Daniela Pavan

Symptomatic Aortic Stenosis: Does Systemic Hypertension Play an Additional Role?

Abstract— Hypertension and aortic stenosis represent 2 different models of left ventricular systolic overload. Previous studies have observed different remodeling patterns in these conditions. There is, however, little information about patients with coexisting aortic stenosis and hypertension. Echocardiography was performed in 193 consecutive patients with symptomatic aortic stenosis (113 males, 80 females; mean age, 68±9 years). The prevalence of systemic hypertension was assessed. Left ventricular mass index and relative wall thickness were measured from M‐mode echocardiography. Four different left ventricular remodeling patterns were identified: normal remodeling, concentric remodeling, concentric hypertrophy, and eccentric hypertrophy. A history of hypertension was present in 62 patients (32%), whereas 131 patients were normotensive. No significant differences were found between hypertensive and normotensive patients with respect to age, male/female ratio, mean New York Heart Association class, distribution of symptoms, left ventricular systolic and diastolic function, and remodeling patterns. In hypertensive patients, however, symptoms were present with larger aortic valve areas and lower stroke work loss. Systemic hypertension is not rare in patients with symptomatic aortic stenosis (32% in our series). Left ventricular remodeling patterns are quite similar in hypertensive and normotensive aortic stenosis. Our results suggest that symptoms of aortic stenosis develop with larger valve area and lower stroke work loss in hypertensive patients, probably because of the additional overload due to hypertension itself. It could suggest that in patients with coexisting hypertension and aortic stenosis, hypertension should be treated more aggressively to delay the occurrence of symptoms, and these patients should be followed‐up more closely.

Progression of aortic valve sclerosis to aortic stenosis

level or low-density lipoprotein cholesterol and high-density lipoprotein cholesterol concentrations. Itwould be interesting to know the effects of thesefactors on severe calcific AS.In summary, this large case-control study showsthat the development of severe AS caused by thecalcific degenerative process is not simply a conse-quence of aging. Thus, systemic hypertension (oddsratio 2.17, 95% con fidence intervals 1.44 to 3.27, p

Stage-related effect of statin treatment on the progression of aortic valve sclerosis and stenosis.

It has been suggested that statins could slow the progression of aortic stenosis (AS), but this hypothesis is still debated and has not been validated in large series of patients by long-term follow-up studies. Moreover, information about the role of statins in patients with different degrees of severity of AS is scarce. From our 1988 to 2007 echocardiographic database, we retrospectively identified all asymptomatic patients with aortic valve sclerosis (abnormal irregular thickening of the aortic valve with a peak aortic velocity [Vmax] > or =1.5 and <2 m/s), mild AS (Vmax > or =2 and <3 m/s), and moderate AS (Vmax > or =3 and <4 m/s), age > or =50 years, and with > or =2 echocardiographic studies > or =2 years apart. Exclusion criteria were moderate/severe aortic regurgitation, bicuspid aortic valve, rheumatic valve disease, and ejection fraction <40%. The final study population consisted of 1,046 patients (mean age 70 +/- 8 years, 587 men); 309 were treated with statins. Mean follow-up duration was 5.6 +/- 3.2 years (range 2 to 19). Progression of AS was slower in patients receiving statins compared with untreated patients in aortic sclerosis (0.04 +/- 0.09 vs 0.07 +/- 0.10 m/s/year, p = 0.01) and mild AS (0.09 +/- 0.15 vs 0.15 +/- 0.15 m/s/year, p = 0.001), but not in moderate AS (0.21 +/- 0.18 vs 0.22 +/- 0.15 m/s/year, p = 0.70). In multivariate analysis only statin therapy, initial Vmax, and dialysis were independently related to progression of aortic valve disease. In conclusion, in a large series of patients with long-term follow-up, statins were effective in slowing the progression of aortic valve disease in aortic sclerosis and mild AS, but not in moderate AS. These results suggest that statin therapy should be taken into consideration in the early stages of this common disease.

Pulmonary Artery Hypertension in Adult Patients With Symptomatic Valvular Aortic Stenosis

Pulmonary hypertension (PH) has been reported in patients with valvular aortic stenosis (AS) and has been found to be associated with a more severe clinical picture and a poor prognosis after aortic valve replacement. The aim of this study was to assess the prevalence of PH in adult patients with symptomatic AS undergoing cardiac catheterization, and to evaluate the relation between pulmonary artery (PA) systolic pressure and hemodynamic and clinical variables to further clarify the pathogenetic mechanisms. We assessed right-sided heart hemodynamics during cardiac catheterization in 388 patients with symptomatic isolated or predominant AS. PA systolic pressure between 31 and 50 mm Hg was used to define mild to moderate PH, whereas PA systolic pressure >50 mm Hg was used to define severe PH. PA systolic pressure showed no significant difference according to age and sex, although it was significantly higher in patients in New York Heart Association functional classes III and IV and in patients with coexistent systemic hypertension than in the others. PH was absent in 136 patients (35%, group 1), mild to moderate in 196 patients (50%, group 2), and severe in 58 patients (15%, group 3). Only the prevalence of overt heart failure was significantly higher in group 3 patients. AS severity was similar among the 3 groups, and PA systolic pressure showed no relation to aortic valve area in the entire population. Also, a poor correlation was found between PA pressure and left ventricular (LV) ejection fraction (r = -0.28), with several patients having moderate or severe PH despite a preserved LV systolic function. PA systolic pressure significantly correlated with LV end-diastolic pressure (r = 0.50) and with PA wedge pressure (r = 0.84). Furthermore, transpulmonary pressure gradient, an index of resistance across the pulmonary vascular bed (obtained as the difference between PA mean and PA wedge pressure), was significantly higher in patients with PH, especially in those with a marked increase in PA systolic pressure, suggesting a reactive component of PH.

Prognostic Value of Ventricular-Arterial Coupling and B-Type Natriuretic Peptide in Patients After Myocardial Infarction: A Five-Year Follow-Up Study

BACKGROUND The aim of this study was to determine the prognostic role of ventricular-arterial coupling compared with B-type natriuretic peptide (BNP) in patients after myocardial infarctions. METHODS Forty-one consecutive patients with history of myocardial infarctions were enrolled. Ventricular-arterial coupling was assessed as the ratio between arterial elastance (E(a)) and end-systolic ventricular elastance (E(es)). E(a) and E(es) were calculated using systolic and diastolic blood pressure, echocardiographically derived stroke volume, left ventricular ejection fraction, and the ratio between aortic preejection time and total systolic time. Cardiovascular mortality was the prespecified endpoint, with 5-year follow-up. RESULTS BNP was significantly correlated with New York Heart Association class and known echocardiographic parameters of systolic and diastolic left ventricular function and also with the E(a)/E(es) ratio (P = .001), which emerged as an independent correlate of BNP in multivariate analysis. The E(a)/E(es) ratio demonstrated good accuracy in predicting long-term cardiovascular mortality (area under the receiver operating characteristic curve, 0.73; P = .019), comparable with that of BNP in patients after myocardial infarctions. CONCLUSION Ventricular-arterial coupling assessed using the E(a)/E(es) ratio is an independent echocardiographic correlate of BNP levels in patients with previous myocardial infarctions and has a significant role in predicting long-term cardiovascular mortality in this setting.

Analysis of β1 and β2-adrenergic receptors polymorphism in patients with apical ballooning cardiomyopathy

Objective The aim of our study was to analyse the frequency of β1 and/or β2 adrenergic receptor polymorphisms in patients with takotsubo cardiomyopathy (TTC). Methods and resultsβ1 and/or β2 adrenergic receptor polymorphisms in 61 patients with TTC were compared with 109 controls. The β1 adrenoreceptor (amino acid position 389) genotype frequencies were signifi cantly diff erent in the two groups; assuming a recessive model for the allelic variant coding for Arg on this position, the odds ratio was 3.14, 95% CI 1.55-6.37 (P= 0.0015). The β2 adrenoreceptor amino acid position 27 genotype was signifi cantly diff erent and assuming a recessive model for the allelic variant coding for Gln on this position, the odds ratio was 0.29, 95% CI 0.12-0.74 (P= 0.009). Conclusions This study showed for the fi rst time an association between TTC phenotype and β1 adrenoreceptor gene polymorphisms. Beta adrenoreceptors gene polymorphisms are probably disease modifi ers, and any risk estimate should be based on a combination of genotypes and on interactions with other genes and environmental features.

Asymptomatic Isolated Congenital Left Ventricular Muscular Diverticulum In An Adult: A Case Report

Congenital ventricular diverticulum is a very rare malformation in adults. We describe a 21‐year‐old male with a congenital muscular left ventricular diverticulum in the inferior wall. The lesion was suspected on two‐dimensional transthoracic echocardiography; transesophageal echocardiography allowed clear detection of the diverticulum as well of mild mitral valve prolapse. The diagnosis was confirmed by cardiac catheterization. There were no other thoracoabdominal or cardiac anomalies, the patient was asymptomatic, and surgery was not deemed necessary. (ECHOCARDIOGRAPHY, Volume 20, February 2003)

Spontaneous closure of a patent foramen ovale and disappearance of impending paradoxical embolism after fibrinolytic therapy in the course of massive pulmonary embolism.

Our case suggests that a negative transesophageal contrast echocardiographic study during stable hemodynamic conditions does not definitively rule out the possibility of a functional PFO with transient right-to-left shunting in situations of increased right heart pressures. In addition, we confirm that thrombolysis can be considered as an alternative to surgery in high-risk patients with impending paradoxical embolism. The risk-to-benefit ratio of this choice, however, should be individually evaluated.

Usefulness of transesophageal echocardiography in evaluation of paracardiac neoplastic masses

Mediastinal paracardiac tumors may cause both cardiovascular complications and problems in differential diagnosis of cardiac diseases. Transesophageal echocardiography (TEE) may give an additional new window to mediastinal neoplasms, but only a few studies have been reported. TEE was performed in 70 patients with paracardiac neoplastic masses. The procedure was indicated to solve particular clinical problems in 20 patients, and as a prospective study on 50 unselected patients with mediastinal neoplasms. Twenty-three patients underwent follow-up studies; a total of 101 echocardiograms were recorded. The procedure was tolerated well or very well by most patients, and provided additional anatomic or hemodynamic data in every patient in group a and in 45 of 50 in group b. The additional data were relevant for clinical management in 14 of 20 patients in group a, and in 3 of 45 in group b. Based on the results of this study, TEE is useful in association with other radiologic techniques in patients with paracardiac neoplasms. As an imaging technique, it may represent a reliable alternative to computed tomography whenever the latter is not feasible.

Carotid Artery Stiffness and Diastolic Function in Subjects without Known Cardiovascular Disease

BACKGROUND The aim of this study was to investigate the relationship between carotid artery stiffness and diastolic function in a cohort of subjects without known cardiovascular risk factors and/or overt cardiovascular disease. METHODS Ninety-two healthy subjects underwent transthoracic echocardiographic Doppler and carotid echo-tracking studies. Measurements of local arterial stiffness were obtained at left common carotid artery level; stiffness parameter (β), and pressure-strain elasticity modulus (Ep) were calculated as well as intima-media thickness (IMT). RESULTS Stiffness parameter and Ep were correlated inversely with transmitral E wave (P < .01), E/A ratio, and septal Em (P < .01) and positively with A wave (P < .001). IMT was also associated with A wave, E/A ratio, Em, and Am but not with E wave. No association was found between IMT, β, and Ep. The correlation between arterial stiffness and left ventricular diastolic function remained significant after multivariate adjustment for age, sex, pulse pressure, and body mass index, but not with IMT. CONCLUSIONS In healthy subjects, changes in central carotid stiffness are in line with left ventricular diastolic function independently of age, sex, pulse pressure, and body mass index.