Classification of aortic stenosis by flow and gradient patterns provides insights into the pathophysiology of disease

Different patterns of flow and valve gradients can lead to diagnostic uncertainty about the severity of aortic stenosis (AS). Consecutive patients with severe AS (valve area <1 cm2) underwent echocardiography and computed tomography. Patients were classified into 4 groups (high-gradient/normal flow [HGNF], high-gradient/low flow [HGLF], low-gradient/normal flow [LGNF], and low-gradient/low flow [LGLF]). Low flow was defined as stroke volume index <35 mL/m2 and low gradient as a mean aortic gradient <40 mm Hg. Aortic valve calcification (AVC) was calculated using the Agatston score. Of 181 patients, 56, 30, 46, and 49 had HGNF, HGLF, LGNF and LGLF with median AVC of 2048, 2015, 1366, and 1178 AU/m2 (P < .0001) and valvuloarterial impedance of 4.5, 6.4, 4.2, and 5.9, respectively (P < .0001). Among those with LGLF, AVC was lower in patients with preserved compared to reduced left ventricular ejection fraction (1018 vs 2550 AU/m2; P < .0001), but valvuloarterial impedance was similar (P = .33). The LGLFAS with preserved ejection fraction is associated with lower AVC and may identify patients with less severe AS in association with an adaptive ventricular response to high afterload

Classification of Aortic Stenosis by Flow and Gradient Patterns Provides Insights into the Pathophysiology of Disease

Different patterns of flow and valve gradients can lead to diagnostic uncertainty about the severity of aortic stenosis (AS). Consecutive patients with severe AS (valve area <1 cm2) underwent echocardiography and computed tomography. Patients were classified into 4 groups (high-gradient/normal flow [HGNF], high-gradient/low flow [HGLF], low-gradient/normal flow [LGNF], and low-gradient/low flow [LGLF]). Low flow was defined as stroke volume index <35 mL/m2 and low gradient as a mean aortic gradient <40 mm Hg. Aortic valve calcification (AVC) was calculated using the Agatston score. Of 181 patients, 56, 30, 46, and 49 had HGNF, HGLF, LGNF and LGLF with median AVC of 2048, 2015, 1366, and 1178 AU/m2 (P < .0001) and valvuloarterial impedance of 4.5, 6.4, 4.2, and 5.9, respectively (P < .0001). Among those with LGLF, AVC was lower in patients with preserved compared to reduced left ventricular ejection fraction (1018 vs 2550 AU/m2; P < .0001), but valvuloarterial impedance was similar (P = .33). The LGLFAS with preserved ejection fraction is associated with lower AVC and may identify patients with less severe AS in association with an adaptive ventricular response to high afterload

Cardiac rehabilitation to improve health-related quality of life following trans-catheter aortic valve implantation: a randomised controlled feasibility study: RECOVER-TAVI Pilot, ORCA 4, for the Optimal Restoration of Cardiac Activity Group

Objectives: Transcatheter aortic valve implantation (TAVI) is often undertaken in the oldest frailest cohort of patients undergoing cardiac interventions. We plan to investigate the potential benefit of cardiac rehabilitation (CR) in this vulnerable population. Design: We undertook a pilot randomised trial of CR following TAVI to inform the feasibility and design of a future randomised clinical trial (RCT). Participants: We screened patients undergoing TAVI at a single institution between June 2016 and February 2017. Interventions: Participants were randomised post-TAVI to standard of care (control group) or standard of care plus exercise-based CR (intervention group). Outcomes: We assessed recruitment and attrition rates, uptake of CR, and explored changes in 6-min walk test, Nottingham Activities of Daily Living, Fried and Edmonton Frailty scores and Hospital Anxiety and Depression Score, from baseline (30 days post TAVI) to 3 and 6 months post randomisation. We also undertook a parallel study to assess the use of the Kansas City Cardiomyopathy Questionnaire (KCCQ) in the post-TAVI population. Results: Of 82 patients screened, 52 met the inclusion criteria and 27 were recruited (3 patients/month). In the intervention group, 10/13 (77%) completed the prescribed course of 6 sessions of CR (mean number of sessions attended 7.5, SD 4.25) over 6 weeks. At 6 months, all participants were retained for follow-up. There was apparent improvement in outcome scores at 3 and 6 months in control and CR groups. There were no recorded adverse events associated with the intervention of CR. The KCCQ was well accepted in 38 post-TAVI patients: mean summary score 72.6 (SD 22.6). Conclusions: We have demonstrated the feasibility of recruiting post-TAVI patients into a randomised trial of CR. We will use the findings of this pilot trial to design a fully powered multicentre RCT to inform the provision of CR and support guideline development to optimise health-related quality of life outcomes in this vulnerable population. Retrospectively registered 3rd October 2016 clinicaltrials.gov NCT02921880. Trial registration: Clinicaltrials.Gov identifier NCT0292188

Towards comprehensive assessment of mitral regurgitation using cardiovascular magnetic resonance

Cardiovascular magnetic resonance (CMR) is increasingly used to assess patients with mitral regurgitation. Its advantages include quantitative determination of ventricular volumes and function and the mitral regurgitant fraction, and in ischemic mitral regurgitation, regional myocardial function and viability. In addition to these, identification of leaflet prolapse or restriction is necessary when valve repair is contemplated. We describe a systematic approach to the evaluation of mitral regurgitation using CMR which we have used in 149 patients with varying etiologies and severity of regurgitation over a 15 month period

Ischaemia as a cause of LVOT gradient reversal in HCM

We present the case of a previously fit 84-year-old female with long-standing systemic hypertension and the echo phenotype of hypertrophic cardiomyopathy (HCM) – asymmetrical septal hypertrophy, significant resting left ventricular (LV) outflow obstruction and mitral regurgitation (MR) secondary to systolic anterior motion (SAM) of the mitral valve. Valsalva provocation caused an increase in LVOT dynamic gradient and MR severity. The patient presented with a progressive decrease in exercise capacity along with chest pain relieved by rest or sublingual GTN. Exercise stress echo demonstrated a paradoxical response with reduction of both LVOT gradient and severity of MR. There was evidence of inducible regional wall motion abnormalities associated with no change in LV cavity size. Coronary angiogram revealed significant triple vessel disease

"Respect when you can, resect when you should": A realistic approach to posterior leaflet mitral valve repair.

OBJECTIVE: Avoiding resection to treat posterior leaflet prolapse has become popular to repair degenerative mitral regurgitation. We never subscribed to such simplification but advocated an alternative approach based on the "respect when you can, resect when you should" concept. The present study reviewed posterior leaflet prolapse in degenerative disease with the aim to expose the 10-year experience with this surgical policy, in particular long-term outcomes such as survival, recurrent/severe mitral regurgitation, and reoperation. METHODS: From January 2005 to December 2015, 701 consecutive patients with severe mitral regurgitation underwent mitral valve repair in 2 distinct institutions. Mitral regurgitation was degenerative in 441 patients, of whom the 376 with posterior leaflet prolapse constituted the study population. Patients were followed up by echocardiograms until December 2017. Longitudinal data stratified by institution were analyzed by mixed-effects models. Outcome measures were analyzed by Kaplan-Meier test. RESULTS: Patients with posterior leaflet prolapse (24.7% isolated P2 and 75.3% P2 associated with other segments) were aged 65.8 +/- 13 years, and 70.5% were male. Median follow-up was 61.1 months. There were 3 hospital deaths (0.8%). Reoperation was necessary in 7 patients (1.9%). After 1, 5, and 10 years, overall survival was 97.8%, 93.6%, and 86.7%, respectively; the overall survival of the proportion of patients with recurrent/residual >2+ mitral regurgitation was estimated at 0.7%, 1.9%, and 5.9% and that of patients with New York Heart Association III/IV at 0.8%, 1.9%, and 5.3%. CONCLUSIONS: The "resect with respect" approach yields low operative mortality, no systolic anterior motion, good surface of coaptation, and low incidence of residual/recurrent mitral regurgitation and of reoperation, thus supporting resection when required concept

Outcome of consistent guideline-based tricuspid management in patients undergoing degenerative mitral regurgitation correction

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Towards comprehensive assessment of mitral regurgitation using cardiovascular magnetic resonance

Abstract Cardiovascular magnetic resonance (CMR) is increasingly used to assess patients with mitral regurgitation. Its advantages include quantitative determination of ventricular volumes and function and the mitral regurgitant fraction, and in ischemic mitral regurgitation, regional myocardial function and viability. In addition to these, identification of leaflet prolapse or restriction is necessary when valve repair is contemplated. We describe a systematic approach to the evaluation of mitral regurgitation using CMR which we have used in 149 patients with varying etiologies and severity of regurgitation over a 15 month period. Following standard ventricular cine acquisitions, including 2, 3 and 4 chamber long axis views and a short axis stack for biventricular function, we image movements of all parts of the mitral leaflets using a contiguous stack of oblique long axis cines aligned orthogonal to the central part of the line of coaptation. The 8–10 slices in the stack, orientated approximately parallel to a 3-chamber view, are acquired sequentially from the superior (antero-lateral) mitral commissure to the inferior (postero-medial) commissure, visualising each apposing pair of anterior and posterior leaflet scallops in turn (A1-P1, A2-P2 and A3-P3). We use balanced steady state free precession imaging at 1.5 Tesla, slice thickness 5 mm, with no inter-slice gaps. Where the para-commissural coaptation lines curve relative to the central region, two further oblique cines are acquired orthogonal to the line of coaptation adjacent to each commissure. To quantify mitral regurgitation, we use phase contrast velocity mapping to measure aortic outflow, subtracting this from the left ventricular stroke volume to calculate the mitral regurgitant volume which, when divided by the left ventricular stroke volume, gives the mitral regurgitant fraction. In patients with ischemic mitral regurgitation, we further assess regional left ventricular function and, with late gadolinium enhancement, myocardial viability. Comprehensive assessment of mitral regurgitation using CMR is feasible and enables determination of mitral regurgitation severity, associated leaflet prolapse or restriction, ventricular function and viability in a single examination and is now routinely performed at our centre. The mitral valve stack of images is particularly useful and easy to acquire.</p