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PubMed1985

[Evaluation of the seriousness of aortic valve stenosis: calculation of the valvular area or peak? Reliability of Hakki's formula].

The severity of aortic valve stenosis should be assessed by means of the calculation of the valvular area; on the other hand, the routine use of the Gorlin's formula for the aortic area is laborious and time consuming. Recently Hakki proposed a simplified formula (area = cardiac output/square root gradient) for the calculation of valvular areas. This method does not require the assessment of the systolic ejection time or the transvalvular flow; furthermore, the peak systolic gradient instead of the mean gradient may be entered into the formula. We have evaluated the reliability of this formula on 83 patients with aortic valve stenosis either pure or with absent to mild aortic incompetence (angiographically first degree maximum). Twenty-eight patients had isolated aortic stenosis, 55 had associated mitral stenosis and/or mitral or tricuspid regurgitation. Our results show a good correlation between the values of valvular areas obtained by Hakki's formula and those obtained by Gorlin's formula (r = 0.90 in the first group and r = 0.91 in the second group of patients). On the contrary we observed a poor relationship between the peak systolic gradient and the valvular area, with a considerable scatter of the data, especially for low values of peak systolic gradient. We therefore conclude that the assessment of the aortic valve stenosis must be based on the estimation of the valvular area; in our hands the Hakki's formula has proven to be easy and sufficiently reliable for routine diagnostic studies.

Adolescent↗
PubMed1988

Color-guided Doppler echocardiographic assessment of aortic valve stenosis.

The severity of valvular aortic stenosis was assessed by Doppler color flow mapping in 100 consecutive patients who underwent successful cardiac catheterization within 2 weeks of the Doppler study. The maximal width of the aortic stenosis jet seen in 61 of these patients (Group A) was measured at the aortic valve. Color-guided continuous wave Doppler examination was used to measure the mean transaortic pressure gradient, and the aortic valve area was estimated using the simplified continuity equation. The aortic stenosis jet was not seen in 39 patients (Group B), and the mean pressure gradient and aortic valve area in these patients were assessed by conventional Doppler echocardiography alone. The mean pressure gradient obtained by continuous wave Doppler study and cardiac catheterization in the 61 Group A patients correlated well (r = 0.90); the correlation was lower in the 39 Group B patients (r = 0.70). The overall correlation for the combined Groups A and B was good (r = 0.82). The aortic valve area estimated by continuous wave Doppler study and cardiac catheterization in 54 Group A patients correlated well (r = 0.92); the correlation in 22 Group B patients was lower (r = 0.71). The correlation for all 76 patients (Groups A and B) was good (r = 0.80). The maximal aortic stenosis jet width also correlated well with the aortic valve area estimated at catheterization in 54 patients (r = 0.90). Group C represented an additional 14 patients in whom the left ventricle could not be entered during cardiac catheterization.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1976

Significance of angina pectoris in aortic valve stenosis.

Of 60 patients aged 45 to 66 years with aortic valve stenosis, 28 (47 per cent) had angina pectoris. Significant coronary arterial obstruction was shown by selective coronary cineangiography in 14 of them. Systolic pressure gradients across the aortic valve were lower in patients with angina than in those without. In those with angina, systolic gradients were higher in those with normal coronary arteriograms than in those with demonstrable coronary arterial disease. Aortic valve replacement relieved the angina in all patients who had normal coronary arteriograms. When valve replacement was combined with coronary bypass grafting in those with coronary arterial disease, surgical mortality was higher and symptomatic relief less predictable. Incapacitating angina in patients with aortic stenosis was nearly always associated with significant coronary disease. In those with less severe angina it was impossible to predict the state of the coronary arteries. Two patients, who did not have angina and who did not undergo coronary arteriography, died after aortic valve replacement and were found at necropsy to have unsuspected severe coronary disease. We, therefore, suggest that coronary arteriography should be carried out in all patients over the age of 40 years in whom surgery is being considered for aortic stenosis.

Adult↗
PubMed1992

[Diffuse subendocardial ischemia in a patient with aortic valve stenosis without coronary artery disease by exercise 201Tl SPECT].

A case of aortic valve stenosis without coronary artery disease was confirmed to have diffuse subendocardial ischemia by exercise Thallium-201 myocardial single photon emission computed tomography. A 72-year-old woman, who had been diagnosed as aortic valve stenosis, was admitted because of chest pain during exercise. In cardiac catheterization findings, the patient angiographically had normal coronary arteries and no asynergy of left ventricular wall motion. The peak flow velocity in continuous wave Doppler echocardiography was about 5.0 m/sec at aortic valve level, providing a pressure drop of 100 mmHg across a stenotic valve with calculating on a modified Bernoulli equation (PG = 4V2). Thallium-201 myocardial SPECT images during exercise showed a transient "dilation and a widespread wall thinning" of left ventricle with apical perfusion defect. Simultaneous electrocardiogram showed further ST depression and the patient had chest pain. In 6 months after aortic valve replacement the patient no longer demonstrated both apical perfusion defect and "wall thinning" in postoperative thallium-201 myocardial SPECT images and also had neither ST depression nor chest pain. Thus; a transient "dilation and wall thinning" of left ventricle in this patient is suspected to be a sign of diffuse subendocardial ischemia.

Aged↗
PubMed1993

Aortic valve pressure gradients in patients with aortic valve stenosis: quantification with velocity-encoded cine MR imaging.

OBJECTIVE: Pressure gradients across the aortic valve due to stenosis of the valve must be measured accurately to evaluate the functional severity of the stenosis. Velocity-encoded cine MR has been used to quantify blood flow and flow direction and, more recently, the regurgitant fraction in aortic regurgitation. The purpose of this study was to determine the feasibility and accuracy of velocity-encoded cine MR for estimating pressure gradients across the aortic valve in patients with aortic stenosis. SUBJECTS AND METHODS: We used velocity-encoded cine MR to measure flow velocity and determine pressure gradients across the aortic valve in 19 subjects. The pressure gradient (delta P) was estimated from the simplified Bernoulli equation by using the maximum instantaneous aortic jet velocity (Vmax): delta P (mm Hg) = 4V2max (m/sec). RESULTS: Maximum and mean systolic pressure gradients determined by using velocity-encoded cine MR were 3-148 mm Hg and 2-87 mm Hg, respectively, for all subjects. The pressure gradients correlated closely with gradients determined by using established methods: Doppler echocardiography and cardiac catheterization. Correlation coefficients (r) were .96 (y = 0.94x - 1.9) and .97 (y = 0.97x + 0.5), respectively. CONCLUSION: We conclude that velocity-encoded cine MR imaging provides a noninvasive and accurate means for quantifying the severity of valvular aortic stenosis. MR is a feasible method for determining pressure gradients across the aortic valve.

Adult↗
PubMed2002

Endoventricular circular patch plasty with aortic valve replacement for post-infarction cardiac rupture complicated with aortic valve stenosis: case report.

Cardiac rupture after acute myocardial infarction (AMI) in patients with aortic valve stenosis (AS) is uncommon and only 2 survival cases after surgery have been reported to date. The present patient, a 69-year-old woman with aortic valve stenosis (AS), suffered an acute myocardial infarction and despite a successful baloon angioplasty to the proximal left anterior descending artery, the condition progressed into congestive heart failure. Echocardiography demonstrated AS with a valve area of 0.7 cm2 and a left ventricular aneurysm with a thin and dyskinetic anterior to apical wall. An urgent operation was performed and the opening of the pericardium revealed oozing rupture of the aneurysm. An endoventricular circular patch plasty combined with aortic valve replacement was successfully performed, and good results during 2-year follow-up were achieved. Physiological repair with exclusion of the infarcted area is essential to achieve a good long-term outcome in such a critical case. Special care should be taken with AMI in a patient with AS because of the possible occurrence of aneurysm and rupture of the left ventricle.

Aged↗
PubMed2004

[Left ventricle TEI index--assessment of clinical role in patients with aortic valve stenosis].

AIM: The study aimed to assess the clinical efficacy of the TEI index in patients with aortic valve stenosis (AVS). METHODS: The study group comprised 30 consecutive patients (12 F; 18 M; mean age: 60.1 +/- 9.2; range: 48-70 years) with aortic valve stenosis. Their clinical status was evaluated according to the NYHA criteria. A complete 2-dimensional, Doppler and color flow Doppler examination was performed. To assess systolic and diastolic left ventricle function we used ejection fraction--EF (%) and transmitral inflow velocity E/A ratio, respectively. The TEI index was calculated as (a - b)/b, were a is the interval between the cessation and onset of mitral inflow, and b is the ejection time. We also determined: maximal transaortic gradient--Ao max gr (mmHg), aortic valve area--AVA (cm2) and left ventricular mass index--LV mass index (g/m2). Based on clinical symptoms we divided patients into two groups: Group 1 (NYHA I/II) and Group 2 (NYHA III and IV). RESULTS: There were no significant differences in age, Ao max gr, AVA, EF and ejection time (b) between groups. But we found significantly prolonged time interval (a) and consequently significantly higher TEI index (p<0.001) in the group with severe symptoms. LV mass index and E/A ratio were also related to the patient's clinical status (p<0.05) but the TEI index seems to be more sensitive in distinguishing severely limited patients. CONCLUSION: The TEI index revealed to be closely related to symptoms in patients with aortic valve stenosis. The patient's clinical status seems to depend more on the TEI than on the conventional measured parameters like aortic valve area and transaortic gradient.

Aged↗
PubMed1996

Mechanisms of regional ischaemic changes during dipyridamole echocardiography in patients with severe aortic valve stenosis and normal coronary arteries.

OBJECTIVE: Vasodilator stress echocardiography can cause myocardial ischaemia in patients with severe aortic valve stenosis and angiographically normal coronary arteries. The aim of the study was to determine the mechanism of ischaemia in this clinical model. METHODS: The study group comprised patients with severe aortic valve stenosis and normal coronary arteries: 25 patients (17 males, eight females; age 63 (SD 11) years) underwent a high dose (up to 0.84 mg/kg over 10 min) dipyridamole echocardiography test both before (2-4 d) and after (10-15 d) aortic valve replacement. Mean aortic pressure gradient was 96 (15) mm Hg, with a left ventricular mass index of 228 (49) g/m2. The dipyridamole echocardiography test was well tolerated and interpretable in all patients. RESULTS: Dipyridamole infusion induced chest pain in seven patients before and in no patient after surgery (28 v 0%, P < 0.01), ST segment depression in 12 patients before and two after surgery (48 v 8%, P < 0.01), and a transient regional dyssynergy in 10 patients before and two after surgery (40 v 8%, P < 0.01). In the preoperative evaluation, patients with an echocardiographically positive dipyridamole echocardiography test were comparable with patients with negative test as far as left ventricular mass index [240 (67) v 230 (64) g/m2, NS] and mean aortic pressure gradient [95 (22) v 92 (21) mm Hg, NS] were concerned. When compared to the preoperative assessment, the resting echo assessment in the postoperative evaluation showed unchanged values of left ventricular mass index [pre 228 (49) g/m2 v post 220 (36) g/m2, NS], but markedly decreased values of mean aortic gradient [pre 95 (15) mm Hg v post 22 (5) mm Hg, P < 0.01] and left ventricular wall stress index [pre 134 (30) g/cm2 v post 89 (19) g/cm2]. CONCLUSIONS: Dipyridamole echocardiography is a suitable clinical technique for assessing the ischaemic vulnerability of the left ventricle in severe aortic valve stenosis with angiographically normal coronary arteries. The frequent disappearance of the ischaemic response early after aortic valve replacement suggests that haemodynamic factors such as compressive diastolic wall stress or afterload reduction are important components of myocardial ischaemic vulnerability under these circumstances.

Adult↗
PubMedDate not supplied

Carotid artery approach to balloon aortic valvuloplasty in infants with critical aortic valve stenosis.

We compare the clinical efficacy of two approaches for balloon aortic valvuloplasty (BAV) in infants with critical aortic valve stenosis. The approaches were through the carotid artery and the femoral artery. Eight catheterizations for BAV were performed in seven consecutive patients with critical aortic stenosis: four BAVs were approached through the femoral artery and four through the right common carotid artery. We inserted a 5F sheath into the right common carotid artery by a cutdown procedure; after BAV the sheath was removed and the carotid arteriotomy sutured with 7-0 monofilament. Two cases in which the femoral artery approach was used resulted in failure to perform BAV; two cases had complications. All four cases with the carotid artery approach were successful, with no complications; aortography performed 3 months after one balloon valvuloplasty revealed a smooth, unobstructed right carotid artery. Use of the carotid artery approach may reduce serious complications with BAV and offers quicker, easier maneuvering in infants and neonates with critical aortic valve stenosis.

Aortic Valve Stenosis↗
PubMed1994

Pressure recovery in aortic valve stenosis.

BACKGROUND: Pressure recovery is the variable increase in lateral pressure downstream from a stenotic orifice. The magnitude and clinical significance of pressure recovery in aortic valve stenosis are poorly defined. METHODS AND RESULTS: We obtained high-fidelity pressure and velocity recordings in 11 patients with isolated significant aortic valve stenosis at the time of diagnostic cardiac catheterization. Systematic catheter pullback from the left ventricular cavity revealed a consistent although variable subvalvular gradient. Further pullback across and distal to the region of the stenosed aortic valve revealed a consistent and progressive increase in the ascending aortic pressure. This increase in lateral pressure occurred pari passu with a diminution in amplitude of the velocity pulse. The extent of pressure recovery was directly related to systemic blood flow and transvalvular flow but inversely related to the Gorlin-derived aortic valve area. CONCLUSIONS: These findings have potentially important implications for the hemodynamic evaluation of mild to moderately severe aortic valve stenosis. The extent of pressure recovery may be of additional utility in the assessment of aortic valve stenosis under varying physiological states.

Aorta↗
PubMedDate not supplied

Residuae, sequelae, and complications of surgery for congenital heart disease.

Definitive, if not curative surgery is available for the eight most common congenital cardiac defects-ductus arteriosus, ASD, coarctation, pulmonary valve stenosis, aortic valve stenosis, tetralogy of Fallot, and transposition. The results of surgery for uncomplicated cases of DA, ASD, VSD, and coarctation usually can be determined by clinical means (including chest radiogram and ECG). Postoperative heart catheterization is recommended for evaluation of the patient who has had surgery for pulmonary valve stenosis or artic stenosis and is necessary after tetralogy of Falot or transposition of the great arteries repair to identify the important postoperrative residua and sequelae. The term "curative" surgery probably shoud be reserved for operation for divion of ductus arteriosus unassociated with pulmonary hypertension and performed in childhood. After closure of ASD, patients should continue to be observed for late development of arrhythmias and persistent cardiac enlargement, although the incidence of these problems is low. After VSD closure the patient is still followed at intervals for possible ill effects of the ventriculotomy scar, manifest as arrhythmias, ventricular aneurysm or myocardial insufficiency. The patient with coarctation repair must be observed for a possible late complication from one of the several clinically silent cardiovascular or cerebrovascular anomalies as well as for the change of restenosis or unrelieved hypertension...

Aortic Coarctation↗
PubMed2006

Familial aggregation of calcific aortic valve stenosis in the western part of France.

BACKGROUND: Calcific aortic valve stenosis (CAVS) is the most common valvular defect in developed countries. Unlike mitral valve prolapse, there is no demonstration that a familial factor could play a role in the occurrence of this disease. The aim of this study was to demonstrate a familial aggregation for CAVS. METHODS AND RESULTS: We used the files of 2527 consecutive patients operated on for CAVS in our institution between 1992 and 2002 to map the distribution of operated CAVS in the western part of France. In a second step, we investigated clinically and genealogically the clusters with the highest rates of operated CAVS to detect familial forms of the disease. The geographic distribution of CAVS is highly heterogeneous, with an average frequency of operated CAVS of 1.13 per 1000 inhabitants but up to 9.38 per 1000 in specific parishes. A screening of the population from the parishes with the highest rate of operated CAVS allowed us to identify 5 families with > or =3 sibs affected by CAVS. A large genealogical analysis performed in one of these families allowed us to link 48 patients who derived from 34 nuclear families. Genealogical information could be traced to a common ancestor within 13 generations. CONCLUSIONS: Identification of clusters and large families affected by a classic form of CAVS demonstrates a familial aggregation for this disease.

Aortic Valve Stenosis↗
PubMed2006

Postinfarction cardiac rupture despite immediate reperfusion therapy in a patient with severe aortic valve stenosis.

A 74-year-old woman with severe aortic valve stenosis (AS) was admitted to our hospital because of dyspnea on exertion. On day 2, she developed acute anterior wall myocardial infarction (MI) with ST elevation. Tissue plasminogen activator (tPA) was administered 10 min after the onset of chest pain, and emergency percutaneous coronary intervention was performed to induce coronary reperfusion after another 50 min. Five hours after MI onset, however, she suddenly went into electromechanical dissociation and died from cardiac rupture. This is the first case report of postinfarct cardiac rupture with severe AS occurring in spite of instituting immediate reperfusion therapy. High intraventricular pressure may be a critical risk factor for cardiac rupture in patients with AS complicated with acute MI. Further studies are required to clarify the risk and benefit of tPA administration before percutaneous coronary intervention and the necessity of the emergency correction of AS to prevent cardiac rupture.

Aged↗
PubMed2003

Can serum lipid and CRP levels predict the "severity" of aortic valve stenosis?

BACKGROUND: Results of the studies performed have suggested that hypercholesterolaemia and inflammation are important aetiologic factors in aortic valve stenosis (AVS). However up to now no such data has been obtained to evaluate whether these predictors may still serve as valuable tools to estimate the progression and severity of AVS. If factors contributing to the "progression" of degenerative process can be understood and preventive measures can be taken, both clinical and economical beneficial effects can be achieved. The objective of this study is to investigate the correlation of serum cholesterol, triglyceride and CRP levels with the severity of aortic stenosis echocardiographically evaluated in patients with aortic valve stenosis. MATERIAL AND METHODS: Aortic valvular areas of 60 patients (pts) hospitalized in our clinic with suspected AVS were calculated with Doppler echocardiography. Patients were grouped into mild, moderate and advanced AVS, each category containing 20 pts, and then were subclassified regarding those with and without coronary artery disease (CAD). RESULTS: Total cholesterol and CRP levels were found to be 215+/-42 mg/dl and 2.0+/-1.4 mg/dl; 224+/-43 mg/dl and 2.4+/-2.1 mg/dl; 225+/-55 mg/dl and 2.7+/-2.1 mg/dl in pts with mild, moderate and advanced AVS, respectively. A statistically significant difference was not detected among the three groups (p>0.05). When subclasses were classified the levels were found to be much more increased in those patients having additional CAD. CONCLUSION: We have demonstrated that severity of AVS does not correlate significantly with hypercholesterolaemia and CRP and their levels do not rise in accordance with increasing severity of AVS. Elevations of lipid levels in AVS were found to correlate with the presence of CAD rather than the severity of AVS. So, not in patients with simply AVS but in patients under higher cardiovascular risks, investigation of CRP plus lipid levels might provide benefit with respect to preventive treatment and benefit from cholesterol-lowering drugs can be expected in such kind of patients.

Aged↗
PubMed2002

[Recurrent epistaxis in a patient with aortic valve stenosis: a variant of Heyde syndrome?].

BACKGROUND: The Heyde syndrome describes the coincidence of aortic valve stenosis and intestinal bleeding. The pathophysiologic link between both entities has remained unclear so far. In several studies the intestinal bleedings have been attributed to angiodysplasia. Cessations of the intestinal bleedings following replacement of the aortic valve have been described by numerous reports. CASE REPORT: We describe the history of a 70-year-old man with a calcified aortic valve stenosis. In addition, he suffered from recurrent severe epistaxis over several years. Replacement of the aortic valve by bioprosthesis resulted in complete cessation of the nasal bleedings over a follow-up period of 6 years. CONCLUSION: This case report suggests that aortic valve stenoses may be associated with extraintestinal bleedings as well.

Aged↗
PubMed1991

[Surgical management of congenital aortic valve stenosis in neonates and infants].

From 1985 to 1989, 4 neonates or infants (3 males and 1 female) underwent open valvotomy for severe aortic valve stenosis. In all patients, preoperative echocardiograms showed abnormal findings of endocardial fibroelastosis and/or poor performance of left ventricle. All patients underwent valvotomy using cardiopulmonary bypass. There was one early death from left ventricular failure. All other patients survived and the pressure gradient through aortic valve was reduced from 50-100 mmHg to 25-50 mmHg postoperatively. We conclude that infants with severe aortic valve stenosis should undergo open valvotomy before the manifestation of endocardial fibroelastosis and/or left ventricular muscle damage, and that open aortic valvotomy using cardiopulmonary bypass is most suitable method for severe aortic valve stenosis in infants.

Aortic Valve↗
PubMed1998

[Diagnostic approach and optimal treatment of aortic valve stenosis].

The slow progression of valvular aortic stenosis enables the left ventricular myocardium to adapt itself to the increasing afterload. When myocardial adaption is exhausted, surgical intervention is urgent, the prognosis, however, is already limited. To quantify the hemodynamic severity of aortic stenosis, transaortic pressure gradients (dp) measured by Doppler echocardiography or hemodynamically are inappropriate, because dp is significantly dependent on the transaortic flow volume. In severe aortic stenosis, despite constant narrowing of the aortic valve area, the reduced stroke volume results in decreasing transaortic pressure gradients. With aortic valve resistance or transaortic pressure loss (PL)--the quotient of pressure gradient and stroke volume--the hemodynamic severity of aortic stenosis can be described accurately. If PL is known, a decompensated aortic stenosis (PL > 1 mm Hg/ml) may be differentiated from myocardial failure of another etiology and a concomitant left ventricular outflow tract obstruction. With respect to medical therapy, the prevention of bacterial endocarditis and thromboembolic complications is important. Knowing the potential danger of syncopies and ventricular arrhythmias during exercise with increasing severity of aortic stenosis, patients have to be informed about their limited functional capacity. The occurrence of typical symptoms during the natural history of chronic aortic stenosis (e.g. dizziness, syncopes, angina pectoris, arrhythmias) manifestation of ST-T-alterations or silent myocardial ischemias and demonstration of an inadequate myocardial adaptation to the chronic pressure overload in asymptomatic patients are accepted indications for a surgical intervention. If the indication for surgery remains uncertain, stress tests (e.g. radionuclidventriculography) may be performed to demonstrate an exhausted myocardial adaptation. If the PL and the severity of aortic valve/anulus calcification is known, the progression of a chronic aortic stenosis can be estimated. This might be important, if a cardiosurgical intervention has to be performed for other indications and aortic stenosis is co-existent but does not require an intervention at that time. For prognostic reasons myocardial decompensation due to aortic stenosis is an indication for an urgent surgical intervention. Attempts for medical recompensation or bridging strategies (e.g. balloon valvotomy) worsens the prognosis significantly.

Aortic Valve Stenosis↗