Morphologic bases for establishing end-points for early plaque detection and plaque instability

The aim of the present study was to investigate which factors could influence the accuracy of aortic stenosis severity assessment by Doppler echocardiography in an unselected population. Doppler echocardiographic determination of mean transvalvular pressure gradient and aortic valve area by continuity equation was performed in 101 patients before catheterization. According to the catheterization data, aortic stenosis was classified into 2 categories: mild to moderate (orifice area [Gorlin formula] > 0.75 cm², mean transvalvular gradient < 50 mmHg) and severe (orifice area < 0.75 cm², mean transvalvular gradient ≥ 50 mmHg). The influence of eight factors on the absolute difference in aortic valve area and mean transvalvular pressure gradient and on the concordant classification in the same category by both methods was investigated.Results. By multivariate analysis, the absolute difference in aortic valve area by both methods was significantly associated with poor image quality, absolute difference between mean catheterization and Doppler transvalvular gradient and inversely related to body mass index. Absolute difference in mean transvalvular gradients by both methods was significantly associated only with image quality. Poor image quality emerged as the only significant factor influencing the concordant classification between invasive and noninvasive studies according to orifice area (but not according to transvalvular pressure gradient).Conclusion. Echographic image quality significantly influences the accuracy of Doppler echocardiographic determination of aortic valve area and, to a lesser extent, of transvalvular pressure gradient. Therefore, the mere noninvasive approach is not suitable to every consecutive patient with aortic stenosis. Qualifications concerning overall image quality should identify patients most likely to benefit from catheterization.     

An alternative to standard continuity equation for the calculation of aortic valve area by echocardiography

Calculation of aortic valve area by echocardiography is sometimes technically difficult. We tested a modified continuity equation to help measure valve area in those difficult cases. The studies of 105 patients with aortic stenosis were analyzed retrospectively. We calculated aortic valve area by standard continuity equation and by the modified method where Doppler-derived stroke volume was replaced by the difference between diastolic and systolic volume according to Simpson's biplane method of disks. The correlation between the 2 methods was excellent. For patients with left ventricular outflow tract acceleration, modified continuity equation correlated better than standard continuity equation with invasively measured aortic valve area by Gorlin equation. We conclude that the modified method is accurate and becomes an attractive alternative to the conventional continuity equation especially for patients in whom stroke volume calculation by Doppler may be unreliable for technical reasons.     

Assessment of left ventricular outflow tract geometry in non-stenotic and stenotic aortic valves by cardiovascular magnetic resonance.

PURPOSE: To assess the geometry and area of the left ventricular outflow tract (LVOT) in non-stenotic and stenotic aortic valves and to determine the aortic valve area (AVA) in non-stenotic valves by magnetic resonance imaging (MRI) using a modified continuity equation. METHODS: Twenty patients (10 male, mean age 54.8 +/- 15 years) without known aortic valve disease and 10 patients (7 male, mean age 65.1 +/- 14 years) with moderate to severe aortic stenosis were included in this study. MRI was performed using a 1.5 T scanner (Philips Intera CV). AVA was assessed by planimetry on high quality SSFP cine sequences and used as reference standard. LVOT area was defined by calculating a circular area using the LVOT diameter from the 3 chamber view (3CV) and by planimetry. Peak flow velocity was assessed in the LVOT and the proximal aorta. AVA was calculated by a modified Gorlin equation, the continuity equation and a modified continuity equation using the planimetric LVOT area. RESULTS: Planimetric AVA ranged from 2.9 to 6.4 cm2 in patients with non-stenotic and from 0.3 to 1.3 cm2 with stenotic valves, LVOT area from 3.4 to 6.1 cm2 and from 2.6 to 6.5 cm2, respectively. The LVOT area based on the LVOT diameter derived from the 3CV was significantly underestimated in comparison to planimetry in non-stenotic and stenotic aortic valves (3.3 +/- 0.7 vs. 4.7 +/- 1.0 cm2, p < 0.0001; mean difference 1.1 +/- 0.12 cm2, CI 0.86-1.36 and 3.7 +/- 1.2 vs. 4.7 +/- 1.5 cm2, p < 0.05; mean difference 1.0 +/- 1.0 cm2, CI 0.24-1.71). The Gorlin formula showed a poor agreement with planimetry, whereas continuity equation and the modified continuity equation revealed a very good agreement. Planimetry of the LVOT displayed an elliptic shape of the LVOT in all patients with the minimum diameter perpendicular to the 3CV, which was the reason for the above mentioned underestimation. CONCLUSION: The LVOT area calculated from the 3CV-LVOT diameter underestimates the LVOT area compared to planimetry due to an elliptic shape of the LVOT in patients with non-stenotic as well as with stenotic aortic valves. The modified Gorlin equation proved to be less useful to assess AVA in non-stenotic valves, whereas the continuity equation and a modified continuity equation displayed a very good agreement with planimetric area measurements.     

Timing of operation in asymptomatic severe aortic stenosis

Calcific aortic stenosis is now the main cause of aortic stenosis in the majority of patients, due to declining incidence of rheumatic fever. Risk factors such as hyperlipidemia play an important role in the progression of aortic stenosis. According to the most recent American College of Cardiology/American Heart Association guidelines, peak velocity greater than 4 m/sec, a mean gradient of more than 40 mmHg and a valve area of less than 1.0 cm² is considered hemodynamically severe aortic stenosis. Aortic valve surgery promptly should be done in symptomatic patients due to dismal prognosis without operation. Features such as high aortic valve calcium and positive exercise test identify asymptomatic patients who would benefit from early aortic valve surgery. Due to improvement in surgical techniques and better prosthesis, aortic valve surgery can now be offered at low risk to a selected group of asymptomatic patients with severe aortic stenosis. Currently percutaneous aortic valves are used in very high-risk patients with severe symptomatic aortic stenosis. Their role may expand in the future, depending on the improvements in design and operator experience. Whether advances in molecular cardiology lead to novel therapies in preventing calcific aortic stenosis in the future remains to be seen.     

The determination of aortic valve area by the Gorlin formula: what the cardiac sonographer should know

The application of the Gorlin formula in the cardiac catheterization laboratory is the standard of reference for the determination of aortic valve area. The continuity equation now enables the cardiac sonographer to determine aortic valve area noninvasively in the echocardiography laboratory. The comparison of the results obtained by the two methods is inevitable. The cardiac sonographer should have a basic understanding of the theory and pitfalls of the Gorlin formula so that when conflicting results are obtained, the possible reasons why will be clear.     

Comparison between cardiovascular magnetic resonance and transthoracic doppler echocardiography for the estimation of effective orifice area in aortic stenosis

Background

The effective orifice area (EOA) estimated by transthoracic Doppler echocardiography (TTE) via the continuity equation is commonly used to determine the severity of aortic stenosis (AS). However, there are often discrepancies between TTE-derived EOA and invasive indices of stenosis, thus raising uncertainty about actual definite severity. Cardiovascular magnetic resonance (CMR) has emerged as an alternative method for non-invasive estimation of valve EOA. The objective of this study was to assess the concordance between TTE and CMR for the estimation of valve EOA.

Methods and results

31 patients with mild to severe AS (EOA range: 0.72 to 1.73 cm²) and seven (7) healthy control subjects with normal transvalvular flow rate underwent TTE and velocity-encoded CMR. Valve EOA was calculated by the continuity equation. CMR revealed that the left ventricular outflow tract (LVOT) cross-section is typically oval and not circular. As a consequence, TTE underestimated the LVOT cross-sectional area (A_LVOT, 3.84 ± 0.80 cm²) compared to CMR (4.78 ± 1.05 cm²). On the other hand, TTE overestimated the LVOT velocity-time integral (VTI_LVOT: 21 ± 4 vs. 15 ± 4 cm). Good concordance was observed between TTE and CMR for estimation of aortic jet VTI (61 ± 22 vs. 57 ± 20 cm). Overall, there was a good correlation and concordance between TTE-derived and CMR-derived EOAs (1.53 ± 0.67 vs. 1.59 ± 0.73 cm², r = 0.92, bias = 0.06 ± 0.29 cm²). The intra- and inter- observer variability of TTE-derived EOA was 5 ± 5% and 9 ± 5%, respectively, compared to 2 ± 1% and 7 ± 5% for CMR-derived EOA.

Conclusion

Underestimation of A_LVOT by TTE is compensated by overestimation of VTI_LVOT, thereby resulting in a good concordance between TTE and CMR for estimation of aortic valve EOA. CMR was associated with less intra- and inter- observer measurement variability compared to TTE. CMR provides a non-invasive and reliable alternative to Doppler-echocardiography for the quantification of AS severity.     

Mitral valve A wave and mitral stenosis

We examined M-mode echocardiograms on 35 patients with catheterization-proven mitral stenosis and normal sinus rhythm to determine whether the presence or absence of an A wave on the mitral echogram predicted mild versus severe mitral stenosis. Mitral valve area (MVA) was determined by the Gorlin formula. Presence of a mitral A wave was defined as 2 mm or greater anterior motion (after a well-defined F point) of the anterior mitral leaflet. In six of 35 patients, the presence of an A wave was equivocal. Of the remaining 29 patients, 16 had no A wave and mean MVA = 1.18 cm² ± 0.45 (SD), and 13 patients had a definite A wave and mean MVA = 2.04 cm² ± 0.71. There was a significant difference (p < 0.001) between the mean MVA for patients with and without definite A waves. No patients with a definite A wave had an MVA less than 1.2 cm². An A wave on the mitral echogram (in sinus rhythm) excludes severe mitral stenosis; when an A wave is not seen, no definite statement concerning severity of mitral stenosis can be made.     

Aortenstenose mit niedrigem transvalvul?ren Druckgradienten und eingeschr?nkter linksventrikul?rer Funktion Dobutamin-Stressechokardiographie hilft bei der Therapieplanung

Zusammenfassung Hintergrund: Der Aortenklappenersatz ist bei symptomatischer hochgradiger Aortenstenose die Therapie der Wahl. Schwer fällt diese Entscheidung bei symptomatischen Patienten mit Aortenstenose und niedrigem transvalvulären Druckgradienten sowie hochgradig eingeschränkter linksventrikulärer Funktion, weil in dieser Gruppe eine hohe perioperative Mortalität beobachtet wird. Dennoch ist ein Aortenklappenersatz bei nachgewiesener hochgradiger Aortenstenose indiziert. Patienten aber, bei denen das Klappenöffnungsverhalten wegen einer primär myokardialen Funktionsstörung behindert ist, profitieren nicht von eimen Aortenklappenersatz. Mit der Ruheechokardiographie gelingt die Differenzierung zwischen beiden Gruppen nicht. Die positiv inotrope Stimulation im Rahmen einer Dobutamin-Stressechokardiographie ermöglicht eine sichere Graduierung der Aortenstenose. Fallbeschreibung: Wir berichten von einem symptomatischen 58-jährigen Patienten mit Aortenstenose und hochgradig eingeschränkter linksventrikulärer Pumpfunktion. Echokardiographisch zeigte sich eine Aortenstenose mit einer hochgradig reduzierten Klappenöffnungsfläche von 0,6 cm² und einem mittleren transvalvulären Druckgradienten von 24 mm Hg. Die Herkatheteruntersuchung erbrachte eine Peak-to-Peak-Gradienten von 20 mm Hg und nach der Gorlin-Formel eine hochgradig reduzierte Aortenöffnungsfläche von 0,6 cm². In der Dobutamin-Stressechokardiographie zeigte sich schließlich unter positiv inotroper Stimulation eine Zunahme der Klappenöffnungsfläche auf 1,5 cm² wie bei mittelgradiger Aortenstenose. Deshalb konnte auf einen operativen Aortenklappenersatz verzichtet werden, und die Herzinsuffizienz wurde medikamentös-konservativ therapiert. Nach 1 1/2 Jahren ist der Patient gut belastbar und beschwerdefrei. Echokardiographisch zeigt sich jetzt eine gute linksventrikuläre Funktion. Abstract Background: Aortic valve replacement is recommended in case of symptomatic severe aortic stenosis. This decision is difficult for patients with low-gradient aortic stenosis and severely impaired left ventricular function because of high perioperative mortality in this group. Although aortic valve replacement is usually justified if severe aortic stenosis is proved, patients with primary myocardial dysfunction and subsequent reduced aortic valve opening do not benefit from aortic valve replacement. Distinguishing these two groups of patients is necessary but not possible with echocardiography at rest. Positive inotropic stimulation with dobutamine stress echocardiography enables a more reliable graduation of aortic stenosis under these circumstances. Case Report: We report on a symptomatic 58-year-old man with aortic stenosis and severely impaired left ventricular function. Using echocardiography at rest, there was a severely reduced aortic valve area of 0.6 cm² and a mean pressure gradient of 24 mm Hg. Determined by cardiac catheterization, the peak-to-peak gradient was 20 mm Hg and the aortic valve area calculated by the Gorlin formula was 0.6 cm². After positive inotropic stimulation using dobutamine stress echocardiography, the aortic valve area increased to 1.5 cm² indicating an only moderate aortic stenosis. Thus aortic valve replacement was not performed and myocardial failure was medically treated. After 1.5 years of follow-up, the patient is in good condition and without complaints.     

Ejection Fraction/Velocity Ratio Identifies Prosthesis‐Patient Mismatches in Patients With Aortic Bioprosthetic Valves and Left Ventricular Dysfunction

Objectives. Recently, a new echocardiographic nonflow corrected index (ejection fraction/velocity ratio [EFVR] = percent left ventricular ejection fraction [EF]/maximum aortic gradient) has been introduced and has shown excellent accuracy in quantifying the effective orifice area (EOA) in native aortic valves and bio‐prostheses. The objective of this study was to assess the utility of the EFVR to quantify the indexed EOA in patients with an aortic bioprosthesis and left ventricular dysfunction considering an indexed EOA value of 0.85 cm²/m² or less to be indicative of a prosthesis‐patient mismatch (PPM), defined as an EOA of the inserted prosthetic valve of less than that of the normal human valve. Methods. We studied 100 patients (62 men and 38 women; mean age ± SD, 71 ± 8.6 years) with an aortic bioprosthesis and left ventricular dysfunction (EF ≤49%), and we evaluated the indexed EOA by both the continuity equation (CE) and EFVR. Results. We found a significant linear correlation between the CE and EFVR (r = 0.85; P < .0001) and good agreement between the two methods in identifying patients with an indexed EOA of 0.85 cm²/m² or less; the correlation began to become nonlinear for patients with an indexed EOA of greater than 1.2 cm²/m², which was not clinically relevant. Notably, all 11 patients with a discrepancy between the indexed EOA and EFVR (ie, EFVR ≤1.0 and indexed EOA >0.85 cm²/m²) also showed an indexed EOA of greater than 0.85 but less than or equal to 1.0 cm²/m² (meaning the presence of a mild PPM). Conclusions. The EFVR can be considered a reliable echocardiographic alternative to the CE, especially in conditions in which that is technically difficult, allowing identification of a PPM (indexed EOA ≤0.85 cm²/m²) with excellent sensitivity and specificity.     

Aortic valve area assessed with 320-detector computed tomography: comparison with transthoracic echocardiography

To evaluate the diagnostic accuracy of aortic valve area (AVA) assessment with 320-detector Computed Tomography (MDCT) compared to transthoracic echocardiography (TTE) in a population with mild to severe aortic valve stenosis. AVA was estimated in 169 patients by planimetry on MDCT images (AVA_MDCT) and by the continuity equation with TTE (AVA_TTE). To generate a reference AVA (AVA_REF) we used the stroke volume from MDCT divided by the velocity time integral from CW Doppler by TTE (according to the continuity equation: stroke volume in LVOT = stroke volume passing the aortic valve). AVA_REF was used as the reference to compare both measures against, since it bypasses the assumption of LVOT being circular in the continuity equation and the potential placement error of PW Doppler in the LVOT. The mean (±SD) age of the patients was 71 (±9) years, 113 (67 %) were males. Mean AVA_TTE was 0.93 (±0.33) cm², mean AVA_MDCT was 0.99 (±0.36) cm² and mean AVA_REF was 1.00 (±0.39) cm². The mean difference between AVA_TTE and AVA_MDCT was ?0.06 cm², p = 0.001, mean difference between AVA_TTE and AVA_REF was ?0.06 cm², p < 0.001, and mean difference between AVA_MDCT and AVA_REF was ?0.01 cm², p = 0.60. Calcification of the aortic valve quantified by Agatston score, significantly decreased the correlation between AVA_MDCT and AVA_REF, (r low Agatston = 0.90, r high Agatston = 0.57). MDCT measured AVA is slightly larger than AVA measured by TTE (0.06 cm²). The accuracy and precision errors on AVA measurements are comparable for MDCT and TTE. Valvular calcification may primarily affect the accuracy of AVA_MDCT.     

二维、三维经食管超声心动图在经导管主动脉瓣植入术中的应用价值

目的探讨二维、三维经食管超声心动图在经导管主动脉瓣植入术（TAVI）中的应用价值。 方法对2010年5月至2015年10月在复旦大学附属中山医院行TAVI的11例重度主动脉瓣狭窄[主动脉瓣狭窄口面积<1.0 cm²,主动脉瓣口最大流速>4 m/s,平均跨瓣压差>40 mmHg（1 mmHg=0.133 kPa）]和1例人工生物主动脉瓣中重度反流患者术前均行常规经胸超声心动图检查及二维、三维经食管超声心动图检查（2DTEE、3DTEE）,术中二维、三维经食管超声心动图监测,术后常规经胸超声心动图随访。采用Pearson相关分析分析3DTEE与计算机断层扫描（MDCT）评价主动脉瓣环最大值、最小值、瓣环面积以及狭窄口面积的相关性及3DTEE、MDCT与连续性方程评价狭窄口面积的相关性。 结果所有患者均成功植入人工生物主动脉瓣,其中1例患者术中发现心脏压塞合并升主动脉夹层分离,经心包穿刺以及升主动脉夹层分离保守治疗3 d后突发心脏压塞死亡。所有患者MDCT与3DTEE评价主动脉瓣环最大径、最小径、瓣环面积及狭窄口面积的相关性均较好（r=0.98、0.97、0.97、0.99,P均<0.01）;术前连续性方程测量的主动脉狭窄口面积与MDCT及3DTEE评价结果的相关性均很好（r值均为0.99,P均<0.01）。 结论2DTEE、3DTEE能快速、准确地定量主动脉瓣环的大小及评价主动脉的解剖结构,能实时引导和监测经导管主动脉瓣植入及其并发症。     

Evolution of the continuity equation in the Doppler echocardiographic assessment of the severity of valvular aortic stenosis

The use of Doppler techniques has greatly enhanced the noninvasive ultrasound technique for evaluation of valvular aortic stenosis. M-mode and two-dimensional echocardiography could not reliably distinguish patients with severe aortic stenosis from those with milder obstructions. The hemodynamic information offered by Doppler complemented echocardiographic imaging and provided an alternative modality for evaluation of patients with aortic stenosis. By application of the modified Bernoulli equation, the pressure gradient across the stenotic aortic valve could be estimated by Doppler echocardiography. Though helpful and widely used, the information provided by the pressure gradient across the valve about the severity of the obstruction was not complete. The assessment of valvular aortic stenosis therefore includes an estimation of the valve area by application of the continuity equation. This review examines the maturation of the continuity equation by Doppler techniques and discusses the implications of the procedure.     

Beat-by-beat aortic valve area measurements indicate constant orifice area in aortic stenosis: analysis of Doppler data with varying RR intervals.

Gorlin formula calculation of aortic valve area suggests that orifice area increases in patients with aortic stenosis with rising cardiac output. Evidence that aortic orifice area varies was sought in patients with aortic stenosis by analyzing Doppler data beat by beat versus RR interval in 22 patients with spontaneous RR variability. Stroke volume increased in all patients from minimum to maximum RR interval by 129% +/- 19%. Over the same range of RR intervals, assessment of aortic valve area by (A) simultaneous inner and outer continuous wave Doppler signals, or (B) nonsimultaneous RR-matched pulsed wave Doppler from the left ventricular outflow tract and continuous wave Doppler from the aortic valve failed to suggest an increase in aortic valve area. A positive relationship between aortic valve area and RR interval was not consistently observed with the exception of seven out of eight patients with mild to moderate (pulsed wave Doppler/continuous wave Doppler time velocity integral ratio of 0.3 to 0.7) aortic stenosis (p less than 0.05). Beat-by-beat measurements of aortic valve orifice area using Doppler techniques do not suggest that the aortic stenosis orifice varies over a wide range of RR intervals and stroke volumes.     

Left ventricular reverse remodeling after transcatheter aortic valve implantation: a cardiovascular magnetic resonance study

Background

In patients with severe aortic stenosis, left ventricular hypertrophy is associated with increased myocardial stiffness and dysfunction linked to cardiac morbidity and mortality. We aimed at systematically investigating the degree of left ventricular mass regression and changes in left ventricular function six months after transcatheter aortic valve implantation (TAVI) by cardiovascular magnetic resonance (CMR).

Methods

Left ventricular mass indexed to body surface area (LVMi), end diastolic volume indexed to body surface area (LVEDVi), left ventricular ejection fraction (LVEF) and stroke volume (SV) were investigated by CMR before and six months after TAVI in patients with severe aortic stenosis and contraindications for surgical aortic valve replacement.

Results

Twenty-sevent patients had paired CMR at baseline and at 6-month follow-up (N=27), with a mean age of 80.7±5.2 years. LVMi decreased from 84.5±25.2 g/m² at baseline to 69.4±18.4 g/m² at six months follow-up (P<0.001). LVEDVi (87.2±30.1 ml /m²vs 86.4±22.3 ml/m²; P=0.84), LVEF (61.5±14.5% vs 65.1±7.2%, P=0.08) and SV (89.2±22 ml vs 94.7±26.5 ml; P=0.25) did not change significantly.

Conclusions

Based on CMR, significant left ventricular reverse remodeling occurs six months after TAVI.     

Emergency aortic valve replacement for critical aortic stenosis

Objective: To demonstrate that emergency aortic valve replacement can be successfully performed in patients with critical aortic stenosis and reduced left ventricular function even in cardiogenic shock with associated severe multiple organ failure. Design: Retrospective, consecutive case series. Setting: Multidisciplinary intensive care unit of a tertiary care university hospital. Patients: Five patients admitted to the intensive care unit with critical aortic stenosis (aortic valve area 0.56 ± 0.13 cm²) and greatly reduced left ventricular ejection fraction (20 ± 3 %) in prolonged cardiogenic shock and associated multiple organ failure (Multiple organ failure score 6.8 ± 0.5; Acute Physiology, Age, and Chronic Health Evaluation III score 91 ± 27). Intervention: Emergency aortic valve replacement. Results: All patients survived with full recovery of organ function. At follow-up (18 ± 10 months) all patients were in New York Heart Association functional class I or II with improvement of left ventricular ejection fraction to 48 ± 25 %. Conclusions: This excellent outcome suggests that emergency aortic valve replacement should be strongly considered in patients with critical aortic stenosis even in cardiogenic shock and multiple organ failure.     

Primary echocardiographic results of the Carpentier–Edwards Perimount Magna

Purpose

The aim of this study was to investigate the primary echocardiographic results of aortic valve replacement using 21- and 19-mm Carpentier–Edwards Perimount Magna bioprosthesis aortic xenografts in patients with small aortic annulus.

Methods

Twenty patients (mean body surface area 1.63?±?0.16?m²) underwent aortic valve replacement between June 2008 and December 2009. Eight and 12 patients received 21- and 19-mm Magna bioprostheses, respectively. After 12?months, hemodynamic data were obtained by echocardiography to estimate the prosthesis–patient mismatch.

Results

At follow-up, significant decreases in peak and mean left ventricular aortic pressure gradients were observed in the 12 patients with aortic stenosis (P?<?0.05). Regression of the left ventricular mass was observed in all the patients (P?<?0.05). The mean measured effective orifice area (EOA) and EOA index (EOAI) were 1.61?±?0.28?cm² and 0.99?±?0.16?cm²/m², respectively. Prosthesis–patient mismatch (EOAI ≤0.85) was documented in three patients.

Conclusion

The primary echocardiographic findings suggested that the hemodynamic performance of the 19- and 21-mm Carpentier–Edwards Perimount Magna bioprostheses was satisfactory in the patients with a small aortic annulus.     

Subvalvular aortic stenosis diagnosed by 3D transesophageal echocardiography

The patient was a 13-year-old male with chief complaints of exertional chest pain and dyspnea. Cardiac murmur was suspected in a medical checkup at 1 month old, at which time he was diagnosed with subvalvular aortic stenosis. He had subsequently been under follow-up observation at a nearby hospital for subvalvular aortic stenosis. He was admitted to our department for surgery due to aggravation of symptoms that had occurred over the previous year. Transthoracic echocardiography after admission showed an abnormal structure in the subvalvular aortic area, and the maximum pressure gradient between the left ventricle and aortic valve was 84 mmHg. The preoperative valve area was 0.71 cm², as measured by the Doppler method. Measurement of valve area by the trace method was difficult. Transesophageal echocardiography (TEE) showed a septum-like structure extending from the ventricular septum in the subvalvular area. On 3D TEE, the valve areas in the systolic and diastolic phases were 0.86 and 0.49 cm², respectively. Postoperative echocardiography showed resection of the structure in the subvalvular area, and the postoperative course was favorable.     

A hybrid approach for quantification of aortic valve stenosis using cardiac magnetic resonance imaging and echocardiography:

Summary We replaced Dopplerderived stroke volume in the continuity equation (method A) by either right heart catheterizationderived stroke volume (method B) or cardiovascular magnetic resonance–derived stroke volume (method C) to calculate aortic valve area in 20 consecutive patients with moderate or severe aortic stenosis. Comparison of both hybrid methods (methods B and C) by Bland–Altman analysis showed a mean difference near zero, a spread within two standard deviations and very similar limits of agreement. More importantly, all patients were classified into the same category of severity by both methods.     

SALTIRE–RAAVE: targeting calcific aortic valve disease LDL-density-radius theory

SALTIRE and RAAVE were the first two studies to evaluate the use of statin therapy for impeding calcific aortic valve disease (CAVD). This review presents the findings of low-density lipoprotein (LDL)-density-radius theory as tested using the combined results from the SALTIRE and RAAVE studies. Patients who received statin therapy had a greater degree of LDL cholesterol lowering, seen as the % change in LDL (47 vs 2%, p = 0.012), which in itself was significantly associated with a lesser change in aortic valve area (AVA; p < 0.001 and R² = 0.27). The percent change in the AVA for the treated patients was 5% and 15% for the nontreated patients (p = 0.579 and R² = 0.03). In summary, these published findings suggest that when applying the LDL-density-radius theory, which combines the cellular biology and the hemodynamics as defined by the continuity equation for AVA, there may be a role for lipid-lowering therapy in contemporary patients with calcific aortic valve disease (CAVD).