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PubMedDate not supplied

Power spectral analysis of heart rate variability in children with aortic stenosis.

Aortic stenosis is a progressive disorder and can be the cause of serious arrhythmias and possibly sudden death. Evaluation and follow-up of the autonomic nervous system may provide some useful information for management of the disease. Our study aimed to examine heart rate variability in children with aortic stenosis in the supine position and to detect the changes in autonomic activity during head-up tilt testing. Sixteen patients and 11 healthy controls participated in the study. In the supine position, seven minutes of continuous echocardiographic (ECG) recording was performed, followed by four consecutive ECG recordings, each consisting of seven minutes in 70 degrees tilt position. To obtain power spectrums, the tachograms were taken on the autoregressive mode. The mean RR interval duration, standard deviation of RR interval, central frequencies of low and high frequency oscillations, their powers, total power and percents of normalized low and high frequency powers were accepted for statistics. There were no significant differences between the groups in the supine position. In tilt position, mean RR interval and its standard deviation were decreased in both groups. The central frequency of low freuquency power significantly (p<0.05) shifted to left, normalized low frequency power increased and normalized high frequency power decreased in the control group at the beginning of tilt position, but at the second phase of tilt position in the patient group. We conclude from the results that children with mild-to-moderate aortic stenosis reflect delayed response to sympathetic provocation.

Adolescent↗
PubMed1985

[Continuous wave Doppler echocardiographic assessment of aortic stenosis and aortic regurgitation].

Twenty-four patients with aortic stenosis and 22 with aortic insufficiency were evaluated using continuous wave Doppler echocardiography (echo). Doppler echo studies were performed 48 hours before cardiac catheterization. Fifteen normal subjects served as controls. Peak velocity in the ascending aorta in aortic stenosis ranged from 2.0 to 6.0 m/sec with a mean of 3.7 m/sec, and this was significantly increased over the normal controls (mean 1.1 m/sec: 0.7-1.4 m/sec). Using the simplified Bernoulli equation (P = 4 V2, P: peak pressure gradient, V: peak flow velocity), the peak pressure gradient across the aortic valve was measured from the peak velocity in patients with aortic stenosis. The results (Y) correlated well with the peak-to-peak pressure gradient (X) between the left ventricular pressure and aortic pressure as obtained by cardiac catheterization (Y = 1.1 X +2.5, r = 0.83). Aortic regurgitation was detected by continuous wave Doppler echo in all patients with aortic insufficiency, but in only half of the patients the peak velocity could be measured (3.8 +/- 0.3 m/sec, mean +/- SD). In the remaining patients, it was difficult to measure the peak velocity, but it seemed to be greater than 3.0 m/sec. On the simultaneous recordings of the gradient between aortic and left ventricular pressures and continuous wave Doppler echo in patients with aortic regurgitation, the shape and pattern of the pressure gradient during diastole were similar to those of continuous wave Doppler echo. We conclude that continuous wave Doppler echo is a very sensitive method for diagnosing aortic stenosis and regurgitation, and it provides a quantitative assessment of the severity of aortic stenosis.

Adult↗
PubMed1994

Aortic valve replacement: procedure of choice in elderly patients with aortic stenosis.

Aortic valve replacement is the treatment of choice for elderly patients with aortic stenosis. It can be accomplished with excellent immediate and long-term results with significant functional improvement. Unfortunately, the literature is replete with enthusiastic reports of aortic catheter balloon valvotomy. Initial findings were controversial and the long-term results have been poor due to early valve restenosis. A retrospective analysis of our surgical experience with aortic valve replacement in the elderly seems appropriate in an effort to put this issue in proper perspective. From January 1973 to June 1993, 200 consecutive patients 70 years of age and older with severe aortic stenosis underwent surgical correction. There were 105 men (52.5%) and 95 women (47.5%), with a mean age of 76.2 years (range 70 to 89). Preoperatively, 195 patients (97.5%) were in New York Heart Association (NYHA) Class III or IV. Over one half (61.0%) of the patients experienced no hospital complications. The hospital mortality was 9.0% (18 patients). This included 14 patients in NYHA Class IV. The mean follow-up was 69.3 months and ranged from 1 to 215 months. The actuarial survival for 182 patients discharged from the hospital was 70.8% +/- 4.0% (SEM) at 72 months (73 patients at risk) and 35.2% +/- 5.4% at 144 months (20 patients at risk). Considering the advanced age and preoperative functional classification in this patient group, the results of aortic valve replacement have been excellent. The survival of patients discharged from the hospital compares favorably with a normal population matched for age and sex. The results of aortic balloon valvotomy have been disappointing.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1990

Neonatal aortic stenosis.

Aortic stenosis in the neonate has been associated in the past with a high operative mortality. As a result, in the current era of percutaneous balloon dilatation, the optimal mode of therapy remains controversial. An approach of stabilization with cardiopulmonary bypass, followed by relief of left ventricular outflow tract obstruction, was used at three institutions, and the results are presented. During the period 1983 to 1989, 40 neonates with isolated aortic stenosis and patent ductus arteriosus or coarctation of the aorta, or both, underwent operative therapy. Ages ranged from 1 to 30 days, median of 12 days, including 17 patients in the first week of life. There were 30 boys and 10 girls; weights ranged from 2.5 to 5.5 kg with a mean of 3.6 kg. Perioperative conditions included congestive heart failure in 38 and mitral regurgitation in 16; left ventricular-aortic gradients ranged from 15 to 130 mm Hg, with a mean of 67 mm Hg. There were 30 open valvotomies and 10 transventricular dilatations. The hospital survival rate was 87.5% (35/40) with no significant difference between the methods of valvotomy (9/10 in the transventricular dilatation group, 90%; 26/30 in the open valvotomy group, 87%). Although multiple methods of perfusion and valvotomy were used, the single unifying factor of cardiopulmonary bypass stabilization was present in all 40 patients. No significant difference in survival was noted between institutions, methods of cardiopulmonary bypass, cardiopulmonary bypass times, crossclamp times, or method of valvotomy. There have been five reoperations, with one late death in a patient requiring mitral valve replacement and an apical-aortic conduit. One sudden death occurred; autopsy revealed endocardial fibroelastosis. Results demonstrate that in the three institutions using the methods described, a high operative and late survival rate is possible. The results of this technique, against which percutaneous dilatation should be compared, are standard in the current era.

Aortic Valve↗
PubMed2003

Continuous spinal analgesia for labor pain in a parturient with aortic stenosis.

Aortic stenosis in pregnancy carries a high fetal and maternal morbidity and mortality. Spinal analgesia/anesthesia is considered by many to be contraindicated in these patients. The rapid onset of sympathetic block induces hypotension, which can result in myocardial hypoperfusion and myocardial ischemia. We describe a case of moderate to severe aortic stenosis, diagnosed during pregnancy, in which pain relief during labor and delivery was managed using a continuous spinal catheter. Pure intrathecal opioid analgesia was used initially to maintain hemodynamic stability. However after two bolus administrations of sufentanil, analgesia was further maintained using ropivacaine and sufentanil. A spinal catheter was chosen to provide reliable anesthesia, which could be extended rapidly for cesarean section.

Journal Article↗
PubMed2006

[Biomarkers for the evaluation of valvular aortic stenosis].

Aortic valve diseases, namely aortic stenosis (AS) and aortic regurgitation (AR), are common in developed countries with AS being the most common valvular heart disease. Symptomatic status and echocardiography are the most important clinical parameters to confirm the diagnosis, to assess the severity and to monitor progression of AS. Aortic valve replacement (AVR) is indicated in symptomatic patients with severe AS, but in asymptomatic patients with severe AS there is an ongoing controversial discussion whether these patients should undergo AVR or should be treated conservatively. For patients with moderate AS, surgical treatment is generally not recommended, even though recent data suggest that the outcome of these patients is worse than commonly assumed.In several studies that included patients with valvular AS, an elevation of BNP and NT-proBNP serum concentrations related to disease severity has been reported (Figure 1). Consequently, in a longitudinal study it was found, that NT-proBNP concentrations decrease after successful surgical therapy but increase in conservatively treated patients with AS (Figure 2). These changes of NT-proBNP values over time were related to changes of the transvalvular pressure gradient (Figure 3). Furthermore, it has been demonstrated in clinical outcome studies that elevated NT-proBNP and BNP values, respectively, were associated with an unfavorable clinical course especially in patients who were treated conservatively (Figure 4).Thus, these results suggest that natriuretic peptides can be used as biomarkers for the diagnostic work-up of patients with AS and might be helpful to decide on the optimal timing of AVR (Table 1).

Aortic Valve↗
PubMed2004

Risk factors for aortic valve dysfunction in children with discrete subvalvar aortic stenosis.

Aortic regurgitation (AR) is a known complication of discrete subvalvar aortic stenosis (DSS), and its detection often triggers referral for surgery. However, risk factors for aortic valve dysfunction in children with DSS remain incompletely defined. The primary goal of this study was to determine independent risk factors for moderate or severe AR at mid-term follow-up in patients with DSS. Clinical records and echocardiograms of 220 patients with DSS (109 patients had DSS resection and 111 had no surgery) were analyzed. The primary outcome variable was AR grade (based on the width of the vena contracta) at latest follow-up. Age at diagnosis, gender, and duration of follow-up (median 7.2 years, range 1 to 20.4) did not differ significantly between medical and surgical patients. By multivariate analysis, independent risk factors for moderate to severe AR (n = 30) were older age at diagnosis of DSS (odds ratio [OR] for age > or =17 years 5.13, p = 0.024), previous balloon or surgical aortic valvuloplasty (OR 19.6, p <0.001), and a longer follow-up period (OR for 1-year increase 1.15, p = 0.032). Excluding patients with previous surgical or balloon aortic valvuloplasty, a higher maximal Doppler gradient was an independent risk factor for moderate to severe AR (OR for peak gradient > or =50 mm Hg 10.8, p = 0.001). Independent predictors of low-risk patients (none or trivial AR and peak gradient < or =30 mm Hg) included thin and mobile aortic valve leaflets (OR 7.86, p = 0.006) and an associated ventricular septal defect (OR 2.18, p = 0.019). These clinical and echocardiographic variables can be used to stratify risk of aortic valve dysfunction in patients with DSS and aid in timing of surgical resection.

Adolescent↗
PubMed2004

When should asymptomatic patients with combined severe aortic stenosis and aortic insufficiency undergo valve replacement? A clinical case.

Indications to prosthetic aortic valve implantation in patients with aortic stenosis or aortic regurgitation or both stenotic or regurgitant aortic valve, who present without symptoms, are controversial. We present the case of an asymptomatic patient with combined severe aortic stenosis and an equally important insufficiency, undergoing surgery for valve substitution with a bileaflet prosthesis. After surgery he was treated with warfarin according to the doses recommended and underwent follow-up with clinical and echocardiographic exams. Eight months after intervention the patient had an embolic stroke with aphasia and right hemiplegia, despite the therapeutic level of INR. At present, even though he has partly recovered motor function, he reports a noteworthy decline in life quality, because of the persistent speech difficulties. We use this case as the starting point for a discussion of the chance of referring patients affected by aortic valvulopathy to valve substitution, in the absence of symptoms.

Anticoagulants↗
PubMed1996

Value of multiplane transesophageal echocardiography in determining aortic valve area in aortic stenosis.

Aortic valve area determination by transesophageal planimetry and by the continuity equation was compared with hemodynamic measurements in 45 patients with symptomatic aortic stenosis. The correlations between transesophageal echocardiography and hemodynamics were dependent on the amount of valvular calcium, whereas the continuity equation correlated well with hemodynamics in all patients.

Adult↗
PubMed2004

Regulation of matrix metalloproteinases and their inhibitors in the left ventricular myocardium of patients with aortic stenosis.

Aortic stenosis (AS) results in myocyte and extracellular matrix remodeling in the human left ventricle (LV). The myocardial renin-angiotensin system is activated and collagens I and III and fibronectin accumulate. We determined the yet unknown regulation of enzymes that control collagen turnover, i.e., LV matrix metalloproteinases (MMP) and their tissue inhibitors (TIMPs) in human AS. We compared LV samples from AS patients undergoing elective aortic valve replacement (n=19) with nonused donor hearts with normal LV function (controls, n=12). MMP-2, MMP-9, MT1-MMP, and extracellular matrix metalloproteinase inducer (EMMPRIN), TIMP-1, TIMP-2, TIMP-3, and TIMP-4 mRNA were quantitated by real-time RCR. MMP-1, MMP-2, MMP-3, TIMP-3, TIMP-4, and EMMPRIN protein were measured by immunoblotting and MMP-9 and TIMP-1 protein by ELISA. Gelatinolytic MMP-2 and MMP-9 activity was measured by zymography. MMP-2 was increased in AS at mRNA, protein, and activity levels (131%, 193%, and 138% of controls). MMP-3 protein (308%) and EMMPRIN mRNA and protein were also upregulated (171% and 200%). In contrast, MMP-1 (37%) and MMP-9 mRNA, protein, and activity (26%, 21%, and 52%) were downregulated. MMP-9 activity was inversely correlated with LV size. TIMP-1 mRNA and protein were decreased (55% and 73%). In contrast, TIMP-2 mRNA (358%), TIMP-3 mRNA and protein (145% and 249%) were increased. TIMP-4 mRNA was not altered, but TIMP-4 protein was upregulated to 350%. Changes were similar in AS patients with normal and impaired LV ejection fraction. The dysregulation of myocardial MMPs and TIMPs in human AS starts at an early disease stage when LV function is still normal. In spite of upregulation of some MMPs the balance between MMP and TIMP is shifted towards MMP inhibition in human AS and may contribute to collagen accumulation.

Aged↗
PubMed2005

Is it time to prescribe statins to patients with calcified aortic stenosis?

Aortic stenosis (AS) is a common disease especially in the older population. It is associated with high mortality and morbidity. Recent data suggest that coronary artery disease and AS share common risk factors. Retrospective studies suggest that statins might slow the progression of AS but there are no randomized clinical trial data available. It would seem that statins can be considered for medical treatment of AS; however, this needs to be investigated in future randomized clinical trials.

Aortic Diseases↗
PubMed2005

[Recommendations for noncardiac surgery in aortic stenosis].

Aortic stenosis (AS) is the most common valve disease in western countries and its prevalence increases with population aging. AS is an important risk factor for perioperative complications in patients undergoing noncardiac surgery, a common situation in older patients. Preoperative evaluation should be based on a careful cardiac and general examination (risk factors and comorbidities) as well as on the type and urgency of the noncardiac surgery (urgent as opposed to elective). Careful teamwork and communication between the cardiologist, the anesthesiologist and the surgeon is mandatory. It is also critical that the anesthesiologist team is used to managing these high-risk patients. In cases of non-severe AS (>0.6 cm2/m2 of body surface area), the noncardiac surgery can be performed first. If AS is severe (< or =0.6 cm2/m2) and the noncardiac surgery elective, it is appropriate to consider an aortic valve replacement first. In the difficult cases of urgent noncardiac surgery in patients with severe AS, which precludes heart surgery, it is possible either to first proceed with the noncardiac surgery under very careful anesthesiologic management or to perform the percutaneous aortic valve commissurotomy first.

Aortic Valve Stenosis↗
PubMed1987

Long-term evaluation of aortic valvotomy for congenital aortic stenosis.

Aortic valvotomy (AV) for relief of congenital aortic stenosis (AS) is a palliative operation, and the purpose of this study was to determine the long-term benefit. After analyzing the symptoms at time of operation, 177 patients were separated by age at AV: newborns (1-14 days) 26, infants (2 weeks-1 year) 19, and children (greater than or equal to 1 year) 132. The newborn with critical AS typically presents with severe cardiac failure and the infant with moderate failure, whereas children may be asymptomatic. In the newborn group, final diagnosis has been made exclusively by noninvasive cardiac echogram since 1984. The presence of a hypoplastic left ventricle (HLV) and/or endocardial fibroelastosis (EFE) are the most important determinants of mortality. Operative survival was 11 of 13 (85%) in the newborn group if HLV/EFE were not present. No operative deaths for AV occurred after 1965 in children. When present, a preoperative electrocardiographic strain pattern resolved in 80% of patients. Of 33 reoperations (21%), four were required 1.0 (0.5-2) years later for newborns, five were required for infants 7.2 (1.5-20) years later, and 24 were required in children 11.0 (1.5-25) years later. These included 10 repeat valvotomies and 23 aortic valve replacements (AVRs) with a 91% survival rate. In summary, although valves of patients with congenital AS are morphologically abnormal, valvotomy is beneficial. It was found that (1) the operative survival rate has been 100% over the past 20 years for children and currently is greater than 80% in newborns in the absence of HLV/EFE; (2) reoperation rate is higher in newborns and infants; (3) benefit was shown by a sharp decrease in obstruction initially and improved ECG later; (4) long-term follow-up revealed a subset of patients who are asymptomatic and have only mild residual obstruction over 20 years after AV.

Actuarial Analysis↗
PubMed1988

Phasic coronary artery flow velocity determined by Doppler flowmeter catheter in aortic stenosis and aortic regurgitation.

Phasic coronary artery flow velocity was recorded in 14 patients with aortic regurgitation (AR), 4 with aortic stenosis, 61 with other heart diseases and in 2 normal subjects by means of a bidirectional Doppler flowmeter catheter. The normal pattern of the phasic coronary artery flow velocity was characterized by a small forward flow during systole (S wave) and a large forward flow during diastole (D wave). The phasic coronary artery flow velocity in patients with AR showed increased S wave and decreased D wave. The area under the S-wave curve divided by the area under the D-wave curve (S/D ratio) in patients with AR increased (left coronary artery flow velocity 0.66 +/- 0.39, p less than 0.05; right coronary flow velocity 0.79 +/- 0.36, p less than 0.01) as compared with the S/D ratio in patients with other heart diseases (left coronary flow velocity 0.32 +/- 0.12; right coronary artery flow velocity 0.38 +/- 0.17). There was a tendency toward a relative positive correlation between S/D ratio values and AR cineangiographic grades. Decreased S/D ratios were observed in 4 patients with aortic stenosis. It is believed that no reports exist on phasic coronary flow velocity recorded in conscious patients who had aortic valve disease.

Adult↗
PubMed1978

Cross-sectional echocardiographic characterization of aortic obstruction. 1. Supravalvular aortic stenosis and aortic hypoplasia.

Cross-sectional echocardiographic and cineangiographic studies of the left ventricular outflow tract and ascending aorta were performed in five patients with supravalvular aortic stenosis (four hourglass and one hypoplastic). Visualization of the area of obstruction was possible in each patient using the cross-sectional system. In each case the echocardiographically determined diameter at the level of obstruction was within 3 mm of the similar angiographic value. Assessment of the extent of the lesion was possible in four of five cases. In three of these four cases the echocardiographic measurement was within 5 mm of the angiographic measurement while in the fourth the obstruction was felt to involve the total ascending aorta by both techniques. Determination of percent decrease in LVOT diameter from the aortic anulus to the level of obstruction was useful in defining obstruction and estimating severity. Cross-sectional echocardiography is a valuable noninvasive method for evaluating the ascending aorta in patients with supravalvular aortic stenosis.

Adolescent↗