Severe Aortic Stenosis in Dialysis Patients

Background: Characteristics and prognosis of hemodialysis patients with severe aortic stenosis have not yet been well defined. Methods and Results: The CURRENT AS (contemporary outcomes after surgery and medical treatment in patients with severe aortic stenosis) registry, a Japanese multicenter registry, enrolled 3815 consecutive patients with severe aortic stenosis. There were 405 hemodialysis patients (initial aortic valve replacement [AVR] group: N=135 [33.3%], and conservative group: N=270) and 3410 nonhemodialysis patients (initial AVR group: N=1062 [31.1%], and conservative group: N=2348). The median follow‐up duration after the index echocardiography was 1361 days, with 90% follow‐up rate at 2 years. The cumulative 5‐year incidence of all‐cause death was significantly higher in hemodialysis patients than in nonhemodialysis patients in both the entire cohort (71% versus 40%, P<0.001) and in the initial AVR group (63.2% versus 17.9%, P<0.001). Among hemodialysis patients, the initial AVR group as compared with the conservative group was associated with significantly lower cumulative 5‐year incidences of all‐cause death (60.6% versus 75.5%, P<0.001) and sudden death (10.2% versus 31.7%, P<0.001). Nevertheless, the rate of aortic valve procedure–related death, which predominantly occurred within 6 months of the AVR procedure, was markedly higher in the hemodialysis patients than in the nonhemodialysis patients (21.2% and 2.3%, P<0.001). Conclusions: Among hemodialysis patients with severe aortic stenosis, the initial AVR strategy as compared with the conservative strategy was associated with significantly lower long‐term mortality risk, particularly the risk for sudden death, although the effect size for the survival benefit of the initial AVR strategy was smaller than that in the nonhemodialysis patients

Decline in Left Ventricular Ejection Fraction during Follow-up in Patients with Severe Aortic Stenosis

Objectives: The aim of this study was to investigate the prognostic impact of the decline in left ventricular ejection fraction (LVEF) at 1-year follow-up in patients with severe aortic stenosis (AS) managed conservatively. Background: No previous study has explored the association between LVEF decline during follow-up and clinical outcomes in patients with severe AS. Methods: Among 3, 815 patients with severe AS enrolled in the multicenter CURRENT AS (Contemporary Outcomes After Surgery and Medical Treatment in Patients With Severe Aortic Stenosis) registry in Japan, 839 conservatively managed patients who underwent echocardiography at 1-year follow-up were analyzed. The primary outcome measure was a composite of AS-related deaths and hospitalization for heart failure. Results: There were 91 patients (10.8%) with >10% declines in LVEF and 748 patients (89.2%) without declines. Left ventricular dimensions and the prevalence of valve regurgitation and atrial fibrillation or flutter significantly increased in the group with declines in LVEF. The cumulative 3-year incidence of the primary outcome measure was significantly higher in the group with declines in LVEF than in the group with no decline (39.5% vs. 26.5%; p 10% declines in LVEF at 1 year after diagnosis had worse AS-related clinical outcomes than those without declines in LVEF under conservative management. (Contemporary Outcomes After Surgery and Medical Treatment in Patients With Severe Aortic Stenosis Registry; UMIN000012140

Initial Surgical Versus Conservative Strategies in Patients With Asymptomatic Severe Aortic Stenosis

AbstractBackgroundCurrent guidelines generally recommend watchful waiting until symptoms emerge for aortic valve replacement (AVR) in asymptomatic patients with severe aortic stenosis (AS).ObjectivesThe study sought to compare the long-term outcomes of initial AVR versus conservative strategies following the diagnosis of asymptomatic severe AS.MethodsWe used data from a large multicenter registry enrolling 3,815 consecutive patients with severe AS (peak aortic jet velocity >4.0 m/s, or mean aortic pressure gradient >40 mm Hg, or aortic valve area <1.0 cm2) between January 2003 and December 2011. Among 1,808 asymptomatic patients, the initial AVR and conservative strategies were chosen in 291 patients, and 1,517 patients, respectively. Median follow-up was 1,361 days with 90% follow-up rate at 2 years. The propensity score–matched cohort of 582 patients (n = 291 in each group) was developed as the main analysis set for the current report.ResultsBaseline characteristics of the propensity score–matched cohort were largely comparable, except for the slightly younger age and the greater AS severity in the initial AVR group. In the conservative group, AVR was performed in 41% of patients during follow-up. The cumulative 5-year incidences of all-cause death and heart failure hospitalization were significantly lower in the initial AVR group than in the conservative group (15.4% vs. 26.4%, p = 0.009; 3.8% vs. 19.9%, p < 0.001, respectively).ConclusionsThe long-term outcome of asymptomatic patients with severe AS was dismal when managed conservatively in this real-world analysis and might be substantially improved by an initial AVR strategy. (Contemporary Outcomes After Surgery and Medical Treatment in Patients With Severe Aortic Stenosis Registry; UMIN000012140

Left Ventricular Diastolic Function during the Normal Peripartum Period

Background:Because cardiovascular function and hemodynamics markedly change during pregnancy, our aim was to elucidate left ventricular (LV) diastolic function in pregnant women. Methods and Results:We prospectively collected the data of 397 pregnant women treated between 2012 and 2013. We evaluated their LV systolic and diastolic functions via echocardiography during the 3rd trimester (28–30 weeks’ gestation) and within 4 days of delivery. Additionally, we analyzed the cardiac geometry: relative wall thickness and LV mass index (LVMI). Diastolic dysfunction was defined as early diastolic mitral annulus velocity (e’) 15. The pregnant women were 33.7±5.0 years old and the prevalence of hypertensive disorders in pregnancy (HDP) was 4.0%. LV systolic function was preserved in all pregnant women. However, diastolic function significantly decreased after delivery (mean e’: 12.6 vs. 11.6 cm/s, P<0.0001; median E/e’ ratio: 6.4 vs. 7.3, P<0.0001). Diastolic function after delivery was associated with the prevalence of HDP (P=0.035) and was correlated with age (R=−0.17, P=0.0009) and LVMI (R=−0.30, P<0.0001). However, these changes in diastolic function remained within the normal range and only 1 woman (1/397, 0.3%) had LV diastolic dysfunction after delivery. Conclusions:LV diastolic function decreased after delivery in pregnant women but was within the normal range

The metabolic profile of a rat model of chronic kidney disease

[Background]The kidney is always subjected to high metabolic demand. The aim of this study was to characterize metabolic profiles of a rat model of chronic kidney disease (CKD) with cardiorenal syndrome (CRS) induced by prolonged hypertension. [Methods]We used inbred male Dahl salt-sensitive (DS) rats fed an 8% NaCl diet from six weeks of age (high-salt; HS group) or a 0.3% NaCl diet as controls (low-salt; LS group). We analyzed function, pathology, metabolome, and the gene expression related to energy metabolism of the kidney. [Results]DS rats with a high-salt diet showed hypertension at 11 weeks of age and elevated serum levels of creatinine and blood urea nitrogen with heart failure at 21 weeks of age. The fibrotic area in the kidneys increased at 21 weeks of age. In addition, gene expression related to mitochondrial function was largely decreased. The levels of citrate and isocitrate increased and the gene expression of alpha-ketoglutaratedehydrogenase and succinyl-CoA synthetase decreased; these are enzymes that metabolize citrate and isocitrate, respectively. In addition, the levels of succinate and acetyl Co-A, both of which are metabolites of the tricarboxylic acid (TCA) cycle, decreased. [Conclusions]DS rats fed a high-salt diet were deemed a suitable model of CKD with CRS. Gene expression and metabolites related to energy metabolism and mitochondria in the kidney significantly changed in DS rats with hypertension in accordance with the progression of renal injury

Factors associated with increased levels of brain natriuretic peptide and cardiac troponin I during the peripartum period.

BACKGROUND:We aimed to investigate the values and the changes of brain natriuretic peptide (BNP) and cardiac troponin in pregnant women. METHODS AND RESULTS:We prospectively collected the data of 405 pregnant women who were treated at Japanese general hospital between 2012 and 2013. We analyzed their laboratory data and echocardiographic findings during the third trimester (28-30 weeks' gestation) and within 4 days of delivery. In addition, we evaluated the factors associated with elevation of BNP and cardiac troponin I (cTnI) levels. The pregnant women were 33.8 ± 5.0 years old and the prevalence of pregnancy induced hypertension (PIH) and placental abnormality was 4.2% and 2.5%, respectively. BNP levels increased after delivery (13.2 pg/mL vs. 23.5 pg/mL; P <0.001), correlated with increased left ventricular diastolic dimension (P = 0.035), left atrial dimension (P <0.001), and decreased hemoglobin (P <0.001). Moreover, cTnI levels increased to over 0.015 ng/mL after delivery in 4.0% of pregnant women. In multivariate analysis, PIH (OR: 18.71, P = 0.003), placental abnormality (OR: 26.78, P = 0.007), and decreased hemoglobin after delivery (OR: 2.59, P <0.001) were the factors associated with elevated cTnI. CONCLUSIONS:BNP levels increased in association with cardiac chamber enlargement and decreased hemoglobin after delivery. Additionally, the factors affecting elevated cTnI levels were related to labor and delivery

Incidence and Predictors of Catheterization-Related Cerebral Infarction on Diffusion-Weighted Magnetic Resonance Imaging

Introduction. The aim of this study was to examine the incidence and risk factors of catheterization-related CI in the contemporary era, using diffusion-weighted magnetic resonance imaging. Methods. We retrospectively analyzed consecutive 84 patients who underwent MRI (magnetic resonance imaging) after 2.81±2.4 days (mean±SD) of catheterization via aortic arch. We categorized the patients by the presence or absence of acute CI determined by diffusion-weighted MRI and analyzed the incidence and predictors. Results. Of 84 patients that underwent MRI after catheterization, acute CI was determined in 27 (32.1%) patients. In univariate analysis, dyslipidemia, age, coronary artery disease, antiplatelet agents, number of catheters used, urgent settings, and interventional procedures were significantly different. Multivariate analysis revealed dyslipidemia (odds ratio [OR], 4.46; 95% confidence interval [CI], 1.41–16.03; p=0.01), higher age (OR, 1.09; 95% CI, 1.007–1.19; p=0.03), and the number of catheters used (OR, 2.21; 95% CI, 1.21–4.36; p=0.01) as independent predictors of the incidence of catheterization-related acute CI. Conclusions. Dyslipidemia, higher age, and number of catheters used were independent predictors for acute CI after catheterization. These findings imply that managing dyslipidemia and comprehensive planning to minimize the numbers of catheters are important