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Raphael Rosenhek

Publications and source records attributed to Raphael Rosenhek.

13 recordsLinked to original sources
PubMed2006

Outcome of watchful waiting in asymptomatic severe mitral regurgitation.

BACKGROUND: The management of asymptomatic severe mitral regurgitation remains controversial. The aim of this study was to evaluate the outcome of a watchful waiting strategy in which patients are referred to surgery when symptoms occur or when asymptomatic patients develop left ventricular (LV) enlargement, LV dysfunction, pulmonary hypertension, or recurrent atrial fibrillation. METHODS AND RESULTS: A total of 132 consecutive asymptomatic patients (age 55+/-15 years, 49 female) with severe degenerative mitral regurgitation (flail leaflet or valve prolapse) were prospectively followed up for 62+/-26 months. Patients underwent serial clinical and echocardiographic examinations and were referred for surgery when the criteria mentioned above were fulfilled. Overall survival was not statistically different from expected survival either in the total group or in the subgroup of patients with flail leaflet. Eight deaths were observed. Thirty-eight patients developed criteria for surgery (symptoms, 24; LV criteria, 9; pulmonary hypertension or atrial fibrillation, 5). Survival free of any indication for surgery was 92+/-2% at 2 years, 78+/-4% at 4 years, 65+/-5% at 6 years, and 55+/-6% at 8 years. Patients with flail leaflet tended to develop criteria for surgery slightly but not significantly earlier. There was no operative mortality. Postoperative outcome was good with regard to survival, symptomatic status, and postoperative LV function. CONCLUSIONS: Asymptomatic patients with severe degenerative mitral regurgitation can be safely followed up until either symptoms occur or currently recommended cutoff values for LV size, LV function, or pulmonary hypertension are reached. This management strategy is associated with good perioperative and postoperative outcome but requires careful follow-up.

Aged↗
PubMed2005

Big endothelin-1 is not a predictor in aortic stenosis, but is related to arterial blood pressure.

BACKGROUND: In aortic stenosis, natriuretic peptides have recently been shown to correlate with ventricular function and to predict symptom-free survival and outcome. Elevated big endothelin-1 (bigET) is associated with poor prognosis in chronic heart failure, but little is known about its role in severe aortic stenosis. METHODS: In 61 patients with aortic stenosis (71+/-10 years, mean gradient 65+/-20 mm Hg, valve area 0.63+/-0.15 cm2), plasma bigET was determined by radioimmunoassay and related to echocardiographic parameters, symptoms and survival. Patients were followed for 1 year. RESULTS: BigET (mean 2.3+/-1.5, range 0.1-7.5 fmol/ml) was elevated > or = 1.9 fmol/ml in 54% of patients, but was not correlated to the transvalvular gradients or valve area. BigET did not differ significantly between 14 asymptomatic (2.4+/-1.0 fmol/ml) and 47 symptomatic patients (2.3+/-1.6 fmol/ml), although the highest levels were observed in 5 patients in NYHA class III-IV (4.2+/-2.2 fmol/ml, p=0.035). No significant difference in bigET was observed between 51 survivors and 10 patients who died during follow-up (2.2+/-1.4 vs 2.7+/-1.6 fmol/ml). BigET did not differ between 7 asymptomatic patients developing symptoms and those remaining asymptomatic during follow-up. BigET was significantly related to the systolic blood pressure and left ventricular systolic pressure (r=0.389, p=0.0025 and r=0.401, p=0.0018, respectively), but not to the diastolic blood pressure or interventricular septal wall thickness. BigET was inversely related to the left ventricular ejection fraction (r=0.327, p=0.01) and fractional shortening (r=0.391, p=0.044). CONCLUSION: Although frequently elevated, bigET-1 is not a useful predictor of symptoms or outcome in patients with severe aortic stenosis. BigET increases inversely with left ventricular function and directly with systolic left ventricular and blood pressure, but is not related to transvalvular gradients or valve area.

Aged↗
PubMed2005

Vascular dysfunction after coarctation repair is related to the age at surgery.

BACKGROUND: Despite repair of aortic coarctation, hypertension is frequent in adults and premature coronary and cerebrovascular disease remain of concern. Persistent impairment of arterial dilation has been suspected to contribute to abnormal blood pressure regulation. We tested the hypothesis that arterial reactivity is more likely to be impaired in patients corrected at older age. METHODS: We studied changes in brachial artery diameter in response to reactive hyperemia (FMD) and to nitroglycerin (NMD) in 36 patients and 25 controls. Depending on their age at surgery, patients were divided in group A (surgery <9 years) and group B (surgery > or =9 years). RESULTS: Cholesterol levels and percentage of smokers were similar in patients and controls, but 16 patients had arterial hypertension compared to none of the controls. Endothelium-dependent vasodilation, FMD, and endothelium-independent vasodilation, NMD, were significantly impaired in patients vs. controls (8.2+/-6.2% vs. 13.0+/-5.1%, p<0.001 and 12.9+/-8.0% vs. 18.8+/-9.2%, p<0.01, respectively), both, in hypertensives (8.3+/-6.0%, p<0.01 and 11.8+/-6.0%, p<0.05) and in normotensives (8.1+/-6.5% p<0.01 and 13.8+/-9.3%, p<0.05). However, FMD and NMD in patients of group A did not significantly differ from that in controls (10.0+/-6.7% n.s. and 15.0+/-7.6% n.s.), whereas they were lowest in patients of group B (5.5+/-4.3%, p<0.0001 and 9.6+/-7.7% p<0.001). CONCLUSIONS: Persistent impairment of FMD and NMD after repair of coarctation is more likely to be present in patients corrected at older age. It may be an important contributor to abnormal blood pressure regulation and late morbidity and mortality.

Adolescent↗
PubMed2005

Doppler echocardiographic assessment of valvular regurgitation severity by measurement of the vena contracta: an in vitro validation study.

BACKGROUND: Noninvasive quantitation of valvular regurgitation remains a difficult problem. Measurements of the vena contracta (VC) by color Doppler echocardiography have been proposed but limited data are available on the actual accuracy of this method. METHODS: To evaluate how closely the color Doppler VC reflects the true fluid dynamic VC and the anatomic regurgitant orifice and whether this measurement is affected by flow changes, various models of valvular regurgitation were studied in an in vitro flow circuit. The VC diameter was measured with color Doppler using two different ultrasound systems (Agilent Sonos 5500; Agilent Technologies Inc, Palo Alto, Calif and Vingmed CFM 800; GE Healthcare, Chalfront St Giles, UK). Optical planimetry of the anatomic regurgitant orifice was performed, the true VC diameter was determined by laser particle flow visualization. RESULTS: Because of flow contraction, the true VC diameter was consistently smaller than the anatomic regurgitant orifice diameter. Anatomic orifice and true VC only marginally changed with flow rate. The diameter of the color Doppler VC, however, not only overestimated the anatomic orifice diameter by 45% to 60% and the true VC diameter by 130% to 160%, but was also highly affected by the flow rate and the ultrasound system. Despite these limitations a color Doppler VC diameter of 0.77 cm or more (Agilent) and 0.89 cm or more (Vingmed) detected severe regurgitation with a sensitivity of 93% and 84% and a specificity of 96% and 79%, respectively. CONCLUSIONS: Color Doppler estimates of the VC markedly overestimate regurgitant orifice and true VC. In contrast to the true VC, Doppler measurements are significantly affected by flow rate and by the ultrasound system used. Nevertheless, they allow semiquantitative assessment of valvular regurgitation separating severe from nonsevere regurgitation with acceptable accuracy.

Aortic Valve Insufficiency↗
PubMed2005

Hand-held miniaturized cardiac ultrasound instruments for rapid and effective bedside diagnosis and patient screening.

RATIONALE, AIMS AND OBJECTIVES: Technological progress in recent years has made it possible that ultrasound industry can now offer affordable, portable and battery-operated ultrasound systems the size of a laptop computer. The purpose of this study was to compare these hand-carried ultrasound instruments with standard echocardiography in order to investigate the facility of a rapid bedside diagnosis in patients with suspected or known cardiovascular disease. METHODS: Fifty consecutive patients were studied with miniaturized ultrasound equipment (SonoHeart) and a conventional scanner (Acuson Sequoia) in a blinded manner. All studies were performed by three board-certified cardiologists skilled and experienced in echocardiographic practice. Investigators were not aware of any previous medical reports. RESULTS: With the new system, adequate images could be obtained in all patients. Left ventricular and left atrial diameters measured with the hand-held system correlated well with those obtained with conventional scanning: r = 0.87, mean difference 3.12 +/- 2.7 mm and r = 0.84, mean difference 2.8 + 2.4 mm, respectively. The presence of left ventricular dysfunction, regional wall motion abnormalities, relevant valvular regurgitation (moderate or more) or valve stenosis was correctly diagnosed in all patients. However, there was a tendency towards underestimating the extent of wall motion abnormalities particularly in patients difficult to image. Discrepancies also frequently occurred in patients with trivial or mild regurgitation, where false-positive and false-negative findings were described. CONCLUSION: Currently available hand-held echocardiography systems can facilitate rapid bedside diagnosis and patient screening. However, this recent development in echocardiography also raises a number of questions and its actual impact on general clinical practice still remains to be evaluated.

Cardiovascular Diseases↗
PubMed2004

Statins but not angiotensin-converting enzyme inhibitors delay progression of aortic stenosis.

BACKGROUND: Recently, statins and angiotensin-converting enzyme inhibitors (ACEIs) have been shown to slow aortic valve calcium accumulation. Although several studies also suggest that statins may reduce the hemodynamic progression of aortic stenosis (AS), no data are available for ACEIs or the combination of both. METHODS AND RESULTS: A total of 211 consecutive patients (aged 70+/-10 years, 104 females) with native AS, defined by a peak velocity >2.5 m/s (valve area 0.84+/-0.23 cm(2), mean gradient 42+/-19 mm Hg), with normal left ventricular function and no other significant valvular lesion who were examined between 2000 and 2002 and who had 2 echocardiograms separated by at least 6 months were included. Of these, 102 patients were treated with ACEIs, 50 patients received statins, and 32 patients received both. Hemodynamic progression of AS was assessed and related to medical treatment. Annualized increase in peak aortic jet velocity for the entire study group was 0.32+/-0.44 m x s(-1) x y(-1). Progression was significantly lower in patients treated with statins (0.10+/-0.41 m x s(-1) x y(-1)) than in those who were not (0.39+/-0.42 m x s(-1) x y(-1); P<0.0001). This effect was observed both in mild-to-moderate and severe AS. ACEI use, however, did not significantly affect hemodynamic progression (P=0.29). Furthermore, ACEIs had no additional effect on AS progression when given in combination with statins (0.11+/-0.42 versus 0.08+/-0.43 m x s(-1) x y(-1) for combination versus statin only; P=0.81). Cholesterol levels did not correlate with hemodynamic progression either in the group receiving statins or in the group that did not. CONCLUSIONS: ACEIs do not appear to slow AS progression. However, statins significantly reduce the hemodynamic progression of both mild-to-moderate and severe AS, an effect that may not be related to cholesterol lowering.

Aged↗
PubMed2004

Natriuretic peptides predict symptom-free survival and postoperative outcome in severe aortic stenosis.

BACKGROUND: The prognostic value of natriuretic peptides in aortic stenosis (AS) remains unknown. METHODS AND RESULTS: B-type natriuretic peptide (BNP), N-terminal BNP (NtBNP), and N-terminal atrial natriuretic peptide (NtANP) were determined in 130 patients with severe AS (mean age, 70+/-12 years; mean gradient, 64+/-21 mm Hg; valve area, 0.64+/-0.15 cm2) who were followed up for 377+/-150 days. Natriuretic peptides increased with NYHA class and with decreasing ejection fraction (EF). Even asymptomatic patients frequently had elevated neurohormones. Asymptomatic patients who developed symptoms during follow-up had higher BNP and NtBNP levels at entry compared with those remaining asymptomatic (median for NtBNP, 131 pmol/L [interquartile range, 50 to 202 pmol/L] versus 31 pmol/L [range, 19 to 56 pmol/L]; P<0.001). Symptom-free survival at 3, 6, 9, and 12 months for patients with NtBNP <80 versus > or =80 pmol/L was 100%, 88+/-7%, 88+/-7%, and 69+/-13% compared with 92+/-8%, 58+/-14%, 35+/-15%, and 18+/-15%, respectively (P<0.001). Seventy-nine patients eventually underwent surgery because of symptoms. Considering preoperative neurohormone levels, age, NYHA class, aortic valve area, EF, and presence of coronary artery disease, we found that neurohormones, EF, and NYHA class predicted survival; neurohormones predicted postoperative symptomatic status; and neurohormones and preoperative EF predicted postoperative EF. However, by multivariate analysis, NtBNP was the only independent predictor of outcome. CONCLUSIONS: In severe AS, natriuretic peptides provide important prognostic information beyond clinical and echocardiographic evaluation. NtBNP independently predicts symptom-free survival, and preoperative NtBNP independently predicts postoperative outcome with regard to survival, symptomatic status, and left ventricular function. Thus, neurohormones may gain particular importance for timing of surgery in asymptomatic severe AS.

Aged↗
PubMed2004

Mild and moderate aortic stenosis. Natural history and risk stratification by echocardiography.

AIMS: To define the natural history and predictors of outcome in mild and moderate aortic stenosis (AS). METHODS AND RESULTS: One hundred and seventy-six consecutive asymptomatic patients (73 women, age 58+/-19 years) with mild to moderate AS (jet velocity 2.5 to 3.9m/s) were followed for 48+/-19 months. Haemodynamic progression and clinical outcome was analysed. Event-free survival with end-points defined as death (n=34) or aortic valve surgery (n=33), was 95+/-2%, 75+/-3% and 60+/-5% at 1, 3 and 5 years, respectively. Both, cardiac and non-cardiac mortality were significantly increased, resulting in a 1.8 times higher mortality than expected (P<0.005). By multivariate analysis, moderate to severe aortic valve calcification, coronary artery disease (CAD) and peak jet velocity were independent predictors of outcome. Event-free survival for patients with moderate or severe valve calcification was 92+/-4%, 61+/-7% and 42+/-7% at 1, 3 and 5 years versus 100%, 90+/-4% and 82+/-5% for patients with no or mild calcification. Patients with calcified aortic valves, CAD or with an event had a significantly faster haemodynamic progression. Of 129 patients with a follow-up echocardiographic exam, 59 (46%) developed severe stenosis during follow-up. CONCLUSION: Outcome of mild and moderate AS is worse than commonly assumed. Rapid progression and excess mortality have to be considered. Significant valve calcification, CAD and rapid progression of aortic jet velocity indicate poor outcome. Patients with these characteristics may require closer follow-up than generally assumed.

Aged↗
PubMed2004

Value and limitations of aortic valve resistance with particular consideration of low flow-low gradient aortic stenosis: an in vitro study.

BACKGROUND: The calculation of valve resistance (R) rather than aortic valve area (AVA) has been proposed for the assessment of aortic stenosis (AS), based on the claim that it is less flow-dependent. Even more importantly, valve resistance has been reported to distinguish between truly severe and "pseudosevere" AS in patients with low cardiac output. However, the diagnostic value of valve resistance remains controversial. METHODS AND RESULTS: Models of stenotic aortic valves (plates and nozzles) and biological stenotic valves were studied in a pulsatile in vitro circuit using Doppler ultrasound and direct pressure and flow measurements. Anatomic AVAs ranged from 0.5 to 1.25 cm2; cardiac output varied from 1.8 to 9.0 l/min. Effective AVA was calculated with the continuity equation. The orifices of the biological valves were recorded with a video camera for planimetry. In low flow-low gradient AS, truly severe stenosis was defined by an AVA remaining <0.85 cm2 after flow normalisation, whereas AVA increased beyond 0.85 cm2 in pseudosevere AS. In rigid stenoses, valve resistance increased significantly with flow, while in bioprostheses this flow dependence was partially masked by an actual increase of the anatomic orifice area. In low flow-low gradient AS, valve resistance was significantly smaller in pseudosevere AS compared to truly severe AS (129 +/- 28 vs. 176 +/- 33 dyne s cm(-5); p<0.001) at a similar baseline effective AVA. After the exclusion of datasets with mean gradients <15 and >35 mmHg, the difference in valve resistance between truly severe and pseudosevere AS was no longer significant (162 +/- 26 vs. 141 +/- 22 dyne s cm(-5); p=0.08). Nevertheless, valve resistance <120 dyne s cm(-5) was found only in pseudosevere stenoses while valve resistance >180 dyne s cm(-5) marked truly severe stenosis. CONCLUSIONS: Valve resistance is flow-dependent and not superior to calculated AVA for the assessment of AS. In low flow-low gradient AS, valve resistance <120 dyne s cm(-5) identifies pseudosevere AS, whereas valve resistance >180 dyne s cm(-5) implies truly severe AS. However, values between 120 and 180 dyne s cm(-5) are nondiagnostic, requiring repeated AVA calculations after flow normalisation.

Aged↗
PubMed2003

Normal values for Doppler echocardiographic assessment of heart valve prostheses.

Assessment of normal and abnormal function of heart valve prostheses remains challenging. Doppler echocardiography has been shown to allow hemodynamic evaluation in various clinical settings and has become the most widely used tool to assess prosthetic valve function. Prosthetic valves, even when they function normally, are to some degree obstructive to the blood flow. The normal values of gradients, pressure half-time, and effective orifice area depend on valve type and valve size. Doppler assessment of prosthetic valve function, thus, requires specification of valve type and valve size, and knowledge of the normal values. This study provides an updated overview on the available data of normal values to facilitate adequate interpretation of Doppler data.

Aortic Valve↗
PubMed2003

Fibrinolytic balance of the arterial wall: pulmonary artery displays increased fibrinolytic potential compared with aorta.

Classic pulmonary thromboembolism research has documented that large pulmonary thromboemboli lyse spontaneously, suggesting potent fibrinolytic activity in human pulmonary artery (Pa). This concept conflicts with published animal studies in which the proximal Pa was reported to be devoid of tissue plasminogen activator (t-PA) expression. The current study used in situ hybridization protocols to demonstrate t-PA expression in samples of human main Pa (n = 30). Real-time PCR was used to demonstrate quantitatively that the levels of t-PA transcripts were higher than those of its primary regulator [ie, plasminogen activator-inhibitor 1 (PAI-1)] in the Pa samples. Immunologic and functional assays extended these observations by demonstrating that levels of t-PA antigen were higher than PAI-1 antigen, which resulted in the detection of free t-PA activity. This contrasted with the fibrinolytic balance of matched samples of aorta (n = 6) in which PAI-1 transcripts and antigen values were higher than the corresponding t-PA values, and only M(r) 110 kDa t-PA-PAI-1 complexes could be detected in functional assays. To assess the relative fibrinolytic contribution of the endothelial cell layer, Pa endothelial cells and aortic endothelial cells were scraped and propagated in culture for 20 +/- 6 days. Pa endothelial cell-conditioned media revealed increased t-PA/PAI-1 antigen ratios. Taken together, our data indicate that the balance between t-PA and PAI-1 is shifted in human main Pa to favor net PA activity.

Aorta, Thoracic↗
PubMed2002

Intraoperative transesophageal echocardiography in valve replacement surgery.

Transesophageal echocardiography (TEE) is applied widely during heart valve replacement surgery. Intraoperative TEE (IOTEE) is used to formulate the surgical plan, assess cardiac function, and evaluate surgical outcome. This review describes the methodology of IOTEE, focusing on its role in valve replacement surgery. Specific aspects, such as its role in surgical decision making, selection of the prosthetic model and size, detection and quantification of paravalvular leaks, outflow tract obstruction, and acute prosthetic valve obstruction, are discussed. Furthermore, a description of the value of IOTEE in newer procedures, such as port access surgery, is presented.

Aortic Valve↗