Outcomes and survival with aortic valve replacement compared with medical therapy in patients with low-, moderate-, and severe-gradient severe aortic stenosis and normal left ventricular ejection fraction

Background: This study determined outcomes and survival with aortic valve replacement (AVR) versus medical therapy in patients with normal left ventricular ejection fraction (LVEF) with severely reduced aortic valve areas (AVA) but nonsevere mean gradients. Methods: We identified 248 aortic stenosis (AS) patients with LVEF ≥ 50% and echocardiographic AVA < 1.0 cm². Group 1 had low‐gradient: <30 mmHg mean gradient; group 2 (moderate: 30 to 40 mm Hg); and group 3 (severe: >40 mm). Results: There were 94, 87, and 67 patients in groups 1, 2, and 3. Incidence of death in groups 1, 2, and 3 were 55%, 39%, and 39% (P not significant). Incidence of AVR in groups 1, 2, and 3 were 23%, 53%, and 49% (P < 0.0001 for group 1 vs. 2; P = 0.0003 for group 1 vs. group 3). Incidence of AVR or death was 71%, 77%, and 76% (P not significant). AVR (hazard ratio = 0.30; 95% CI, 0.18, 0.51; P < 0.0001) and mitral annular calcification (hazard ratio = 2.33; 95% CI, 1.40, 3.88; P = 0.001) were independently associated with time to mortality. Kaplan–Meier curves for time to death did not differ significantly among the three groups. Kaplan–Meier survival curves for patients with and without AVR showed patients in all three groups who underwent AVR had significantly greater survival. Conclusion: Among patients with normal LVEF and AVA < 1.0 cm², overall survival does not differ among those with low‐, moderate‐, or severe‐aortic valve gradients. Survival is significantly improved with AVR, regardless of gradient. (Echocardiography 2011;28:378‐387)     

Bicuspid aortic valve morphology when associated with coarctation of the aorta

Thirteen children and young adults with coarctation of the aorta as their principal cardiovascular abnormality, 11 with bicuspid aortic valves, were evaluated by orifice-view aortography to evaluate their aortic valvular morphology. For comparison 30 individuals with aortic valvular deformities but without coarctation of the aorta were similarly studied. Two distinct forms of bicuspid valves could be identified characterized by either the appearance of gross inequality of size of the two valve leaflets or an appearance wherein each leaflet closely approximated the size of the other, thus equally bicuspid. Excepting two individuals with normal, tricuspid, aortic valves, all of the patients with coarctation of the aorta had equally bicuspid aortic valves which contrasted to the group without coarctation in which the unequally bicuspid type predominated. This difference in bicuspid aortic valve morphology associated with coarctation of the aorta suggests a different developmental process involving the aortic valve as opposed to the situation in individuals without coarctation.     

经导管主动脉瓣置换的介入瓣膜的现状及展望

经导管主动脉瓣置换术（TAVR）经过最近几年快速发展已经取得巨大进步。迄今为止全球接受TAVR的患者数已近3万例,已成为无法耐受传统手术患者的标准备选治疗措施。从目前已临床应用的介入瓣膜到正在实验研究的新型介入瓣膜可以看出,未来介入瓣膜的发展目标是尺寸更小、长期有效、安全性高、并发症少、操作简单及定位精准。随着TAVR的推广,新型介入瓣的研发,操作者经验的积累,以及长期随访的开展,将给TAVR提供更科学的病例选择标准,减少介入手术的相关并发症,提高更安全有效的治疗效果。未来此项技术还会逐渐扩大适用人群的范围,成为代替传统的主动脉瓣置换术举足轻重的治疗措施。     

Transthoracic Echo-Doppler Appearances of Perforation of a Bicuspid Aortic Valve by Bacterial Endocarditis

The echo-Doppler diagnosis of aortic valve perforation has seldom been made before. We describe a combination of findings in a patient with severe aortic regurgitation following endocarditis of a bicuspid aortic valve, which suggests the presence of aortic cusp perforation: (A) discontinuity of cusp contour in parasternal long-axis view; (B) emergence of aortic regurgitant jet through a cusp rather than between the two cusps; (C) fine flutter of a cusp, but not on the free apposed edges; (D) severe aortic regurgitation without flail cusp motion, following bacterial endocarditis.