cardiovascular-agents and Aortic-Valve-Insufficiency

Aortic regurgitation (AR) has an estimated prevalence of 4.9% in the Framingham study, with moderate or severe AR occurring in 0.5% of the study population. The incidence and severity of AR increases with age, and may occur acutely or as a chronic valvular disease with distinct presentations, natural history and management strategy. Our review is a comprehensive description of the varied presentation of aortic regurgitation and its management.

Topics: Aortic Valve; Aortic Valve Insufficiency; Cardiovascular Agents; Heart Valve Prosthesis Implantation; Hemodynamics; Humans; Incidence; Predictive Value of Tests; Risk Factors; Severity of Illness Index; Treatment Outcome

A series of hemodynamic and pathological responses occur in chronic aortic regurgitation, which eventually result in myocardial fibrosis and irreversible left ventricular dysfunction. According to guidelines, valvular surgery is recommended with the development of symptoms, left ventricular systolic dysfunction, or left ventricular dilatation. The optimal timing of surgical intervention has recently been questioned with documentation of irreversible myocardial damage resulting in incomplete left ventricular recovery and adverse clinical outcomes after surgery. Recognizing the shortcomings of the guidelines, we performed a comprehensive review on the novel diagnostic methods that have been shown to improve the detection of subclinical ventricular dysfunction in chronic aortic regurgitation and to improve prediction of outcomes.

Topics: Aged; Aortic Valve Insufficiency; Asymptomatic Diseases; Cardiovascular Agents; Chronic Disease; Disease Progression; Early Diagnosis; Female; Fibrosis; Heart Valve Prosthesis Implantation; Humans; Hypertrophy, Left Ventricular; Male; Middle Aged; Myocardium; Predictive Value of Tests; Recovery of Function; Time Factors; Time-to-Treatment; Treatment Outcome; Ventricular Dysfunction, Left; Ventricular Function, Left; Ventricular Remodeling

Topics: Antihypertensive Agents; Aortic Valve Insufficiency; Aortic Valve Stenosis; Cardiac Catheterization; Cardiology; Cardiovascular Agents; Disease Management; Echocardiography; Evidence-Based Medicine; Exercise Test; Heart Defects, Congenital; Heart Valve Diseases; Heart Valve Prosthesis Implantation; Hemodynamics; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Mitral Valve Insufficiency; Mitral Valve Stenosis; Patient Care Team; Pharyngitis; Referral and Consultation; Rheumatic Fever; Secondary Prevention; Severity of Illness Index; Streptococcal Infections; United States; Vasodilator Agents; Ventricular Dysfunction, Left

Topics: Aortic Valve Insufficiency; Aortic Valve Stenosis; Calcinosis; Cardiovascular Agents; Heart Valve Diseases; Humans; Mitral Valve Insufficiency; Mitral Valve Stenosis; Risk Factors

Background Concurrent presence of aortic stenosis and aortic regurgitation is termed mixed aortic valve disease (MAVD). Although multiple articles have addressed patients with "isolated" aortic stenosis or aortic regurgitation, the natural history, impact, and outcomes of MAVD are not well defined. Here, we evaluate long-term outcomes in patients with MAVD and cardiovascular adaptations to chronic MAVD. Methods and Results This observational cohort study evaluated 862 adult patients (56.8% male) with preserved left ventricular ejection fraction and at least moderate aortic regurgitation and moderate aortic stenosis. Primary outcome was all-cause mortality. Subgroup analysis was based on treatment modality (aortic valve replacement [AVR] versus medical management). A regression analysis of longitudinal echocardiographic parameters was performed to assess the natural history of MAVD. Mean age was 68±15 years, and mean left ventricular ejection fraction was 58±5%. At 4.6 years (25th-75th percentile range, 1.0-8.7), 58.6% of patients underwent an AVR and 48.8% patients died. In both unadjusted and adjusted Cox survival analysis, AVR was associated with improved survival (hazard ratio, 0.41; 95% CI, 0.34-0.51,

Topics: Adaptation, Physiological; Aged; Aged, 80 and over; Aortic Valve; Aortic Valve Insufficiency; Aortic Valve Stenosis; Cardiovascular Agents; Female; Heart Valve Prosthesis Implantation; Humans; Male; Middle Aged; Prognosis; Retrospective Studies; Risk Assessment; Risk Factors; Stroke Volume; Time Factors; Ventricular Function, Left

Aortic regurgitation (AR) is a valvular disease that can lead to systolic heart failure. Treatment options besides cardiac surgery are limited and consequently severe AR is associated with higher mortality and morbidity when not operated. In this investigation, we examined the effects of a novel cardiac myosin activator, Omecamtiv-mecarbil (OM), in rats with chronic severe AR.. AR was created by retrograde puncture of the aortic valve leaflets in 20 adults Wistar rats. 12 animals survived the acute AR phase and were randomized 2 months thereafter into OM (n = 7) or placebo groups (n = 5). Two rats underwent a sham operation and served as controls. Equal volumes of OM or placebo (NaCl 0.9%) were perfused in the femoral vein by continuous infusion (1.2 mg/kg/hour) during 30 min. Doppler-echocardiography was performed before and at the end of the infusion periods.. OM increased indices of global cardiac function (cardiac output, stroke volume), and increased systolic performance (fractional shortening, ejection fraction, left ventricular end systolic diameter) (all p < 0.05). These effects concurred with decreases in indices of LV preload (left atrial size, left ventricular end diastolic diameter) as well in the aortic pre-ejection period / left ventricular ejection time ratio (all p < 0.05). The severity score of the regurgitant AR jet did not change. Placebo infusion did not affect these parameters.. The cardiac myosin activator OM exerts favorable hemodynamic effects in rats with experimental chronic AR.

Topics: Animals; Aortic Valve; Aortic Valve Insufficiency; Cardiac Myosins; Cardiovascular Agents; Chronic Disease; Disease Models, Animal; Echocardiography, Doppler; Hemodynamics; Infusions, Intravenous; Male; Rats, Wistar; Recovery of Function; Severity of Illness Index; Stroke Volume; Urea; Ventricular Function, Left

Predicting the occurrence of aortic insufficiency (AI) during left ventricular assist device (LVAD) support has remained unsolved.. We enrolled 52 patients who had received continuous flow LVAD (14 axial and 38 centrifugal pumps) and who been followed for ≥6 months between Jun 2006 and Dec 2013. Native aortic valve (AV) opening was observed in 18 patients (35%) with improved LV systolic function, and none of them had AI. On multivariate logistic regression analysis preoperative shorter heart failure duration was the only independent predictor of postoperative native AV opening (P=0.042; odds ratio [OR], 0.999). Of the remaining 34 patients (65%) with closed AV, 11 had AI with enlargement of the aortic root and narrow pulse pressure. Among those with closed AV, axial pump use (n=13) was the only significant predictor of the development of AI (P=0.042; OR, 4.950). Patients with AI had lower exercise capacity and a higher readmission rate than those without AI during 2-year LVAD support (55% vs. 8%; P<0.001).. Native AV opening during LVAD support is profoundly associated with reversal of LV systolic function, especially in patients with preoperative shorter heart failure duration. Among those in whom the native AV remains closed, low pulsatility of axial flow pump may facilitate aortic root remodeling and post-LVAD AI development that results in worse clinical outcome.

Topics: Adult; Aortic Valve; Aortic Valve Insufficiency; Cardiovascular Agents; Combined Modality Therapy; Equipment Design; Female; Heart Failure; Heart Valves; Heart-Assist Devices; Hemodynamics; Humans; Male; Middle Aged; Postoperative Complications; Radiography; Retrospective Studies; Ultrasonography; Ventricular Dysfunction, Left

Transcatheter aortic valve-in-valve (VIV) implantation in high-risk patients with degenerative surgical bioprosthetic aortic valves is a novel application of transcatheter aortic valve replacement technology. Although transcatheter aortic VIV procedure is clinically effective in most patients, it is a more demanding procedure in terms of the technical aspects of procedural planning. VIV carries a higher risk of coronary occlusion which is associated with a higher rate of in-hospital mortality. We hereby report a technique of pre-emptive left main (LM) protection, by positioning a coronary stent in the proximal left anterior descending artery prior to VIV implantation. The patient treated was considered to be at an increased risk of LM occlusion as a result of the procedure. The technique was performed in anticipation of emergent bailout stenting of the LM. As predicted, the LM occluded during the procedure and LM protection facilitated the safe and effective treatment of an otherwise life-threatening procedure.

Topics: Aged; Aortic Valve Insufficiency; Bioprosthesis; Cardiac Catheterization; Cardiovascular Agents; Coronary Occlusion; Drug-Eluting Stents; Everolimus; Female; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Humans; Prosthesis Design; Prosthesis Failure; Risk Factors; Sirolimus; Tomography, X-Ray Computed; Treatment Outcome; Ultrasonography, Interventional

New-onset aortic insufficiency (AI) can be encountered after instituting mechanical circulatory support and seems more common and severe with continuous flow (CF) left ventricular assist devices (LVADs) compared with pulsatile devices. Treatment algorithms for de novo, post-LVAD AI have not been well defined. In the present report, we have described 6 patients who underwent aortic valve surgery for new-onset post-LVAD AI.. From 2005 to 2011, 271 patients underwent LVAD implantation. Of these LVADs, 225 were CF devices (203 HeartMate II devices, Thoratec Corp, Pleasanton, Calif; and 22 HVAD devices, HeartWare Intl, Inc, Framingham, Mass). The patients were examined for new-onset severe AI requiring surgical intervention.. During follow-up, 6 CF LVAD patients developed new, severe AI that was accompanied by heart failure. After medical therapy had failed, 4 patients underwent redo sternotomy for aortic valve procedures (1 bioprosthetic valve replacement, 1 Dacron patch closure, and 2 aortic valve repairs), and 2 patients underwent transcatheter aortic valve procedure, with 1 requiring revision by open surgery for aortic valve replacement. Of the 6 patients, 5 experienced significant improvement in functional capacity and symptoms. One patient died postoperatively secondary to multiorgan failure and sepsis.. Surgical treatment of post-LVAD AI with aortic valve oversewing or leaflet repair or by bioprosthetic aortic valve replacement is effective at restoring functional capacity for CF LVAD patients who develop symptomatic, severe AI and can be performed safely with good results. Various transcatheter approaches to these difficult problems are also available and offer less invasive alternatives to conventional surgery.

Topics: Adult; Aged; Aortic Valve Insufficiency; Cardiac Catheterization; Cardiovascular Agents; Female; Heart Failure; Heart Valve Prosthesis Implantation; Heart-Assist Devices; Humans; Male; Prosthesis Design; Recovery of Function; Reoperation; Severity of Illness Index; Sternotomy; Suture Techniques; Treatment Outcome; Ventricular Function, Left

Topics: Aortic Valve Insufficiency; Aortic Valve Stenosis; Cardiac Valve Annuloplasty; Cardiovascular Agents; Combined Modality Therapy; Endovascular Procedures; Heart Valve Diseases; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Humans; Mitral Valve Insufficiency; Mitral Valve Stenosis; Tricuspid Valve Insufficiency; Tricuspid Valve Stenosis

The purpose of this study was to define the link between aortic regurgitation (AR) quantitation and clinical outcome in asymptomatic patients with AR.. Quantitative American Society of Echocardiography (QASE) thresholds are recommended for AR assessment, but impact on clinical outcome is unknown.. We prospectively enrolled (1991 to 2003) 251 asymptomatic patients (age 60 +/- 17 years) with isolated AR and ejection fraction > or =50% with quantified AR and left ventricular (LV) volumes using Doppler-echocardiography.. Survival under medical management was independently determined by baseline regurgitant volume (RVol) (adjusted hazard ratio [HR] 1.22 [95% confidence interval (CI) 1.08 to 1.35] per 10 ml/beat, p = 0.002) and effective regurgitant orifice (ERO) (adjusted HR 1.52 [95% CI 1.19 to 1.91] per 10 mm(2), p = 0.002), which superseded traditional AR grading. Patients with QASE-severe AR (RVol > or =60 ml/beat or ERO > or =30 mm(2)) versus QASE-mild AR (RVol <30 ml and ERO <10 mm(2)) had lower survival (10 years: 69 +/- 9% vs. 92 +/- 4%, p = 0.05) independently of all clinical characteristics (adjusted HR 4.1 [95% CI 1.4 to 14.1], p = 0.01) and lower survival free of surgery for AR (10 years: 20 +/- 5% vs. 92 +/- 4%, p < 0.001, adjusted HR 12.9 [95% CI 5.4 to 38.5]). Cardiac events were considerably more frequent with QASE-severe versus -moderate or -mild AR (10 years: 63 +/- 8% vs. 34 +/- 6% and 21 +/- 8%, p < 0.0001). Independent determinants of cardiac events were quantitative AR grading (QASE-severe adjusted HR 5.2 [95% CI 2.2 to 14.8], p < 0.001; QASE-moderate adjusted HR 2.4 [95% CI 1.06 to 6.6], p = 0.035), which superseded traditional AR assessment (p < 0.001) and LV end-systolic volume index (ESVI) (adjusted HR 1.09 [95% CI 1.03 to 1.14 per 10 ml/m(2)], p = 0.002), which superseded LV M-mode diameters. In QASE-severe AR, patients with ESVI > or =45 versus <45 ml/m(2) had higher cardiac event rates (10 years: 87 +/- 8% vs. 40 +/- 10%, p < 0.001). Cardiac surgery for AR reduced cardiac events in patients with QASE-severe AR (adjusted HR 0.23 [95% CI 0.09 to 0.57], p = 0.002).. Echocardiographic quantitation of AR severity and ESVI provides independent and superior predictors of clinical outcome in asymptomatic patients with AR and ejection fraction > or =50% and should be widely clinically applied. Patients with QASE-severe AR and ESVI > or =45 ml/m(2) should be carefully considered for cardiac surgery, which reduces cardiac events risk.

Topics: Adult; Aged; Aortic Valve Insufficiency; Cardiac Surgical Procedures; Cardiovascular Agents; Cardiovascular Diseases; Echocardiography, Doppler; Humans; Kaplan-Meier Estimate; Middle Aged; Predictive Value of Tests; Proportional Hazards Models; Prospective Studies; Risk Assessment; Severity of Illness Index; Stroke Volume; Time Factors; Treatment Outcome; Ventricular Function, Left

Topics: Aortic Valve Insufficiency; Cardiovascular Agents; Chronic Disease; Humans; Hypertrophy, Left Ventricular; Practice Guidelines as Topic; Systole; United States; Ventricular Dysfunction, Left

Topics: Aged; Aged, 80 and over; Aortic Valve Insufficiency; Cardiovascular Agents; Echocardiography; Female; Heart Failure; Humans; Male; Middle Aged; Prognosis; Prospective Studies; Regression Analysis; Stroke Volume; Survival Rate

Aortic regurgitation is a serious disorder that can challenge the best clinicians in terms of both diagnosis and management. The chronic form requires valve replacement when patients have symptoms or show evidence of left ventricular dysfunction. The acute form requires urgent aortic valve replacement. In all cases, medical management is only a temporizing procedure that can potentially mask the progression of left ventricular dysfunction. Endocarditis prophylaxis for indicated procedures is mandatory for all patients.

Topics: Acute Disease; Adult; Aortic Valve Insufficiency; Cardiovascular Agents; Chronic Disease; Diagnosis, Differential; Heart Function Tests; Heart Valve Prosthesis; Humans; Middle Aged