual anatomy is critical to achieving successful results. Therefore, given the increasing frequency of BAV stenosis in younger patients, and the worldwide expansion in the application of TAVR in younger and lower surgical-risk patients, preprocedural multimodality imaging involving CT scan and three-dimensional echocardiography is mandatory to understand the complex and variable anatomy of BAV disease and improve both procedural results and short- and long-term outcomes in these patients.

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Sex-Specific Features of Calcific Aortic Valve Disease

International Journal of Molecular Sciences ◽

10.3390/ijms21165620 ◽

2020 ◽

Vol 21 (16) ◽

pp. 5620 ◽

Cited By ~ 1

Author(s):

Volha I. Summerhill ◽

Donato Moschetta ◽

Alexander N. Orekhov ◽

Paolo Poggio ◽

Veronika A. Myasoedova

Keyword(s):

Aortic Valve ◽

Aortic Stenosis ◽

Aortic Valve Disease ◽

The Elderly ◽

Developed Countries ◽

Left Ventricular ◽

Valve Disease ◽

Calcific Aortic Valve Disease ◽

Men And Women ◽

Increased Risk

Calcific aortic valve disease (CAVD) is the most common valvular heart disease in developed countries predominantly affecting the elderly population therefore posing a large economic burden. It is a gradually progressive condition ranging from mild valve calcification and thickening, without the hemodynamic obstruction, to severe calcification impairing leaflet motion, known as aortic stenosis (AS). The progression of CAVD occurs over many years, and it is extremely variable among individuals. It is also associated with an increased risk of coronary events and mortality. The recent insights into the CAVD pathophysiology included an important role of sex. Accumulating evidence suggests that, in patients with CAVD, sex can determine important differences in the relationship between valvular calcification process, fibrosis, and aortic stenosis hemodynamic severity between men and women. Consequently, it has implications on the development of different valvular phenotypes, left ventricular hypertrophy, and cardiovascular outcomes in men and women. Along these lines, taking into account the sex-related differences in diagnosis, prognosis, and treatment outcomes is of profound importance. In this review, the sex-related differences in patients with CAVD, in terms of pathobiology, clinical phenotypes, and outcomes were discussed.

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Real-time observation of a high-echoic mass in the left ventricle during transcatheter aortic valve implantation: a case report

European Heart Journal - Case Reports ◽

10.1093/ehjcr/ytaa392 ◽

2020 ◽

Author(s):

Akiko Masumoto ◽

Takeshi Kitai ◽

Mitsuhiko Ota ◽

Kitae Kim ◽

Natsuhiko Ehara ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Stenosis ◽

Transcatheter Aortic Valve Implantation ◽

Severe Aortic Stenosis ◽

Cerebral Arteries ◽

Transoesophageal Echocardiography ◽

Transcatheter Aortic Valve ◽

Transcatheter Heart Valve ◽

Aortic Valve Implantation ◽

Valve Implantation

Abstract Background Increasing number of symptomatic patients with severe aortic stenosis is treated with transcatheter aortic valve implantation (TAVI). Stroke is one of the most serious complications of TAVI, and the majority of cerebral events in patients undergoing TAVI have an embolic origin. Case summary A 90-year-old female underwent trans-femoral TAVI for symptomatic severe aortic stenosis. Just before the implantation of the transcatheter heart valve (THV), transoesophageal echocardiography (TOE) showed a mobile, high-echoic mass attached to the THV, which gradually enlarged to 26 mm, then spontaneously detached from the THV and flowed up the ascending aorta, disappearing from the TOE field of. After the procedure, the patient presented with ischaemic stroke. The patient’s stroke was thought to have resulted from the embolism migrating to the distal cerebral arteries. Discussion The detailed images acquired with TOE during TAVI enabled the prompt identification of the unusual intracardiac mass.

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Valvular heart disease in autoimmune diseases in Mexico

European Heart Journal - Cardiovascular Imaging ◽

10.1093/ehjci/jeaa356.071 ◽

2021 ◽

Vol 22 (Supplement_1) ◽

Author(s):

J Aceituno Melgar ◽

JF Fritche-Salazar ◽

ME Soto-Lopez

Keyword(s):

Heart Disease ◽

Mitral Valve ◽

Aortic Valve ◽

Aortic Stenosis ◽

Autoimmune Diseases ◽

Tricuspid Valve ◽

Tricuspid Regurgitation ◽

Valvular Heart Disease ◽

Valve Disease ◽

Calcium Deposit

Abstract Funding Acknowledgements Type of funding sources: None. Background The autoimmune diseases (AD) have high morbidity and mortality due to their affection to the heart. Purpose Our objective was to describe the valvular heart disease (VHD) in patients with AD. Methods Patients with systemic lupus erythematous (SLE), rheumatoid arthritis (RA), and systemic sclerosis (SS) diagnosis were included, from January 1st 2008 to December 31th 2018. Prevalence rates of valve involvement were calculated. Results A total of 163 patients (57.6% with SLE, 23.3% with RA, 19.0% with SS) were included. The global prevalence of VHD was 5.4% in SLS, 23.6% en RA, and 15.9% in SS. The more affected valve in SLS was the tricuspid valve in 24% (12% with severe tricuspid regurgitation (STR), p = 0.028), in RA was the aortic valve in 26% (13% with severe aortic stenosis (SAS), p = 0.02), and with SS was the tricuspid valve in 48% (29% with moderate tricuspid regurgitation (MTR)). The calcium deposit was present in 66% in RA (37% in aortic valve, p < 0.001). The valve thickening (>5 mm) was higher in RA (50%, p < 0.001), with predominance in mitral valve (26%). Conclusions We found significant higher rates of STR in SLE, SAS in RA, and MTR in SS compared with the literature. Moreover, calcification and valve thickening were found more often in RA. Early diagnosis of subclinical VHD is mandatory to improve the long-term prognosis of these patients. Valvular heart disease. Autoimmune Disease (n = 163) P value* SLE (n = 94) RA (n = 38) ES (n = 31) Demographic characteristics Age, years. Gender, Male / Female, n Body Mass Index (kg/m2) Arterial hypertension, n (%) Diabetes Mellitus, n (%) 38.8 (12.6) 9/85 26.2 (5.9) 21(22.3%) 6 (6.3%) 62.45 (12.3) 7/31 26.6 (7.1) 14(36.8%) 4 (10.5%) 53.8 (13.3) 2/29 25.4 (4.7) 12 (38.7) 5 (16.1%) <0.001 NS NS NS NS Echocardiographic findings. Valve thickening Aortic Mitral 8 (9%) 1 (1%) 7 (7%) 19 (50%) 9 (24%) 10 (26%) 1 (3%) 0 1 (3%) <0.001 Calcium Deposit Aortic Mitral 4 (4%) 2 (2%) 2 (2%) 25 (66%) 14 (37%) 11 (29%) 8 (26%) 4 (12.8%) 4 (12.9%) <0.001 Aortic valve disease 4 (4%) 10 (26%) 0 Aortic stenosis Moderate Severe 0 0 0 7 (18%) 2 (5%) 5 (13%) 0 0 0 0,02 Moderate Aortic Regurgitation 4 (4%) 3 (8%) 0 NS Mitral valve disease 8 (9%) 2 (5%) 2 (6%) Mitral stenosis Moderate Severe 4 (4%) 2 (2%) 2 (2%) 1 (3%) 0 1 (3%) 1 (3%) 0 1 (3%) NS Mitral Regurgitation Moderate Severe 4 (4%) 2 (2%) 2 (2%) 1 (3%) 0 1 (3%) 1 (3%) 0 1 (3%) NS Tricuspid Regurgitation Moderate Severe 22 (24%) 11 (12%) 11 (12%) 8 (21%) 7 (18%) 1 (3%) 15 (48%) 9 (29%) 6 (19%) 0,028 Pulmonic valve disease Moderate Pulmonic Stenosis Moderate Pulmonic Regurgitation 6 (6%) 1 (1%) 5 (5%) 1 (3%) 0 1 (3%) 0 0 0 NS * Not Significant.

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