Simultaneous left ventricular and ascending aortic pressure measurements via single artery access for assessment of aortic stenosis
Amar NathGeorge W. VetrovecJhulan MukharjiSharon ColeStephen A. LewisGermano DiSciascioMichael J. Cowley
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Abstract In order to determine the reliability of a single arterial access technique for hemodynamic assessment of aortic stenosis, data obtained from this method was compared with that from dual arterial access in 13 patients. A 59 cm long, 8 Fr. Mullins Transseptal Sheath (MTS) was placed in the ascending aorta (AA) and a 5 Fr. pigtail catheter advanced through the MTS (using a hemostatic “Y” adapter) into the left ventricle for simultaneous pressure recordings. Another 5 Fr. pigtail catheter (PTC) was advanced in the AA from the contralateral femoral artery. Peak pressures, AA pressure‐tracing characteristics, mean gradients, and the aortic valve area using tracings from the MTS and the PTC were compared. Peak pressures 120 ± 8 vs. 119 ± 8 mmHg (r = .998), “T” time .16 ± .01 vs. .15 ± .01 sec. (r = .913), “U” time .36 ± .02 vs. .36 ± .02 sec. (r = .983), mean gradients 38.4 ± 6.1 vs. 39.6 ± 6.9 mmHg (r = .990) and the AV area .78 ± .08 vs. 79 ± .08 cm 2 (r = .994) were similar. Therefore, this single arterial technique provides data comparable to the traditional dual access system for hemodynamic assessment of aortic stenosis.Keywords:
Aortic pressure
若年女性に対しステントレス弁大動脈弁置換術後,オーバーサイジングsub-coronary法が原因と考えられた大動脈弁狭窄症に対する再手術例を経験した.症例は17歳,女性.12歳時に他院にて21mm Freestyle stentless porcine valve (Freestyle生体弁)を用い,modifled sub-coronary法にて大動脈弁置換術(AVR)を施行された.術直後より心不全が続いていたが,手術5年後に心臓カテーテル検査で大動脈弁収縮期圧較差が115mmHgである弁輪部狭窄が顕在化し心不全症状が再悪化したため,今回当科にて弁輪拡大術を併用したATS AP 18mmによるAVRを施行した.術中所見として,Freestyle生体弁がオーバーサイジングsub-coronary法で縫着されたことが弁輪部狭窄の原因に関与している可能性が示唆された.
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Surgical aortic valve replacement (SAVR) is the current treatment of choice for good surgical candidates with moderate to severe symptomatic aortic stenosis (AS). As transcatheter aortic valvular replacement (TAVR) has shown an improved one and two-year all-cause mortality, it has been chosen for moderately symptomatic severe AS patients. The purpose of this review was to perform a clinical comparison of TAVR vs. SAVR and to analyze the Health Index Factor (HIF) that makes TAVR a treatment of choice in asymptomatic AS patients. An extensive literature search of PubMed, Cochrane, and Embase databases was performed using the keywords “Aortic stenosis”, “SAVR”, “TAVR”, and “Asymptomatic”. A total of 45 prospective randomized clinical trials in the English language that were published from the year 2000 onwards were included in the final analysis. It has been found that 59.3% of asymptomatic AS patients are likely to die in the next five years without proactive treatment. Multiple studies have proven that early intervention with aortic valve replacement is superior to conservative treatment in severe asymptomatic AS; however, the choice between SAVR and TAVR is not well established. The NOTION Trial, SURTAVI Trail, and PARTNER 3 study have shown the non-inferiority of TAVR over SAVR, during one-year follow-up for low surgical risk patients. Evolut Low-Risk study and Early TAVR are the only two prospective studies performed to date that have enrolled patients with asymptomatic severe AS. The Evolut Trial demonstrated no difference in all-cause mortality at 30 days (1.3% vs. 4.8%. p=0.23), and 12 days (1.3% vs. 6.5%, p=0.11). Additionally, TAVR also decreases the risk of post-procedural atrial fibrillation, acute kidney injury (AKI), and rehospitalization, and leads to significant improvement in the mean trans-aortic pressure gradient. TAVR also showed marked improvement in the 30-day Quality of Life (QOL) index, where SAVR did not report any significant change in the QOL index. However, the official recommendations of Early TAVR are still awaited. TAVR has consistently shown a statistically non-significant difference in case mortality, risk of stroke, and rehospitalization with moderate to high surgical risk patients whereby recent initial trials have shown significant improvement in the QOL index and hemodynamic index for patients with asymptomatic disease. More extensive studies are required to prove the risk stratifications, long-term outcomes, and clinical characteristics that would make TAVR a preferred intervention in asymptomatic patients.
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Background and aim of the study The relationship between aortic valve pathology and the aortic root and ascending aortic dimensions in cardiac surgery patients is unclear, and its clarification was the objective of this study. Methods The severity of valve pathology, whether aortic valve stenosis (AS) or aortic valve regurgitation (AR), and the aortic dimensions (aortic root and ascending aorta) were prospectively evaluated with echocardiography in 500 consecutive patients with tricuspid aortic valve (TAV) or bicuspid aortic valve (BAV) who had undergone surgery due to aortic valve and/or ascending aortic disease. Results The distribution of valve pathology was similar in TAV and BAV patients when the aorta was non-dilated. However, when the aorta was dilated, AS was seen predominantly in BAV patients (n = 76) compared to TAV patients (n = 2). In TAV and BAV patients with non-dilated aortas, an increased severity of valve pathology was associated with smaller dimensions of the aortic root and the ascending aorta. In TAV and BAV patients with dilated aortas, an increase in the severity of AR was associated with a decreasing dimension of the ascending aorta but an increasing dimension of the aortic root. In BAV patients with aneurysm, the severity of AS was associated with a decreased dimension of the aortic root and the ascending aorta. Conclusion Patients with AS and ascending aortic dilatation almost exclusively have a BAV. An increasing severity of valve pathology was related to decreasing dimensions of the aortic root and the ascending aorta, and the pattern was strikingly similar in TAV and BAV patients. The high frequency of ascending aortic dilatations in BAV patients cannot be explained by the valve pathology.
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Objective: Aortic hemodynamics and wave reflections are independent predictors of adverse cardiovascular events. Surgical aortic valve replacement (SAVR) is still the first choice for treatment of patients with aortic stenosis. We sought to investigate in this pilot study the effect of SAVR upon aortic vascular function and hemodynamics. Design and method: Twenty-five patients (mean age 71.0 ± 7.1 years, 11 female) with severe aortic stenosis undergoing SAVR were included. Aortic hemodynamics and wave reflections (aortic pressures, aortic augmentation index [[email protected]], augmented pressure) and subendocardial viability ratio (SEVR) were measured with Sphygmocor. Measurements were conducted prior to the surgery and at discharge. Results: There was a statistically significant decrease in aortic systolic blood pressure (SBP) (134 ± 24 vs 118 ± 17mmHg with p = 0.002, respectively). that was not apparent in peripheral SBP. Diastolic blood pressure (both peripheral and aortic) did not change significantly, while heart rate was increased after the surgery (67 ± 11 vs 88 ± 15 bpm with p < 0.001, respectively). We observed a marginally significant decrease in aortic [email protected] (29 ± 13 vs 22 ± 12% with p = 0.05, respectively) and a decrease in aortic AIx (p < 0.001, Figure) and augmented pressure (20 ± 10 vs 8 ± 7 mmHg with p < 0.001, respectively). Moreover, there was a marginally non-significant trend for an increase in SEVR (137 ± 30 vs 149 ± 35%, p = 0.095). Conclusions: Our study shows that shortly after SAVR subjects show a decrease in aortic wave reflections with a small improvement of myocardial perfusion. These findings further elucidate the short-term hemodynamic consequences of SAVR.
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