Replacement of the Proximal Arch: Should It Be Routine in Patients with Bicuspid Aortic Valve and Ascending Aneurysms?

Multiple lines of evidence establish a relationship between BAV and proximal aortic aneurysms. Emerging indications and techniques are leading to a more standardized surgical approach to these patients. In the individual patient, however, one must use judgment to determine the best approach on the basis of several factors, including age, comorbidities, extent of concomitant surgery, and the expected risk of subsequent complications.     

Infective Endocarditis in Patients With Bicuspid Aortic Valve or Mitral Valve Prolapse

Background

There is little information concerning infective endocarditis (IE) in patients with bicuspid aortic valve (BAV) or mitral valve prolapse (MVP). Currently, IE antibiotic prophylaxis (IEAP) is not recommended for these conditions.

Aortic Valve Endocarditis with Bartonella Quintana—a Rare Entity

Endocarditis caused by Bartonella species is difficult to diagnose and still remains a rare entity. Therefore, a young male patient undergoing aortic valve replacement for culture-negative endocarditis is reported in whom the diagnosis of a Bartonella quintana infection was made with a great delay postoperatively.     

Does Transcatheter Aortic Valve Implantation Mean the End of Surgical Aortic Valve Replacement?

Although the results of the early TAVI experience are promising, longer-term follow-up is necessary before the procedure can be extended to lowerrisk patients. Many issues are not yet resolved, including the long-term effects of paravalvular leaks (which occur in most TAVI patients), the true stroke rate in TAVI patients (which is probably in the range of 5% to 6%), and the need for permanent pacemaker implantation (which ranges from 5% to 40% in TAVI patients, depending upon the device used). As the procedure is extended into the lower-risk population, these issues will assume greater import than they have in the population currently in treatment—very elderly, high-risk patients with limited life expectancy. As in the coronary-revascularization paradigm of percutaneous coronary intervention versus coronary artery bypass grafting, there will be increasing adoption of the transcatheter approach. Just as the rumors of the demise of surgical bypass were premature, conventional AVR will continue to be the predominant technique for the treatment of aortic stenosis during at least the next decade. Although the percentage of patients treated by a transcatheter approach will continue to increase, regulatory and reimbursement factors are likely to be the primary determinants of the rate of adoption.     

Can the Proximal Isovelocity Surface Area Method Calculate Stenotic Mitral Valve Area in Patients with Associated Moderate to Severe Aortic Regurgitation? Analysis Using Low Aliasing Velocity of 10% of the Peak Transmitral Velocity

To assess the ability of the proximal isovelocity surface area (PISA) method to accurately measure the stenotic mitral valve area (MVA), and to assess whether aortic regurgitation (AR) affects the calculation, we compared the accuracy of the PISA method and the pressure half-time (PHT) method for determining MVA in patients with and without associated AR by using two-dimensional echocardiographic planimetry as a standard. The study population consisted of 45 patients with mitral stenosis. Seventeen of the 45 patients had associated moderate-to-severe AR. The PISA method was performed using low aliasing velocity (AV) of 10% of the peak transmitral velocity, which provided the most accurate estimation of MVA when compared with planimetry. The maximal radius r of the PISA was measured from the orifice to blue-red aliasing interface. Using the PISA method, MVA was calculated as (2pir(2)) x theta / 180 x AV/Vmax, where theta was the inflow angle formed by mitral leaflets, AV was the aliasing velocity (cm/sec), and Vmax was the peak transmitral velocity (cm/sec). MVA by the PISA method correlated well with planimetry both in patients with AR (r = 0.90, P < 0.001, SEE = 0.17 cm(2)) and without AR (r = 0.92, P < 0.001, SEE = 0.16 cm(2)). However, MVA by the PHT method did not correlate as well with planimetry (r = 0.57, P < 0.05, SEE = 0.37 cm(2)) in patients with associated AR, and the PHT method produced a significant overestimation (24%) of MVA obtained by planimetry in these patients. We conclude that the PISA method allows accurate estimation of MVA and is not influenced by AR.     

How Long Should a Long-Term Esophageal Motility Study Be?

It was the aim of this study to analyze whether a shorter measuring period would render the same diagnostic information on esophageal motility as a circadian measuring period in ambulatory esophageal manometry. In an investigation on normal volunteers (n = 10), patients with gastroesophageal reflux disease without esophageal motility disorders (n = 13), and patients with esophageal motility disorders (n = 14), a comparison was performed between a 5-hr and a 24-hr motility study. An analysis was performed on inter- and intraindividual reproducibility of time periods, prandial phases, and motility sequences (Wilcoxon and Spearman test). There was no significant difference between the two analyzed measuring periods in all three groups with regard to the diagnostic information on esophageal motility in 44 of 45 comparisons for intraindividual variability. A measuring period restricted to 5 hr offers the same diagnostic information on esophageal peristaltic activity as a 24-hr motility study.     

Sarcoidosis and Aortic Stenosis: A Role for Transcatheter Aortic Valve Replacement?

Sarcoidosis is an infiltrative disease known to affect multiple layers of the heart.¹ Although rare, aortic valve involvement has been seen.^17,18 The role of transcatheter aortic valve replacement (TAVR) has been described in amyloidosis,⁴ a well-known infiltrative disease, but not in sarcoidosis. As the awareness of cardiac sarcoidosis grows,¹⁷ as in amyloidosis, its impact on the aortic valve will grow too. Our review highlights the epidemiology, pathophysiology, and treatment of cardiac sarcoidosis with a discussion for TAVR in patients affected by aortic valve insult.     

Aortic Valve Sclerosis: Is It a Cardiovascular Risk Factor or a Cardiac Disease Marker?

BACKGROUND: Aortic valve sclerosis, without stenosis, has been associated with an increased cardiovascular mortality and morbidity due to myocardial infarction. However, it is unclear whether it is a cardiovascular risk factor or a cardiac disease marker. The goal of our study is to evaluate the difference in the prevalence of cardiovascular disease and risk factors among patients with or without aortic sclerosis. METHODS: This observational study compared a group of 142 consecutive subjects with aortic valve sclerosis, assigned as group S, with a group of 101 subjects without aortic sclerosis, assigned as group C. Patients with bicuspid aortic valves and those with antegrade Doppler velocity across aortic valve leaflets exceeding 2.0 m/sec were excluded. RESULTS: Mean ages of groups S and C were 71 +/- 8, and 68.8 +/- 6 years, respectively (P value = not significant). The prevalence of smoking, diabetes, hypercholesterolemia, hypertension, pulse pressure, left ventricular diastolic dysfunction, atrial fibrillation, and stroke was not significantly different between the two groups. However, there was a significantly higher prevalence of left ventricular hypertrophy (P = 0.05), ventricular arrhythmias (P = 0.02), myocardial infarction (P = 0.04), and systolic heart failure (P = 0.04) in aortic sclerosis group. CONCLUSIONS: Aortic sclerosis is associated with a higher prevalence of left ventricular hypertrophy, ventricular arrhythmias, myocardial infarction, and systolic heart failure, while the prevalence of cardiovascular risk factors is not different between aortic sclerosis patients and controls. Hence, aortic sclerosis represents a cardiac disease marker useful for early identification of high-risk patients beyond cardiovascular risk factors rate.     

Should the Metabolic Syndrome Patient with Prediabetes Be Offered Pharmacotherapy?

Impaired fasting glucose and impaired glucose tolerance reflect perturbations in glucose metabolism and define a prediabetic state in which risk for type 2 diabetes mellitus (T2DM) is increased. There is overlap between prediabetes and the metabolic syndrome, which itself increases the risk for T2DM and cardiovascular disease. The utility of medical interventions to prevent progression to diabetes in prediabetic individuals, many of whom also manifest metabolic syndrome, has been examined in several large clinical trials. Intensive lifestyle intervention consistently results in drastic reductions in the incidence of T2DM and reversal of metabolic syndrome. Additionally, pharmacotherapies—including metformin, acarbose, thiazolidinediones, glucagon-like peptide 1 receptor agonists, and renin-angiotensin inhibitors—also reduce diabetes incidence with variable effects on metabolic syndrome components. Taken together, we recommend that prediabetic patients undergo intensive lifestyle intervention, with the addition of pharmacotherapy based on the presence of specific features of the metabolic syndrome, for diabetes prevention.