Almanac 2014: Aortic Valve Disease

Tijekom zadnjih nekoliko godina došlo je do značajnog napretka u dijagnosticiranju bolesti aortnog zalistka i u našem razumijevanju patofiziologije te bolesti, a transkateterska implantacija aortnog zalistka preobrazila je njezino kliničko liječenje. Ovaj članak sažeto prikazuje nova istraživanja o bolestima aortnog zalistka objavljena u časopisu Heart u 2013. i 2014. godini u kontekstu drugih velikih istraživanja objavljenih u općim medicinskim časopisima, uz raspravu o mogućem utjecaju tih, novih otkrića na klinički pristup liječenju odraslih pacijenata s bolesti aortnog zalistka.The past few years have seen major advances in the diagnosis of aortic valve disease and in our understanding of the pathophysiology of disease. In addition, transcatheter aortic valve implantation has transformed our clinical management options. This article summarises new aortic valve disease research published in Heart in 2013 and 2014, within the context of other major studies published in general medical journals, including a discussion of the potential impact of these new research findings on the clinical approach to management of adults with aortic valve disease

Hemodynamic progression of aortic stenosis in adults assessed by doppler echocardiography

AbstractDoppler echocardiography was used to follow the hemodynamic severity of aortic stenosis. First, the reproducibility of repeat recordings (mean interval 28 ± 36 days) of aortic jet velocity, made by two independent observers, was tested in 38 adults with aortic stenosis and unchanged clinical status. The two recordings of maximal velocity correlated well (r = 0.96, y = 0.88x + 0.46m/s, SEE = 0.21 m/s) with a mean coefficient of variation of 3.2%. Repeat recording of left ventricular outflow tract velocity by two independent observers in 10 other patients with aortic stenosis also correlated well (r = 0.94, y = 1.06x + 0.0 m/s, SEE = 0.06 m/s) with a mean coefficient of variation of 4.6%.Next, Doppler echocardiography was used to study 42 patients with aortic stenosis (mean age 66 years) over a follow-up interval of 6 to 43 months (mean 20). Maximal aortic jet velocity increased by 0.36 m/s per year (range −0.3 to +1.0 m/s per year). Mean transaortic pressure gradient changed by −7 to +23 (mean 8) mm Hg/year. Aortic valve area by the continuity equation (n = 25) decreased by 0 to 0.5 cm2/year (mean decrease 0.1 cm2/year). year patients had a worsening of stenosis (decrease in valve area) even though they had no change or a decrease in pressure gradient, because of concurrent decreases in transaortic volume flow.Twenty-one patients (50%) developed new or progressive symptoms of aortic stenosis necessitating valve replacement. These patients had a higher maximal aortic jet velocity at follow-up (4.5 versus 3.9 m/s, p < 0.01) and a greater rate of increase in mean pressure gradient (15 versus 7 mm Hg/year, p < 0.01) than did those who remained asymptomatic; however, there were no significant differences in age, follow-up interval or maximal aortic jet velocity at entry.It is concluded that Doppler echocardiographic measures of aortic stenosis severity are reproducible. The rate of change of transaortic pressure gradient varies among patients and the gradient may not increase even when stenosis severity worsens. Although stenosis severity progresses more rapidly in patients who develop symptoms requiring valve replacement, these patients cannot be identified at the initial study

Infective endocarditis, 1983–1988: Echocardiographic findings and factors influencing morbidity and mortality

The echocardiograms and clinical records of 70 patients with infective endocarditis seen between 1983 and 1988 were examined to evaluate the role of two-dimensional and Doppler echocardiography in the diagnosis of infective endocarditis and identify risk factors for morbidity and mortality. A blinded observer reviewed the echocardiograms for the presence and size of vegetations and the severity of the valvular regurgitation. Vegetations were identified in 54 (78%) of 69 technically satisfactory echocardiograms. In 38 patients whose heart was examined at surgery or autopsy, all vegetations diagnosed by echocardiography were confirmed, but six additional vegetations were found.Abnormal (≥2+) valvular regurgitation was present in 88% of patients. No patient with ≤1+ regurgitation (n = 8) died or required valve surgery for heart failure, but three of the eight patients did undergo surgery for mycotic aneurysm, recurrent embolism or paravalvular abscess. In patients without embolism before echocardiography, there was a trend toward a greater incidence of subsequent embolism in those with vegetations >10 mm in size (26% [8 of 31] compared with 11% [2 of 18] with vegetations ≤10 mm) (p = 0.19). By multivariate analysis, risk factors for in-hospital death (n = 7) were an infected prosthetic valve (p < 0.007), systemic embolism (p < 0.02) and infection with Staphylococcus aureus(p = 0.05).It is concluded that 1) if valvular regurgitation is ≤1+, the risk of in-hospital death is low, and progression to cardiac surgery for hemodynamic instability is unlikely; 2) there is a trend toward a higher risk of embolization in patients with vegetations >10 mm in size; 3) early mortality now relates to infected prosthetic heart valves, embolism and Staphylococcus aureus; and 4) when a paravalvular abscess or prosthetic valve endocarditis is suspected, transthoracic echocardiographic findings are often equivocal and transesophageal echocardiography may be of benefit

Using the DELPHI Method to Collect Feedback on Student\u27s Perceptions of Teaching Quality

In educational institutions, teaching effectiveness is a highly valued asset among administrators, professors, and students alike. Information gathered from students is often used as a basis for promotion and tenure decisions (Abrami & d’Apollonia, 1999; Waters, Kemp, & Pucci, 1988), and, ideally, formative purposes. However, students do not always believe that their evaluations carry much weight (Chen & Hoshower, 2003; Spencer & Schmelkin, 2002). This is likely due to the fact that summarized results from student evaluations often do not get in the hands of professors until after that particular course has concluded and, therefore, the feedback does not directly benefit the students who provided it. The goal of the current paper is to introduce a method that can be used by instructors to evaluate the effectiveness of their teaching in a particular course in such a way as to implement change in the course if necessary for those very same students. First, we will discuss teaching effectiveness in general; second we will introduce the DELPHI method and its usefulness in evaluating effective teaching; and third we will report on the results of using this method in our courses with the goal of improving the learning experience for the students providing the feedback

Standards for heart valve surgery in a ‘heart valve centre of excellence’

Surgical centres of excellence should include multidisciplinary teams with specialist expertise in imaging, clinical assessment and surgery for patients with heart valve disease. There should be structured training programmes for the staff involved in the periprocedural care of the patient and these should be overseen by national or international professional societies. Good results are usually associated with high individual and centre volumes, but this relationship is complex. Results of surgery should be published by centre and should include rates of residual regurgitation for mitral repairs and reoperation rates matched to the preoperative pathology and risk