scholarly journals When Aortic Stenosis Is Not Alone: Epidemiology, Pathophysiology, Diagnosis and Management in Mixed and Combined Valvular Disease

2021 ◽  
Vol 8 ◽  
Author(s):  
Francesca Mantovani ◽  
Diego Fanti ◽  
Elvin Tafciu ◽  
Simone Fezzi ◽  
Martina Setti ◽  
...  
Keyword(s):  
Aortic Stenosis ◽  
Aortic Regurgitation ◽  
Treatment Strategies ◽  
Valve Disease ◽  
Clinical Implications ◽  
Diagnosis And Management ◽  
Valve Prostheses ◽  
Transcatheter Valve ◽  
Valvular Lesion ◽  
Valve Diseases

Aortic stenosis (AS) may present frequently combined with other valvular diseases or mixed with aortic regurgitation, with peculiar physio-pathological and clinical implications. The hemodynamic interactions between AS in mixed or combined valve disease depend on the specific combination of valve lesions and may result in diagnostic pitfalls at echocardiography; other imaging modalities may be helpful. Indeed, diagnosis is challenging because several echocardiographic methods commonly used to assess stenosis or regurgitation have been validated only in patients with the single-valve disease. Moreover, in the developed world, patients with multiple valve diseases tend to be older and more fragile over time; also, when more than one valvular lesion needs to address the surgical risk rises together with the long-term risk of morbidity and mortality associated with multiple valve prostheses, and the likelihood and risk of reoperation. Therefore, when AS presents mixed or combined valve disease, the heart valve team must integrate various parameters into the diagnosis and management strategy, including suitability for single or multiple transcatheter valve procedures. This review aims to summarize the most critical pathophysiological mechanisms underlying AS when associated with mitral regurgitation, mitral stenosis, aortic regurgitation, and tricuspid regurgitation. We will focus on echocardiography, clinical implications, and the most important treatment strategies.

New Trends and Developments in Patients with Severe Aortic Stenosis – Towards Optimal Treatment?

2009 ◽  
Vol 5 (2) ◽  
pp. 81 ◽  
Author(s):  
Martijn WA van Geldorp ◽  
Johanna JM Takkenberg ◽  
Ad JJC Bogers ◽  
A Pieter Kappetein ◽  
◽  
...  
Keyword(s):  
Aortic Stenosis ◽  
Severe Aortic Stenosis ◽  
Surgical Techniques ◽  
Treatment Strategies ◽  
Tissue Doppler ◽  
Doppler Imaging ◽  
Treatment Modalities ◽  
Diagnostic Tools ◽  
Number Of Patients ◽  
Transcatheter Valve

Over the next few decades the number of patients diagnosed with aortic stenosis is expected to rise as the population ages and the use of several diagnostic tools expands. This will result in a growing need for both medical and surgical treatment and stimulate the development of new diagnostic and surgical techniques. This article briefly describes the prevalence, pathogenesis and clinical presentation of patients with aortic stenosis and focuses on developments in diagnostic tools, treatment strategies and treatment modalities: the use of echocardiography, tissue Doppler imaging, stress testing and biomarkers is discussed, as well as timing of surgery and the role microsimulation can play in prosthesis selection. Furthermore, newly developed transcatheter valve implantation techniques and their possible role in treating ‘inoperable’ or ‘elderly’ patients are discussed.

Abstract 2312: High Prevalence of Novel Amyloid Protein Deposition in Surgically Removed Heart Valves

Circulation ◽  
2008 ◽  
Vol 118 (suppl_18) ◽  
Author(s):  
Arnt V Kristen ◽  
Bettina Winter ◽  
Burkhard M Helmke ◽  
Philipp A Schnabel ◽  
Stefan Hardt ◽  
...  
Keyword(s):  
Mitral Regurgitation ◽  
Aortic Stenosis ◽  
Aortic Regurgitation ◽  
Mitral Stenosis ◽  
Heart Valves ◽  
Amyloid Fibrils ◽  
Amyloid Deposition ◽  
Valve Disease ◽  
Amyloid Proteins ◽  
Clinical Indicators

Amyloid deposition has been described in degenerative cardiac valve failure, but the prevalence, pathophysiology, and clinical indicators have not been clarified yet. Extensive histological analysis of 150 consecutive, surgically resected heart valve specimens (aortic n = 119, mitral n ± 31; 67.4 ± 1.0 years) was performed. Amyloid deposition was graded semi-quantitatively and classified by specific antisera identifying the most common amyloid proteins. Histological findings were correlated with clinical data. 119 patients had aortic valve disease: aortic stenosis (AS; 100/119; 84%), aortic regurgitation (19/119; 16%); 31 patients had mitral valve disease: mitral stenosis (7/31; 22.6%), mitral regurgitation (24/3177.4%). Amyloid was found in 83/150 (55.3%) specimens with the highest prevalence in aortic stenosis (74/100; 74%), intermediate in mitral stenosis (n = 2/7; 28.6%) and mitral regurgitation (n = 7/24; 29.2%), and lowest in aortic regurgitation (2/19; 10.5%). Moderate to severe amyloid deposition was almost exclusively found in aortic stenosis. Similarily coarse polymorphic amyloid deposits by morphologic analysis were most abundant in aortic stenosis (n = 35/100; 35%). Filamentous cloudy amyloid patterns occurred with the same frequency in aortic stenosis (n = 29/100; 29%). A combination of both was only found in aortic stenosis (n = 7/100; 7%). By immunohistochemical staining none of the most common amyloid proteins was identified. Some of the specimens were weakly stained by the apolipoprotein-AI antibody, more markedly adjacent to the amyloid fibrils. Amyloid deposition in aortic stenosis depended on hyperlipidemia, echocardiographic valvular thickening, and - by trend - on the presence of coronary artery disease, and obesity. Dystrophic valvular amyloidosis appears to represent an underestimated local manifestation of progressive destruction and scarring with diverse deposition pattern predominantly affecting stenotic aortic valves. It appears to depend on risk factors for atheroinflammatory processes and high shear-stress hemodynamic. The underlying protein structure has to be clarified in further studies.

Ventricular mechanics in patients with aortic valve disease: longitudinal, radial, and circumferential components

2013 ◽  
Vol 24 (1) ◽  
pp. 105-112 ◽  
Author(s):  
Benedetta Leonardi ◽  
Renee Margossian ◽  
Stephen P. Sanders ◽  
Marcello Chinali ◽  
Steven D. Colan
Keyword(s):  
Aortic Valve ◽  
Aortic Stenosis ◽  
Aortic Regurgitation ◽  
Aortic Valve Disease ◽  
Longitudinal Strain ◽  
Circumferential Strain ◽  
Wall Stress ◽  
Left Ventricular ◽  
Valve Disease ◽  
Mass Volume

AbstractBackgroundReduced long-axis shortening despite enhanced global function has been reported in aortic stenosis. We sought to improve the understanding of this phenomenon using multi-dimensional strain analysis in conjunction with the evaluation of left ventricular rotation and twist – ventricular torsion – using tissue Doppler techniques.MethodsA total of 57 patients with variable severity of aortic stenosis, aortic regurgitation, or mixed aortic valve disease, subdivided into six groups, were studied. Ventricular morphology was assessed using long-axis/short-axis and mass/volume ratios, afterload using end-systolic meridional wall stress, and global performance using ejection fraction. The circumferential and longitudinal strain was measured from two-dimensional images, and left ventricular rotation and twist were estimated as the difference in rotation between the base and apex of the ventricle.ResultsAortic stenosis was associated with higher mass/volume, ejection fraction, circumferential strain and left ventricular rotation and twist, significantly lower end-systolic wall stress, and a trend towards lower longitudinal strain compared with normal. Myocardial mechanics in aortic regurgitation were normal despite ventricular dilation. Mixed aortic valve disease showed findings similar to aortic stenosis. Left ventricular rotation and twist correlated with midwall circumferential strain (r = 0.62 and p < 0.0001), endocardial circumferential strain (r = 0.61 and p < 0.0001), and end-systolic wall stress (r = 0.48 and p < 0.0001), but not with longitudinal strain (r = 0.18 and p > 0.05).ConclusionsMyocardial mechanics are normal in patients with aortic regurgitation, independent of abnormalities in cardiac geometry. Conversely, in aortic stenosis and mixed aortic valve disease, significant alterations in the patterns of fibre shortening are found. The effects of stenosis on cardiac function seem to dominate the effect of ventricular remodelling.

scholarly journals Superimposed tissue formation in human aortic valve disease: differences between stenotic and regurgitant valves

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
B P T Kruithof ◽  
A L Van Wijngaarden ◽  
B Mousavi Gourabi ◽  
M Palmen ◽  
N Ajmone Marsan
Keyword(s):  
Aortic Valve ◽  
Aortic Stenosis ◽  
Aortic Regurgitation ◽  
Aortic Valve Disease ◽  
Smooth Muscle Actin ◽  
Body Part ◽  
Free Edge ◽  
Mechanical Stresses ◽  
The Body ◽  
Valve Disease

Abstract Introduction The formation of superimposed tissue (SIT), a layer on top of the original valve leaflet, has been described in patients with mitral regurgitation, as a major contributor of valve thickening and probably secondary to increased valve mechanical stress. However, little is known whether SIT formation also occurs in aortic valve disease. Both in the case of aortic stenosis or aortic regurgitation, the aortic valve (AV) is subjected to increased mechanical stresses, although different in type, extent and location. Purpose To characterize SIT formation in aortic stenosis and regurgitation. Methods Human diseased AV leaflets (n=31) were obtained from patients undergoing aortic valve replacement because of aortic stenosis (n=17) or aortic regurgitation (n=14). Histological analysis was performed and elastin staining was used to distinguish the SIT from the original leaflet. Alpha-smooth muscle actin (SMA) staining was performed to identify myofibroblasts and Masson's Trichrome staining to identify collagen fibres. Results In both regurgitant leaflets (RL) and stenotic leaflets (SL) SIT was found at both the ventricular and aortic side (94% of SL, 93% of RL) and could reach up to 50% of total leaflet thickness (Fig. A-C). Although the average SIT thickness did not differ between SL and RL (0.30 mm, standard error of the mean (SEM): ±0.04 for SL vs 0.38 mm, SEM: ±0.05 for RL; p=0.61), the distribution of SIT differed. The SIT at the free edge of the aortic valve was significantly thicker in the RL (0.39 mm, SEM: ±0.06 for SL vs 0.88 mm, SEM: ± 0.07 for RL; p&lt;0.0001), whereas the SIT at the aortic side of the body part was thicker in the SL (0.099 mm, SEM: ±0.023 for SL vs 0.033 mm, SEM: ± 0.021 for RL; p&lt;0.05). Although the SIT comprised of various compositions of extracellular matrix, the overall collagen content was higher in SIT of the SL (212 a.u., SEM: ±4.37 for SL vs 169 a.u., SEM: ±4.06 for RL; p&lt;0.0001). Myofibroblasts were predominantly observed in the SIT as compared to the original leaflet in SL and RL (Fig. D,E; myofibroblast-positive area: 11.6%, SEM: ±3.1 for SIT vs 1.2%, SEM: ±0.3 for original leaflet; p&lt;0.001). The density of myofibroblast in the SIT of the body part of the aortic leaflet, however, was higher in the SL (myofibroblast-positive area: 15.5%, SEM: ±2.0 for SL vs 4.1%, SEM: ±1.3 for RL; p&lt;0.01), whereas the density of myofibroblast in the SIT of the free edge was higher in the RL (myofibroblast-positive area: 15.3%, SEM: ±3.7 for SL vs 4.0%, SEM: ±1.4 for RL; p&lt;0.001). Conclusions Both in aortic stenosis and aortic regurgitation, the AV is characterized by SIT formation but with difference in distribution and composition. These observations suggest the involvement of hemodynamic and mechanical stresses in the regulation of SIT formation of the AV. Understanding the formation of SIT might provide new insights in pathology of AV disease. FUNDunding Acknowledgement Type of funding sources: None.

Can Aortic Regurgitation Evolve into Aortic Stenosis? New Insights on Mixed Aortic Valve Disease

2020 ◽  
Vol 33 (3) ◽  
pp. 406-408 ◽  
Author(s):  
Li-Tan Yang ◽  
Patricia A. Pellikka ◽  
Maurice Enriquez-Sarano ◽  
Sushil A. Luis ◽  
Ratnasari Padang ◽  
...  
Keyword(s):  
Aortic Valve ◽  
Aortic Stenosis ◽  
Aortic Regurgitation ◽  
Aortic Valve Disease ◽  
Valve Disease

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

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.

Sign in / Sign up

Export Citation Format

Share Document