Anterograde balloon valvuloplasty for the treatment of neonatal critical valvar aortic stenosis.

We report our experience with anterograde balloon valvuloplasty in 17 neonates treated between November 1996 and June 2001 for critical aortic stenosis. Patients with hypoplastic left heart syndrome were excluded. Anterograde balloon valvoplasty of the aortic valve was possible in all 17 patients. The mean peak systolic gradient prior to cardiac catheterization was 73 mm Hg (range, 30-117 mm Hg) and decreased to 37 mm Hg (range, 21-60 mm Hg) after the dilation. Aortic regurgitation after balloon valvoplasty was absent or mild in 14/17 patients, moderate in 2 patients, and severe in 1 patient. There was no mortality or echocardiographic evidence for aortic cusp perforation or mitral regurgitation associated with the procedure. Redilation was necessary in 3/17 patients. Two patients are awaiting elective Ross operation. One patient with endocardial fibroelastosis died at 11 months of age. Anterograde balloon valvoplasty can be safely and effectively performed to palliate neonates with critical aortic valve stenosis.     

Aortic valve replacement for patients with mild to moderate aortic stenosis undergoing coronary artery bypass surgery

Aortic valve replacement (AVR) is not normally recommended in asymptomatic patients, even if aortic stenosis is severe. However, as the population ages, an increasing number of patients with mild or moderate aortic stenosis will require coronary artery bypass grafting (CABG). In these cases, risk of "prophylactic" AVR needs to be weighed against risks of subsequent worsening of the mildly or moderately diseased aortic valve. If unoperated, aortic stenosis will worsen at an average of 6-8 mmHg per year (-0.1 cm2/year valve area), and one-quarter of such patients will require late AVR with a high operative mortality (14-24%). If AVR is performed at the time of CABG, operative risk is increased only slightly (from 1-3% to 2-6%), as are late mortality (1-2% per year) and morbidity (1-2% per year), mainly from hemorrhagic complications. Intrinsic gradients of most prosthetic valves are sufficiently low that even patients with low aortic valve gradients are likely to derive hemodynamic benefit from AVR. Thus, if there is a measurable (>20-25 mmHg) gradient across the aortic valve in a patient who requires CABG, the patient is at considerable risk for developing symptomatic aortic stenosis prior to reaching the end of expected benefit from CABG; in this case AVR should be considered. It may be reasonable in patients with very mild gradients (<25 mmHg) to defer aortic valve surgery; however, it should be noted that aortic stenosis progression is generally more rapid when the initial gradient is small.     

The prognostic value of calcification and impaired valve motion in combined aortic stenosis and coronary artery disease

BACKGROUND AND AIMS OF THE STUDY: Optimal management of patients with coronary artery disease and concomitant aortic valve stenosis remains a subject of controversy. In this retrospective study, an attempt was made to identify criteria indicating rapid progression of aortic valve stenosis in patients with coronary artery disease. METHODS: Between 1990 and 1999, 47 patients underwent aortic valve replacement (AVR) after previous coronary artery bypass grafting (CABG) at the authors' institution. The postoperative data, including cardiac catheterization films, were reviewed. RESULTS: Aortic valve disease, mainly aortic stenosis, showed a rapid rate of progression. During a mean interval between CABG and AVR of 5.9 +/- 2.9 years, the mean peak-to-peak pressure gradient across the aortic valve rose from 16.1 +/- 13.8 to 61.4 +/- 23.9 mmHg in patients where presence of calcification and impaired aortic valve motion was found (66.0% of patients had calcified aortic valves; 72.3% had impaired valve motion) at the time of CABG; whereas in those without calcification and/or impaired leaflet motion a mean of 9.2 +/- 0.8 years elapsed before AVR became necessary. CONCLUSION: If a patient must undergo surgery for coronary artery disease, then AVR should be considered not only on the basis of hemodynamic criteria but also with regard to calcification of the aortic valve and its leaflet motion.     

The natural history of aortic valve disease after mitral valve surgery

OBJECTIVES

The present study evaluates the long-term course of aortic valve disease and the need for aortic valve surgery in patients with rheumatic mitral valve disease who underwent mitral valve surgery.

BACKGROUND

Little is known about the natural history of aortic valve disease in patients undergoing mitral valve surgery for rheumatic mitral valve disease. In addition there is no firm policy regarding the appropriate treatment of mild aortic valve disease while replacing the mitral valve.

METHODS

One-hundred thirty-one patients (44 male, 87 female; mean age 61 ± 13 yr, range 35 to 89) were followed after mitral valve surgery for a mean period of 13 ± 7 years. All patients had rheumatic heart disease. Aortic valve function was assessed preoperatively by cardiac catheterization and during follow-up by transthoracic echocardiography.

RESULTS

At the time of mitral valve surgery, 59 patients (45%) had mild aortic valve disease: 7 (5%) aortic stenosis (AS), 58 (44%) aortic regurgitation (AR). At the end of follow-up, 96 patients (73%) had aortic valve disease: 33 AS (mild or moderate except in two cases) and 90 AR (mild or moderate except in one case). Among patients without aortic valve disease at the time of the mitral valve surgery, only three patients developed significant aortic valve disease after 25 years of follow-up procedures. Disease progression was noted in three of the seven patients with AS (2 to severe) and in six of the fifty eight with AR (1 to severe). Fifty two (90%) with mild AR remained stable after a mean follow-up period of 16 years. In only three patients (2%) the aortic valve disease progressed significantly after 9, 17 and 22 years. In only six patients of the entire cohort (5%), aortic valve replacement was needed after a mean period of 21 years (range 15 to 33). In four of them the primary indication for the second surgery was dysfunction of the prosthetic mitral valve.

CONCLUSIONS

Our findings indicate that, among patients with rheumatic heart disease, a considerable number of patients have mild aortic valve disease at the time of mitral valve surgery. Yet most do not progress to severe disease, and aortic valve replacement is rarely needed after a long follow-up period. Thus, prophylactic valve replacement is not indicated in these cases.     

Impact of valvular calcification on the diagnostic accuracy of transesophageal echocardiography for the detection of congenital aortic valve malformation

BACKGROUND: Degeneration of congenital bicuspid or unicuspid aortic valves can progress more rapidly than that of tricuspid valves, and an early diagnosis significantly impacts decision making and outcome. We hypothesized that the extent of valvular calcification would negatively influence the diagnostic accuracy of multiplane transesophageal echocardiography (TEE) for the diagnosis of congenital aortic valve disease. METHODS: TEE was performed in 57 patients undergoing aortic valve replacement surgery for aortic stenosis (n = 46), pure regurgitation (n = 9), or significant regurgitation with less than severe aortic stenosis (n = 2). The degree of aortic valve calcification and the number of valve cusps were determined at surgery. RESULTS: Surgical inspection confirmed 14 bicuspid and 43 tricuspid aortic valves. Sensitivity and specificity of TEE for the diagnosis of congenital aortic valve malformation was 93% (13/14) and 91% (39/43) (P = 0.0001), respectively. In patients with no or mild aortic valve calcification (n = 13), sensitivity and specificity of TEE for the diagnosis of congenitally malformed aortic valve was 100% (5/5) and 100% (8/8) (P = 0.001), respectively. In patients with moderate or marked aortic valve calcification (n = 44), sensitivity and specificity of TEE for the diagnosis of congenitally malformed aortic valve was 89% (8/9) and 89% (31/35) (P<0.0001), respectively. In this subgroup of 44 patients, there were four false-positive and one false-negative diagnoses due to valvular calcification. CONCLUSIONS: Although TEE is highly sensitive and specific for the detection of congenital aortic valve malformations, presence of moderate or marked calcification of the aortic valve may result in false positive and false negative diagnoses.     

Effect of catheter positioning on the variability of measured gradient in aortic stenosis

The purpose of this study was to quantify the variation in measured aortic valve gradient and calculated aortic valve area when different techniques of cardiac catheterization were utilized. Hemodynamic assessment of aortic stenosis severity requires an accurately determined pressure gradient. In aortic stenosis, the presence of intraventricular pressure gradients and downstream pressure recovery within the aorta means that a range of aortic valve gradients could be measured in a given patient depending upon catheter position and measurement technique. To quantify the degree of variation in measured gradient and calculated aortic valve area, we generated transvalvular gradients by nine different techniques in 15 patients (11 men, 4 women; 29-86 years old). Patients were divided into those with severe aortic stenosis (aortic valve area ≤ 0.6 cm², n = 6) and those with moderately severe aortic stenosis (aortic valve area 0.61-0.90 cm², n = 9). Considerable variation in measured gradient and calculated aortic valve area was observed. The maximum variation in gradient was similar in severe and moderately severe aortic stenosis groups (33 mm Hg. vs. 32 mm Hg., p = NS). However, the variation in gradient as a percent of maximum gradient was greater (P < 0.05) in the moderately severe aortic stenosis group. The maximum variation in calculated aortic valve area was 0.1 cm² in the severe group and 0.3 cm² in the moderately severe group (P < 0.01). An intraventricular gradient, present in 13 of 15 (87%) patients, was partially responsible for the variation in pressure gradient measurement and calculated aortic valve area. We conclude that in patients with valvular aortic stenosis, catheterization technique has an important impact on the hemodynamic assessment of aortic stenosis severity. This is particularly true in patients with moderately severe aortic stenosis where any variation tends to represent a larger percentage of the total gradient. © 1993 Wlley-Liss, Inc     

Postoperative follow-up of fibromuscular subaortic stenosis

Objectives. This study attempted to determine whether early subaortic resection at lower levels of obstruction reduces the rate of recurrence of subaortic stenosis or reduces secondary damage to the aortic valve, or both.Background. Fibromuscular subaortic stenosis is a progressive condition, and at present it is unclear whether early operation reduces the recurrence rate along with decreasing the incidence of aortic insufficiency.Methods. Thirty-seven patients with fibromuscular subaortic stenosis and no other significant cardiac abnormality who under-went open subaortic resection were evaluated. The preoperative, early and late postoperative catheterization or echocardiographic findings as well as the operative reports were reviewed. The median age at operation was 6.4 years (range 1.1 to 17.3). The entire group has been followed up postoperatively for a median of 5.2 years (range 1.1 to 11). Mean systolic gradients across the left ventricular outflow tract were used for the purpose of this study.Results. There was a significant correlation between the preoperative mean systolic gradient and the incidence of preoperative aortic regurgitation and late postoperative aortic valve thickening as well as the incidence and degree of late postoperative aortic regurgitation. Late postoperative gradient and degree of aortic regurgitation correlated significantly with the follow-up interval. Aortic regurgitation was progressive in some patients despite subaortic resection. A preoperative mean gradient >30 mm Hg provided a reasonable cutoff for the likelihood postoperatively of needing a reoperation, having a postoperative shelf, a thickened aortic valve, moderate aortic regurgitation or a gradient of > 10 mm Hg.Conclusions. Our results suggest that although early subaortic resection may not reduce the rate of recurrence of fixed subaortic stenosis, it is likely to reduce acquired damage to the aortic valve.     

球扩式瓣膜Prizvalve®经导管主动脉瓣膜系统治疗重度主动脉瓣狭窄的初步研究

目的初步评价Prizvalve^?经导管主动脉瓣膜系统治疗重度主动脉瓣狭窄的安全性及可行性。方法本研究为单中心前瞻性的单组观察性研究,入选2021年3至5月于四川大学华西医院住院的外科手术高风险或不适合常规外科手术的11例重度主动脉瓣狭窄患者,经评估后使用Prizvalve^?经导管主动脉瓣膜系统行经导管主动脉瓣植入术。人工瓣膜植入后立即通过经胸超声心动图测量主动脉瓣平均跨瓣压差和峰值流速,计算即刻器械成功率。即刻器械成功定义为:(1)器械成功进入血管入路、被输送、释放和植入,输送系统成功撤出体外;(2)植入瓣膜达到预期的疗效,即手术结束时超声心动图测量主动脉瓣平均跨瓣压差<20 mmHg(1 mmHg=0.133 kPa)或主动脉瓣最大流速<3 m/s,且无严重的人工主动脉瓣反流或瓣周漏。术后30 d复查经胸超声心动图,随访术后30 d内全因死亡及严重心脑血管不良事件(包括急性心肌梗死、致残性出血性或缺血性卒中)的发生情况。结果本研究共纳入11例重度主动脉瓣狭窄患者,年龄(78.1±6.3)岁,其中男性8例,纽约心脏病协会(NYHA)心功能Ⅲ、Ⅳ级患者10例。11例患者均成功完成器械的输送、释放和植入,输送系统成功撤出体外。术后即刻主动脉瓣平均跨瓣压差为(7.55±4.08)mmHg,峰值流速为(1.78±0.44)m/s,与术前相比平均跨瓣压差以及峰值流速均下降(P均<0.05)。无严重的人工主动脉瓣反流或瓣周漏,11例(11/11)患者均达到即刻器械成功。术后30 d,11例患者中无死亡及严重心脑血管不良事件发生。主动脉瓣平均压差为(9.45±5.07)mmHg,峰值流速为(2.05±0.42)m/s,均维持在较为理想的水平,与术后即刻相比差异均无统计学意义(P均>0.05)。结论本研究初步表明,对于中国人群中传统手术高风险或不适合常规外科手术,且为传统内科治疗无法逆转的重度主动脉瓣狭窄患者,使用Prizvalve^?经导管主动脉瓣膜系统行经导管主动脉瓣植入术是一种可行的、相对安全的方法,可进一步开展第2阶段的临床研究。     

Comparison of Doppler-derived pressure gradient to that determined at cardiac catheterization in adults with aortic valve stenosis: implications for management

Over a 1-year period cardiac catheterization was performed in 58 patients, mean age 66 years, who had elevated aortic blood flow velocity (more than 1.7 m/s) by continuous-wave Doppler echocardiography. Doppler echo signals were initially judged acceptable for quantitative analysis in 95% of patients, usually from the apical transducer position. Cardiac catheterization was performed within a mean of 8 days (60% within 1 day) of the Doppler echo study. The aortic valve mean pressure gradients at catheterization ranged from 0 to 93 mm Hg. The linear correlation coefficient (r value) between the mean pressure gradient determined by Doppler echocardiography and catheterization was 0.87. The correlation was maintained in 15 patients with aortic regurgitation (r = 0.91) and in 16 patients with significant coronary artery disease (r = 0.93). In the 16 patients with reduced cardiac output (mean 3.2 liters/min, range 2.2 to 3.9) the correlation was 0.81. A strategy for using the Doppler echo-calculated pressure gradient to manage patients with valvular aortic stenosis (AS) was derived by investigating the relation of the Doppler echo gradient to the aortic valve area in 35 patients with no aortic regurgitation detected at catheterization. All 12 patients with a Doppler echo mean gradient of less than 30 mm Hg had an aortic valve area of more than 0.75 cm2 and all 11 patients with a Doppler echo mean gradient of more than 50 mm Hg had an aortic valve area of less than 0.75 cm2.(ABSTRACT TRUNCATED AT 250 WORDS)     

Echocardiographic left ventricular wall thickness: a poor predictor of the severity of aortic valve stenosis

Echocardiographic left ventricular hypertrophy is thought to be helpful in grading the severity of aortic stenosis. This study compared M-mode echocardiographic left ventricular wall dimensions with Gorlin aortic valve area. Good quality echocardiograms were obtained in 294 patients with aortic stenosis who also underwent cardiac catheterization. Patients with grade 3 or 4 aortic regurgitation were excluded. The correlation was calculated between the aortic valve area and the left ventricular wall dimensions. Correlation coefficients were poor; r = 0.13 for the septum, r = 0.15 for the posterior wall, and r = 0.17 for the mean wall dimension. Correlation was not improved significantly if patients with poor left ventricular function or systemic hypertension were excluded. Correlation with other hemodynamic parameters was better, peak left ventricular systolic pressure having r values of 0.36 and 0.30 for posterior wall and septum. Mean and peak aortic valve gradient had r values approaching 0.30 for both dimensions. If the peak gradient was included in multivariate analysis, the wall dimensions then had no predictive power for severity of aortic stenosis. This study demonstrates that the degree of left ventricular wall hypertrophy is not related to the severity of aortic outflow obstruction and therefore cannot be used to grade the severity of aortic stenosis.     

Preliminary experience in the assessment of aortic valve calcification by ECG-gated multislice spiral computed tomography

BACKGROUND: The aim was to correlate the degree of valvular calcification in patients with aortic stenosis determined by retrospectively electrocardiogram (ECG)-gated multislice spiral computed tomography with stenosis severity assessed by cardiac catheterization. METHODS: Prospective study on 41 patients (18 men, mean age 71+/-8 years) with aortic stenosis, who underwent four detector row multislice spiral computed tomography and cardiac catheterization. Severity of aortic stenosis was classified by cardiac catheterization. Aortic valve area, peak to peak and mean transvalvular gradients were correlated with the degree of calcification determined by multislice spiral computed tomography. Aortic valve calcification was assessed using aortic Agatston score, aortic mass score and aortic volume score. RESULTS: All measured aortic valve calcification scores were significantly higher in patients with severe aortic stenosis (n=29) than in patients with moderate (n=7) or mild aortic stenosis (n=5, p<0.001). Aortic valve calcification scores correlated significantly with aortic valve area (r=-0.49, p=0.001 for aortic mass score) and with peak to peak (r=0.68, p<0.001) and mean (r=0.60, p<0.001) transvalvular gradients. CONCLUSIONS: Severity of aortic valve calcification assessed by cardiac multislice spiral computed tomography is inversely related to aortic valve area and positively correlated with transvalvular gradients. Based on this preliminary data larger studies should be performed with echocardiography as a reference standard in order to validate this new information and its utility in the clinical management of the patient.     

Transfemoral transcatheter aortic valve implantation after aortic valve repair with HAART 300 device

We report the first successful case, to our knowledge, of CoreValve Evolut R (Medtronic, Minneapolis, MN) implantation into a failed HAART 300 aortic annuloplasty device (BioStable Science & Engineering, TX). An 81‐year‐old man presented with severe symptomatic aortic regurgitation secondary to failure of the 21 mm HAART 300 device, which had been implanted 45 days previously. Transthoracic echocardiography (TTE) revealed grade 3 aortic regurgitation with central jet, without aortic valve stenosis. Because of the high risk for redo surgery, the heart team proceeded with femoral transcatheter aortic valve implantation. The 26 mm CoreValve Evolut R was deployed into the 21 mm HAART 300 device without difficulty or complications. There were no intraoperative or postoperative complications. The patient was discharged after 5 days. TTE showed a mean aortic valve gradient of 18 mmHg, with minimal paravalvular leak. Our experience suggests that CoreValve Evolut R implantation may be an attractive option in patients with failed HAART 300 aortic annuloplasty.     

Long-term follow-up results of balloon valvuloplasty for congenital aortic stenosis: predictors of late outcome

AIMS: Long-term follow-up of patients with aortic valve stenosis undergoing balloon valvuloplasty was evaluated with respect to survival, the need for repeat intervention and factors predicting late outcome. METHODS AND RESULTS: Forty-five patients between 3.5 to 23 years old (mean 11.7 +/- 4.5) were followed for 62 +/- 30 months (range 11-122). The transvalvar aortic gradient decreased from 84 +/- 20 to 36 +/- 10 mmHg (p < 0.001) and remained significantly lower (50 +/- 26 mmHg; p < 0.001) at follow-up. At that time, 10 patients (including 4 with significant valve incompetence) had gradients >/= 60 mmHg. The procedure resulted in significant valve incompetence (grade >/= 3) in 8 patients (17.8%). There was a progression of incompetence and 13 patients (28.9%) had significant regurgitation at follow-up. All survived. Fifteen patients (33.3%) required re-intervention 51 +/- 24 months after valvuloplasty. The indications were: aortic stenosis in 5 patients; regurgitation in 6 patients; and stenosis with regurgitation in 4 patients. Actuarial freedom from re-intervention at 2, 4, 6 and 8 years was 96%, 88%, 61% and 56% of patients, respectively. The residual post-valvuloplasty gradient was the only predictor of re-intervention for valve stenosis (odds ratio = 3.2 for every 10 mmHg gradient increase; p = 0.017). A residual post-valvuloplasty gradient >/= 40 mmHg increased the relative risk of re-intervention sixfold. The immediate post-valvuloplasty aortic regurgitation grade was the only risk factor of re-intervention for regurgitation (odds ratio = 34 for every incompetence degree increase; p = 0.0019). Incompetence grade >/= 2 increased the risk of re-intervention tenfold. CONCLUSIONS: Valvuloplasty carries the risk of development of valve incompetence, which progresses with time. Some patients develop restenosis. The 相似文献   

Left Ventricular Response to Isometric Exercise in Aortic Valve Diseases and Its Value in the Optimal Timing of Aortic Valve Replacement

ABSTRACT In order to evaluate the left ventricular response to isometric exercise in different types of aortic valve disease, isometric exercise tests were performed during cardiac catheterization in 14 patients with pure aortic stenosis, 20 with combined aortic stenosis and regurgitation, and 18 with pure aortic regurgitation. Patients with angina pectoris in whom coronary angiography had not been performed were excluded. Thirty-seven patients were recatheterized 12 months after aortic valve replacement, and the ventricular response to exercise was re-evaluated. Preoperatively, the ejection fraction did not change significantly during excercise in patients with aortic stenosis, tended to decrease in patients with combined valve lesion, and decreased significantly in patients with aortic regurgitation (p<0.001). In the three patients whose ejection fraction during preoperative exercise decreased to below 0.40, it remained below 0.50 after successful aortic valve replacment. It appears possible to reveal left ventricular dysfunction in many patients with aortic regurgitation and in some with combined aortic valve disease by means of isometric exercise. The severely depressed ventricular dysfunction during exercise does not appear to correct totally after surgery.     

Hemodynamic findings during exercise on a bicycle ergometer following balloon valvuloplasty of pulmonary stenosis in children and adolescents.

Eleven patients (4 female, 7 male), age range 3.3 to 24.8 years (mean 11.10 years) treated for isolated pulmonary stenosis underwent cardiac catheterization and percutaneous transluminal balloon valvuloplasty (PTVP). The right ventricular systolic pressure (RVSP) before valvuloplasty ranged from 31 to 127 mmHg (mean 79 mmHg) decreasing to 28 to 62 mmHg (mean 42 mmHg) immediately after the dilatation. The peak systolic gradient of the pulmonary valve (delta p RV-PA) before valvuloplasty ranged from 22 to 107 mmHg (mean 61 mmHg) and decreased to a range of 14 and 45 mmHg (mean 23 mmHg) immediately after the dilatation. Balloon valvuloplasty was performed using balloons of 13 to 31 mm in diameter. On 11 patients cardiac catheterization and Doppler echocardiography were repeated between 11 months and 5.3 years (mean 3.11 years) after the balloon valvuloplasty showed a further significant fall in the gradient of pressure. The right ventricular systolic pressure ranged from 20 to 51 mmHg (mean 31.7 mmHg) while the transpulmonary gradient varied from 3 to 24 mmHg (mean 11.6 mmHg). At the time of follow-up examination the patients were aged between 7.2 and 25.7 years (mean 15.9 years). On average the second catheterization was performed 3.11 years following the first hemodynamic study. The follow-up examination encompassed clinical examination, electrocardiogram, Doppler echocardiography, and right heart cardiac catheterization. During right heart cardiac catheterization the children exercised on a bicycle ergometer for three min at 50 or 100 W depending on their body surface area. During this exertion, pressures of the right ventricle and the pulmonary artery as well as heart rate and oxygen saturation were recorded.(ABSTRACT TRUNCATED AT 250 WORDS)     

Progression of aortic valve dysfunction in 51 adult patients with congenital bicuspid aortic valve: assessment and follow up by Doppler echocardiography.

OBJECTIVE--To assess the pattern and progression of aortic valve dysfunction by serial Doppler echocardiographic examinations in ambulatory adult patients with congenital bicuspid aortic valve. DESIGN AND SETTING--Retrospective analysis of patients referred for Doppler echocardiography over a four year period. SUBJECTS--Fifty one adult patients with echocardiographic diagnosis of congenital bicuspid aortic valve had serial Doppler echocardiographic studies at least six months apart. There were 40 men and 11 women with a mean age of 36 years. MAIN OUTCOME MEASURE--Doppler echocardiographic values of aortic valve dysfunction. Cardiac events including endocarditis and aortic valve replacement were also evaluated. RESULT--Coarctation was present in five patients. 31 (61%) patients had a functionally normal bicuspid aortic valve defined as a mean gradient < 25 mm Hg and mild regurgitation. Significant aortic regurgitation was present in 15 patients (moderate in 12 and severe in three). Three patients had isolated aortic stenosis and two patients had combined aortic valve dysfunction. At a median follow up of 21 months (range six to 46 months), six patients had aortic valve surgery (one for aortic stenosis, three for aortic regurgitation, and two for endocarditis). Only 22 patients (43%) continued to have a functionally normal aortic valve. CONCLUSION--In this cohort of fairly young patients, aortic regurgitation is more common than aortic stenosis. Progression of aortic valve dysfunction occurs in patients with pre-existing valve dysfunction and even in those with normal aortic valve function at the initial echocardiographic examination.     

Serial assessment of mitral regurgitation by pulsed Doppler echocardiography in patients undergoing balloon aortic valvuloplasty

Mitral regurgitation was serially assessed by pulsed Doppler echocardiography in 144 patients undergoing balloon aortic valvuloplasty for symptomatic aortic stenosis. Regurgitant scores of 0, 1, 2 and 3 were assigned to pulsed Doppler patterns corresponding to no, mild, moderate and severe mitral regurgitation, respectively. Before balloon aortic valvuloplasty, mitral regurgitant score correlated significantly (p less than 0.005) but weakly with aortic valve area (r = -0.24), left ventricular ejection fraction (r = -0.34) and left ventricular systolic pressure (r = 0.23). There was no significant correlation between mitral regurgitation and either mean catheterization or mean Doppler aortic valve gradient. Balloon aortic valvuloplasty produced significant decreases in both catheterization and Doppler mean transvalvular aortic valve gradients (56 +/- 19 to 31 +/- 12 and 60 +/- 19 to 48 +/- 16 mm Hg, respectively; both p less than 0.0001) and a significant increase (p less than 0.0001) in aortic valve area assessed by catheterization (0.6 +/- 0.2 to 0.9 +/- 0.3 cm2). Left ventricular ejection fraction did not change, but cardiac output increased (p less than 0.001) and pulmonary capillary wedge pressure decreased (p less than 0.0001). Pulsed Doppler findings of mitral regurgitation were present in 102 of the 144 patients. Eighty-eight patients had a score compatible with mild or more severe degrees of mitral regurgitation, and 49 had a score indicative of moderate or severe valvular insufficiency. In the entire group of 144 patients, mitral regurgitant score decreased significantly from 1.1 +/- 1.0 to 1.0 +/- 1.0 (p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)     

Discrepancy between Gradients Derived by Cardiac Catheterization and by Doppler Echocardiography in Aortic Stenosis: How Often Does Pressure Recovery Play a Role?

Studies have shown very good correlation between Doppler-derived gradients and gradients obtained by cardiac catheterization (cath) in aortic stenosis (AS). However, the phenomenon of pressure recovery may lead to significant overestimation of aortic valve (AV) gradients by Doppler echocardiography (echo). We hypothesized that echo-derived gradients will be higher in mild–moderate AS because of pressure recovery. We studied 94 patients who had echo and cardiac caths in a span of 1 week. The mean age was 72 ± 13 years, 54% males, 79% had coronary artery disease, and the mean left ventricular ejection fraction was 45 ± 22%. The mean cardiac output and cardiac indices were 5.1 ± 1.4/2.7 ± 0.6 (l/mt), (l/m²), respectively. For those with mild AS, echo overestimated gradients in 9.5% of patients (4/42) by an average of 19 mmHg, thus misclassifying the degree of stenosis. In those with moderate AS, 14% (3/21) were misclassified as severe AS (gradient overestimation by an average of 13.6 mmHg). In those with severe AS, echo underestimated gradients in 13% (4/31) by an average of 22.7 mmHg. The aorta at the sinotubular junction was 2.8 cm in those patients with mild AS in whom gradients were overestimated by more than 20 mmHg compared to a sinotubular junction diameter of 3.12 cm in those with mild AS and no overestimation of gradients. The AV area/aortic root ratio was 0 .4 in those with mild AS and 0.2 in those with severe AS (P < 0.05).     

Flexible aortic valve prostheses: long-term functional results with porcine bioprostheses without mechanical commissure stent and aortic homografts

The long-term performance of two different types of flexible aortic prostheses was evaluated in 10 patients who received a stentless porcine prosthetic valve (group A) and in 18 patients who underwent aortic valve replacement with an aortic homograft (group B). In group A early postoperative angiography (5-16 days post surgery) revealed a mean gradient across the aortic prosthesis of 8 +/- 6 mmHg. Late postoperative Doppler echocardiography (3.2 +/- 0.9 years post surgery) suggested a mean gradient of 6 +/- 3 mmHg with a Doppler derived valve orifice area of 1.8 +/- 0.6 cm2. Color Doppler visualized mild prosthesis regurgitation in two of the 10 patients and two-dimensional imaging showed no significant leaflet calcification. In group B late postoperative Doppler echography (5.2 +/- 1.6 years post surgery) suggested a mean gradient of 11 +/- 14 mmHg with a mean graft orifice area of 1.8 +/- 0.5 cm2. Color Doppler revealed prosthesis regurgitation in 15 patients (severe 1, moderate 2, mild 12) and two-dimensional imaging visualized significant prosthesis leaflet calcification in two patients. The good hemodynamic function of a stentless porcine bioprosthesis which seems to be preserved for at least several years indicates that the use of the flexible aortic xenograft is worthwhile pursuing. The long-term performance of an aortic homograft is relatively poor and may be due to unsolved problems with regard to sterilizing and storing the valves.     

Aortic stenosis and rupture of mitral chordae tendineae

Ten patients with aortic stenosis and ruptured mitral chordae tendineae constituted 8% of 125 consecutive surgical cases of chordal rupture. Their ages ranged from 54 to 87 years (mean 68). Six patients presented with acute onset of congestive heart failure, and eight were in New York Heart Association functional class III or IV at the time of cardiac catheterization. Extensive mitral anulus calcification was observed by fluoroscopy in seven patients. The mean aortic valve area index was 0.4 cm2/m2 and nine patients had moderate to severe mitral regurgitation by angiography. Calcific aortic stenosis affected a tricuspid valve in nine cases and a bicuspid valve in one case. One patient had a rheumatic mitral valve and one a redundant myxomatous mitral valve; the remaining eight had no abnormality of the mitral apparatus commonly regarded as predisposing to chordal rupture. Mitral anulus calcification and ventricular anatomic and hemodynamic alterations in aortic stenosis may contribute to rupture of the mitral chordae tendineae.