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PubMed2006

Bilateral ostial coronary stenosis and rheumatic aortic valve stenosis.

A 49-year-old patient presented with angina pectoris and clinical findings of aortic valve stenosis and regurgitation. Rheumatic aortic valve stenosis and regurgitation was diagnosed on echocardiography. Coronary angiography findings showed severe calcification in the aorta root with right coronary ostial occlusion, and were suggestive of left main ostial stenosis and proximal main stem stenosis, which was confirmed on CT angiography. Curvilinear calcification of the aorta was present on CT angiography. The findings suggested syphilitic aortitis. Syphilis serology was positive (RPR titre 1/16). The angina was caused by severe coronary ostial disease likely due to syphilitic aortitis and exacerbated by the rheumatic aortic valve stenosis and regurgitation.

Aortic Valve Stenosis↗
PubMed2001

Treatment decision in asymptomatic aortic valve stenosis: role of exercise testing.

OBJECTIVE: To determine the prognostic value of exercise testing, valve area, and maximum transaortic pressure gradient in asymptomatic patients with aortic valve stenosis. SETTING: The outpatient service of a tertiary referral centre for cardiology. DESIGN: Prospective clinical study. PATIENTS: 66 consecutive patients with isolated severe aortic stenosis (aortic valve area </= 1.0 cm(2)) were selected over a 58 month period. Mean (SD) follow up was 14.77 (11.93) months. INTERVENTIONS: At the initial visit Doppler echocardiography and exercise testing were performed to evaluate ST segment depression and the development of symptoms of aortic stenosis, ventricular arrhythmia, or inadequate rise of systolic blood pressure during exercise. Follow up clinical examinations were performed every three months thereafter to record the onset of symptoms. MAIN OUTCOME MEASURES: Sudden death or the development of symptoms. RESULTS: Eight patients developed dizziness during exercise testing but made a rapid and spontaneous recovery. No other complications of exercise testing occurred. Survival curves, with or without the occurrence of end point events for the variables studied, showed significant differences for positive versus negative exercise testing (p = 0.0001) and aortic valve area < 0.7 cm(2) v >/= 0.7 cm(2) (p = 0.0021). There was no relation between the end points and transaortic gradient (p = 0.6882). In multivariate analysis, a hazard ratio of 7.43 was calculated for patients with a positive versus a negative exercise stress test. Although asymptomatic in daily life, 6% of the patients (4/66) experienced sudden death; all these had a positive exercise test and an aortic valve area of </= 0.6 cm(2). CONCLUSIONS: Exercise testing is safe and is of prognostic value in asymptomatic patients with aortic stenosis.

Adolescent↗
PubMed1993

[Neurohormonal profile in aortic valve stenosis].

The authors studied the responses of the main systems of sympathetic and hormonal regulation in valvular aortic stenosis, a special model of dissociation between arterial pressure and left ventricular function. The series comprised 14 patients with an average age of 70 +/- 9 years without diuretic therapy presenting with pure calcific aortic stenosis without other valvular or coronary disease. All were in sinus rhythm; 5 were taking an angiotensin converting enzyme inhibitor. Plasma concentrations of endothelin 1, atrial natriuretic factor (ANF), arginine vasopressin (AVP), catecholamines, plasma renin activity (PRA), angiotensin II and aldosterone were measured in resting, fasting patients, by blood samplings from a peripheral vein immediately before cardiac catheterisation. The results were compared with the severity of the aortic stenosis (aortic valve area greater or less than 0.7 cm2), the ratio of left ventricular work/myocardial mass (greater or less than 0.6) and treatment (with or without ACE inhibitors). Catecholamine levels were much higher in severe aortic stenosis (noradrenaline: 579 +/- 66 pg/ml when valve surface area > 0.7 cm2 versus 900 +/- 92 pg/ml when valve surface area < 0.7 cm2; p < 0.01). Endothelin -1 and AVP concentrations were normal. Whereas PRA was normal, aldosterone levels were increased in patients without treatment by ACE inhibitors. This treatment did not, however, normalise the noradrenaline levels. The increase in ANF concentration was large when left ventricular work decreased with respect to myocardial mass (190.8 +/- 42.3 pg/ml if W/M was decreased versus 82.7 +/- 15.4 pg/ml when W/M was normal): this could be related to the degree of left ventricular hypertrophy.

Aged↗
PubMed1989

[Angioplasty of the left main coronary artery--report of a case with left main coronary stenosis and aortic valve stenosis].

A 58-year-old woman was admitted to our hospital suffering from repeated chest pain. Selective coronary angiography (CAG) showed severely stenotic lesion in the left main coronary artery. There was no additional lesion in the left anterior descending and circumflex arteries. Aortography showed severe calcification in the aortic valve. The aortic was incised and divided completely at the aortic root 1 cm distal to the aortic valve. The incision was then extended toward the opening of the left coronary artery. An atheromatous plague was found and resected at the ostium. A saphenous vein patch was used to enlarge the internal diameter of the artery. The aortic valve was replaced using #21 SJM prosthetic valve. The patient recovered the surgery well, and anginal attacks have disappeared. Postoperative coronary angiograms revealed no stenotic lesion in the left main coronary artery.

Aortic Valve Stenosis↗
PubMed1990

[Konno procedure for congenital aortic valve stenosis with pulmonary valve stenosis].

Although aortic and pulmonary valve stenosis are among the most common congenital heart defects, the combination of both aortic and pulmonary valve stenosis in the same patient appears to be very uncommon. Accurate diagnosis of combined valvular stenosis is imperative prior to surgical correction, otherwise surgery of one of the lesions may result in an insufficient hemodynamic improvement. A seven-year-old girl with congenital aortic and pulmonary valve stenosis associated with hypoplastic aortic annulus underwent Konno's operation, pulmonary valvotomy and resection of anomalous muscle of the right ventricular outflow tract simultaneously. The operation was successfully performed and postoperative course was uneventful.

Aortic Valve Stenosis↗
PubMed2005

First report on a human percutaneous transluminal implantation of a self-expanding valve prosthesis for interventional treatment of aortic valve stenosis.

BACKGROUND: Percutaneous aortic valve replacement is a new technology for the treatment of patients with significant aortic valve stenosis. We present the first report on a human implantation of a self-expanding aortic valve prosthesis, which is composed of three bovine pericardial leaflets inserted within a self-expanding nitinol stent. The 73-year-old woman presented with severe symptomatic aortic valve stenosis (mean transvalvular gradient of 45 mmHg; valve area of 0.7 cm2). Surgical valve replacement had been declined for the patient because of comorbidities, including previous bypass surgery. METHOD AND RESULTS: A retrograde approach via the common iliac artery was used for valve deployment. The contralateral femoral vessels were used for a temporary extracorporal circulation, unloading the left ventricle during the actual stent expansion. Clinical, hemodynamic, and echocardiographic outcomes were assessed serially during the procedure. Clinical and echocardiographic follow-up at day 1, 2, and 14 post procedure was performed to evaluate the short-term outcome. The prosthesis was successfully deployed within the native aortic valve, with accurate and stable positioning and with no impairment of the coronary artery or vein graft blood flow. 2D and doppler echo immediately after device deployment showed a significant reduction in transaortic mean pressure gradient (from 45 to 8 mmHg) without evidence of aortic or mitral valve insufficiency. The clinical status has then significantly improved. These results remained unchanged up to the day 14 follow-up. CONCLUSION: This case report demonstrates a successful percutaneous implantation of a self-expanding aortic valve prosthesis with remarkable functional and clinical improvements in the acute and short-term outcome.

Aged↗
PubMed2006

Severe aortic valve stenosis and nosebleed.

Aortic valve stenosis is known to be associated with loss of high molecular von Willebrand multimers. This can lead to gastrointestinal bleeding in patients with gastrointestinal angiodysplasia, the Heyde syndrome. Here we present a case of anaemia and severe epistaxis associated with acquired von Willebrand syndrome. Gastrointestinal endoscopy revealed no bleeding source. Calcifying aortic stenosis was confirmed by echocardiography. Loss of high molecular weight multimers of von Willebrand factor in our patient was shown by immunoblot analysis. If severe epistaxis occurs in the context of symptomatic aortic valve stenosis, it might be an additional reason to recommend valve replacement surgery to the patient.

Aged, 80 and over↗
PubMed2000

[Aortic valve replacement for aortic valve stenosis due to congenital bicuspid aortic valve with abnormal positioning of coronary orifice, pseudotendon, and persistent left superior vena cava, report of a case].

A patient was a 65-year-old female who had a complaint of palpitation was diagnosed aortic valve stenosis due to congenital bicuspid aortic valve with pseudotendon by the echocardiographic examination. We suspected left single coronary artery by the aortography and the coronary artery angiography. Aortic valve replacement and resection of pseudotendon was performed with Carbomedics supra-annular aortic valve (21 A). During surgery, persistent left superior vena cava was detected. High-posterior take-off right coronary artery was casually detected at aortic closure. Ventricular fibrillation due to insufficient supply of cardioplegic solution at right coronary area frequently occurred after cardio-pulmonary bypass and percutaneous cardiopulmonary support was required. The patient was discharged 32 days after the operation. Preoperative and intraoperative evaluation was important in the case of aortic valvular disease.

Aged↗
PubMed1987

Contribution of afterload, hypertrophy and geometry to left ventricular ejection fraction in aortic valve stenosis, pure aortic regurgitation and idiopathic dilated cardiomyopathy.

To investigate the relation of left ventricular (LV) afterload, hypertrophy, geometry and systolic pump function, 17 normal persons, 24 patients with aortic stenosis (AS), 20 with aortic regurgitation (AR) and 15 with idiopathic dilated cardiomyopathy (DC) were studied. Two-dimensional echograms were used to assess end-systolic meridional and circumferential stresses and their ratio, LV mass, relative wall thickness (h/R ratio) and the ratio of LV minor axis to length, used as an index of shape. Independently obtained ejection fraction (EF) was used to determine which patients had normal (EF greater than or equal to 55%) and which had depressed (EF less than 55%) pump function. Patients with AS and low EF had similar LV mass (228 vs 215 g) but larger LV cavity (5.6 vs 4.5 cm), lower h/R ratio (0.53 vs 0.73, p less than 0.01), and therefore higher circumferential stress (336 vs 268 kdyne/cm2, p less than 0.05). Compared with normal persons, patients with DC had a lower h/R ratio (0.28 vs 0.38, p less than 0.01), higher circumferential stress (362 vs 215 kdyne/cm2, p less than 0.01) and more uniform stress distribution (meridional to circumferential stress ratio 0.57 vs 0.39, p less than 0.01), implying that meridional stress overestimates effective afterload. Afterload excess and LV shape change may be important to pump function in patients with AS or DC. In contrast, in those with AR, no significant shape differences were noted, although LV mass was higher in those with low EF (279 vs 211 g, p less than 0.05). Depressed pump function may result from impaired myocardial performance in AR without afterload excess.

Adult↗
PubMed1989

[A case report of ultrasonic decalcification for calcified bicuspid aortic valve stenosis].

Calcified stenotic aortic valve are usually replaced by the artificial valve. Recently, we are trying to decalcify the calcification of the aortic valve by ultrasonic energy. This case report reviewed a small physique, 47 year old female, who had the calcified stenotic bicuspid aortic valve and the narrow aortic valve ring (18 mm diameter). The ultrasonic decalcification was performed by the ultrasonic surgical instrument, SUS-201D (ALOKA), ultrasonic energy output range from 25% to 45%. After the ultrasonic decalcification, the movability of the aortic cusps were improved and the aortic opening was enlarged. The systolic pressure gradient across the aortic valve was improved from 100 mmHg to 20 mmHg. This method "ultrasonic decalcification" is very useful technique for the repair of the calcified aortic valve stenosis.

Aortic Valve Stenosis↗
PubMed2002

Comparison of simultaneous invasive and noninvasive measurements of pressure gradients in congenital aortic valve stenosis.

PURPOSE: Congenital aortic valve stenosis is a common problem in pediatric cardiology. The catheter peak to peak systolic gradient is the accepted standard used for prognosis and intervention, but noninvasive correlation in pediatric patients is frequently associated with underestimation or overestimation of this gradient. The purpose of this study was to compare different noninvasive measurements with simultaneous catheter gradients to identify which best predicts the catheter peak to peak gradient. METHODS: Twenty-five simultaneous Doppler and catheter measurements of aortic stenosis gradient were performed in 14 children (all 14 before valvuloplasty and 11 after valvuloplasty). Noninvasive estimates of pressure gradient were compared with catheter measurements with linear regression and Bland-Altman analysis. RESULTS: The Doppler peak instantaneous pressure gradient overestimated the catheter peak to peak gradient but correlated well with the catheter peak instantaneous gradient. The Doppler mean systolic gradient correlated well with the catheter peak to peak gradient at low gradients and underestimated higher catheter gradients but agreed well at all levels with the catheter mean gradient. The modification of a catheter-derived correlation equation produced good correlation with the catheter peak to peak gradient (slope, 1.14; intercept, -1.8; R, 0.92), as did the use of estimated pressure recovery (slope, 1.04; intercept, 5.0; R, 0.94), calculated from a defined fluid mechanic equation. CONCLUSION: The catheter peak to peak gradient can be accurately estimated noninvasively using estimated pressure recovery or correlation equations incorporating Doppler measurements.

Adolescent↗
PubMed2004

Diagnosing heart failure in aortic valve stenosis.

OBJECTIVE: In aortic valve stenosis (AS), heart failure (HF) omens a high risk of death and is an indication for prompt valve replacement. We studied whether its detection can be facilitated by measuring plasma N-terminal B-type natriuretic peptide (Nt-BNP) or by estimating pulmonary capillary wedge pressure (PCWP) using echocardiography. DESIGN AND SETTING: A cross-sectional cohort study in a university hospital. SUBJECTS AND METHODS: We studied 137 consecutive adult patients referred to our unit for invasive evaluation of isolated AS. All patients underwent cardiac catheterization, measurement of plasma Nt-BNP and estimation of PCWP by Doppler echocardiography of transmitral and pulmonary venous flow velocities. The final diagnosis of HF was based on the combined criteria of dyspnoea on ordinary effort and PCWP >14 mmHg at cardiac catheterization. The performance of Nt-BNP and the PCWP estimate in the detection of HF were studied using receiver operating characteristic (ROC) analysis. RESULTS: Totally 42 patients had HF. A cardiologist's clinical diagnosis of HF had high specificity (94%) but poor sensitivity (66%). With an optimized cut-off point, plasma Nt-BNP had moderate sensitivity (77%) and specificity (79%) for HF; the ROC area was 0.83. The echocardiographic PCWP estimate classified 90% of patients correctly as having normal or truly elevated (>14 mmHg) PCWP. Its sensitivity and specificity for the diagnosis of HF were 80 and 95% respectively; the ROC area was 0.88. With a cut-off point of 12 mmHg, the sensitivity of the PCWP estimate was 85% and specificity, 88%. CONCLUSION: The recognition of HF in patients with AS can be improved by estimating PCWP using Doppler echocardiography of transmitral and pulmonary venous flow velocities.

Adult↗
PubMed2004

Dilatation of the aorta in pure, severe, bicuspid aortic valve stenosis.

BACKGROUND: Aortic complications are more frequent after bicuspid aortic valve (BAV) replacement (AVR), than tricuspid aortic valve replacement. We studied the size of the proximal thoracic aorta in patients with BAV undergoing AVR for pure, severe aortic stenosis, looking for dilatation in comparison with patients with a matched tricuspid aortic valve (TAV) and normograms of aortic size. METHODS: Aortic root and ascending aortic diameter measurements were taken at 3 levels, from electrocardiographic-gated multidetector row computed tomograms, in 28 patients with pure, severe aortic stenosis before AVR. The patients were divided in 2 groups (BAV, n = 10; TAV, n = 18). Patients with greater than mild aortic regurgitation or who were scheduled for aortic root replacement were excluded. RESULTS: Although patients in the BAV group were younger (P <.0001) and less likely to have hypertension (P <.005), their aortic diameters were larger than those of patients in the TAV group at all levels measured (aortic sinus, 41.1 +/- 8.1 mm vs 33.8 +/- 3.3 mm; sino-tubular junction, 39.0 +/- 7.8 mm vs 31.1 +/- 3.8 mm; right pulmonary artery level, 42.8 +/- 7.1 mm vs 33.7 +/- 4.3 mm; P <.005 for all). Whereas 60% (6/10) of patients in the BAV group had >/=1 aortic diameter measurements greater than the 95th age-adjusted percentile, 0% (0/18) of patients in the TAV group did. CONCLUSIONS: Patients with BAV undergoing AVR with pure, severe aortic stenosis commonly have moderate dilatation of the thoracic aorta, whereas matched patients with a TAV do not. This finding may contribute to the increased frequency of aortic complications seen in follow up of patients with a BAV after AVR.

Aged↗
PubMedDate not supplied

[Postoperative changes in diastolic function of the left ventricle in patients with aortic valve stenosis].

INTRODUCTION: Diastolic dysfunction in valvular aortic stenosis frequently precedes systolic dysfunction. The purpose of this study was to examine the changes in left ventricular diastolic function after aortic valve replacement. METHODS: Seventy eight patients with significant isolated valvular aortic stenosis were enrolled in the study. The echocardiographic examination was performed with ACUSON-XP 10 imaging system. Complete M-mode, 2-dimensional and Doppler echocardiographic results were obtained. In 48 patients right and left heart catheterisation was performed. Left ventricular diastolic function was evaluated by pulse Doppler recording of inflow velocity on the tips of the mitral valve leaflets. Forty two underwent aortic valve replacement. They were followed up 6-12 months postoperatively. RESULTS: Abnormal patterns of left ventricular diastolic filling were noticed in almost all patients (Table 1). Most prominent changes were found in subjects with marked and diffuse hypertrophy (Table 2). After aortic valve replacement decrease in left ventricular size, mass, pressures and improvement in systolic Function (Table 3). Twelve months after the operation late diastolic filling velocity was lower (A = 64 +/- 15 cm/s, Avti = 7.1 +/- 1.8 cm), early diastolic filling velocity was higher (E = 83 +/- 14 cm/s, Evti = 10.3 +/- 1.4 cm), deceleration time (DT = 123 +/- 14 ms) and isovolumetric relaxation time (IRT = 66 +/- 6 ms) were longer in patients with preoperative moderate hypertrophy (Table 4). In patients with severe left ventricular hypertrophy changes in diastolic function were slower. We found decrease in early diastolic filling velocity (A = 44 +/- 6 cm/s, Avti = 4.6 +/- 04 cm), increase in late diastolic filling velocity (E = 67 +/- 14 cm/s, Evti = 9.4 +/- 1.7 cm), with prolongation of deceleration (DT = 131 +/- 18 ms) and isovolumetric relaxation time (IRT = 94 +/- 23 ms) (Table 5). DISCUSSION: In adults with significant sympthomatic aortic valve stenosis, aortic valve replacement is therapy of choice. Replacement of the diseased aortic valve with a prosthetic valve yields relief of left ventricular outflow obstruction. Myocardial remodeling with regression of mass transpires as the heart adapts to the new level of afterload. In patients with moderate left ventricular hypertrophy improvement in diastolic function during the first year after aortic valve replacement is visible, while in patients with extreme myocardial hypertrophic changes it was slower.

Adolescent↗
PubMed1990

[Intermediate results of balloon valvuloplasty in children with congenital aortic valve stenosis].

Eleven children with aortic valve stenosis requiring treatment underwent percutaneous balloon valvuloplasty instead of surgery. Three were newborns or infants and 8 were aged 2-18 years. Aortic valve gradient was 45-160 mm Hg (mean 83 mm Hg) before valvuloplasty; after the procedure the gradients ranged from 7-43 mm Hg (mean 25). One newborn with critical stenosis and associated left ventricular fibroelastosis died 48 hours after valvuloplasty. All others showed marked clinical improvement after the procedure. Main complications included permanent loss of peripheral pulses in the catheterized leg (2 cases, age 2 months and 20 months) and aortic valve regurgitation. This was estimated as moderate (++) in 2 and moderately severe (3+) in one; it was minimal or absent in the others. All patients were followed up for 3 months to 4 years. There was one recurrence of aortic stenosis, 2 years after valvuloplasty, requiring surgery. Two infants also underwent late surgery after successful valvuloplasty, one for mitral valve replacement and one for severe subvalvular aortic stenosis. In the remaining seven children the good initial result was maintained. Aortic valve gradient was estimated with Doppler at regular intervals and did not increase significantly over the follow-up period. In conclusion, balloon valvuloplasty is an alternative to open heart surgery in aortic valve stenosis in the young; both procedures are palliative.

Adolescent↗
PubMed1998

Accuracy of computer-based quantification of aortic valve stenosis.

In patients with aortic valve stenosis, the quantification of stenosis is usually performed using fluid-filled catheters and a computerized calculation program. The aim of this study was to determine the accuracy of this technique in comparison to the manual planimetry of the area between the curves of a simultaneous registration, using a multitip micromanometer catheter. The study was performed in 19 patients, in whom left and right heart catheterization was warranted. Systolic left ventricular and aortic peak pressures were significantly overestimated using a fluid-filled catheter (206 +/- 35 vs. 199 +/- 37 mm Hg, P = 0.0003, and 148 +/- 18 vs. 143 +/- 21 mm Hg, P = 0.0052). However, peak-to-peak pressure gradients were identical comparing both techniques (58 +/- 31 vs. 56 +/- 32 mm Hg, r = 0.983). The mean pressure gradients and aortic valve areas based on simultaneous measurements of left ventricular and aortic pressures by micromanometer catheters were identical to the values determined by a computer-based program using fluid-filled catheters (54 +/- 21 vs. 52 +/- 21 mm Hg, r = 0.923, P < 0.05, and 0.75 +/- 0.25 vs. 0.77 +/- 0.25 cm2, r = 0.935). Thus, the conventional use of fluid-filled catheters and of a computerized calculation of aortic valve area is valid for quantification of aortic stenosis in patients with sinus rhythm and without significant aortic regurgitation.

Adult↗
PubMed2000

[Clinicopathologic study of calcified aortic valve stenosis in the aged, and evaluation of the indications for percutaneous aortic balloon valvuloplasty].

OBJECTIVES: We performed clinicopathologic study of 56 aged patients with calcified aortic valve stenosis and investigated the indications for percutaneous aortic balloon valvuloplasty. METHODS: The patients were 24 men and 32 women with a mean age of 81.9 years, who were classified into the following 3 types by etiology: 33 patients (58.9%) had senile aortic stenosis, 10 patients (17.9%) had bicuspid aortic stenosis, and 13 patients (23.2%) had rheumatic aortic stenosis. The sites of calcification were divided into the following 3 categories: cusp bases (base type), free edges (edge type), and both bases and edges (mixed type). RESULTS: Among the 33 patients with senile aortic stenosis, 10 (30.3%) had calcification of base type, 2 (6.1%) of edge type and 21 (63.6%) of mixed type. Among the 10 patients with bicuspid aortic stenosis, one (10%) had calcification of base type and 9 (90%) of mixed type. Among the 13 patients with rheumatic aortic stenosis, 3 (23.1%) had calcification of edge type and 10 (76.9%) of mixed type. In addition, 2 or 3 commissures were fused in patients with rheumatic aortic stenosis. The cusps of the aortic valves in the bicuspid type were the most severely thickened among the 3 groups. Soft X-ray imaging showed the aortic valves of rheumatic aortic stenosis were the most severely calcified (calcification score: 2.4), followed by those of bicuspid aortic stenosis (1.9) and senile aortic stenosis (1.6). CONCLUSIONS: Percutaneous aortic balloon valvuloplasty is most suitable in patients with calcified senile aortic stenosis because of the milder calcification, compared with those of the other 2 types.

Aged↗