Raphael Rosenhek

Guidelines on the management of valvular heart disease (version 2012)

ACEn: angiotensin-converting enzymenAFn: atrial fibrillationnaPTTn: activated partial thromboplastin timenARn: aortic regurgitationnARBn: angiotensin receptor blockersnASn: aortic stenosisnAVRn: aortic valve replacementnBNPn: B-type natriuretic peptidenBSAn: body surface areanCABGn: coronary artery bypass graftingnCADn: coronary artery diseasenCMRn: cardiac magnetic resonancenCPGn: Committee for Practice GuidelinesnCRTn: cardiac resynchronization therapynCTn: computed tomographynEACTSn: European Association for Cardio-Thoracic SurgerynECGn: electrocardiogramnEFn: ejection fractionnEROAn: effective regurgitant orifice areanESCn: European Society of CardiologynEVERESTn: (Endovascularxa0Valvexa0Edge-to-Edge REpairxa0STudy)nHFn: heart failurenINRn: international normalized rationLAn: left atrialnLMWHn: low molecular weight heparinnLVn: left ventricularnLVEFn: left ventricular ejection fractionnLVEDDn: left ventricular end-diastolic diameternLVESDn: left ventricular end-systolic diameternMRn: mitral regurgitationnMSn: mitral stenosisnMSCTn: multi-slice computed tomographynNYHAn: New York Heart AssociationnPISAn: proximal isovelocity surface areanPMCn: percutaneous mitral commissurotomynPVLn: paravalvular leaknRVn: right ventricularnrtPAn: recombinant tissue plasminogen activatornSVDn: structural valve deteriorationnSTSn: Society of Thoracic SurgeonsnTAPSEn: tricuspid annular plane systolic excursionnTAVIn: transcatheter aortic valve implantationnTOEn: transoesophageal echocardiographynTRn: tricuspid regurgitationnTSn: tricuspid stenosisnTTEn: transthoracic echocardiographynUFHn: unfractionated heparinnVHDn: valvular heart diseasen3DEn: three-dimensional echocardiographynnGuidelines summarize and evaluate all evidence available, at the time of the writing process, on a particular issue with the aim of assisting physicians in selecting the best management strategies for an individual patient with a given condition, taking into account the impact on outcome, as well …

Predictors of Outcome in Severe, Asymptomatic Aortic Stenosis

BACKGROUNDnWhether to perform valve replacement in patients with asymptomatic but severe aortic stenosis is controversial. Therefore, we studied the natural history of this condition to identify predictors of outcome.nnnMETHODSnDuring 1994, we identified 128 consecutive patients with asymptomatic, severe aortic stenosis (59 women and 69 men; mean [+/-SD] age, 60+/-18 years; aortic-jet velocity, 5.0+/-0.6 m per second). The patients were prospectively followed until 1998.nnnRESULTSnFollow-up information was available for 126 patients (98 percent) for a mean of 22+/-18 months. Event-free survival, with the end point defined as death (8 patients) or valve replacement necessitated by the development of symptoms (59 patients), was 67+/-5 percent at one year, 56+/-5 percent at two years, and 33+/-5 percent at four years. Five of the six deaths from cardiac disease were preceded by symptoms. According to multivariate analysis, only the extent of aortic-valve calcification was an independent predictor of outcome, whereas age, sex, and the presence or absence of coronary artery disease, hypertension, diabetes, and hypercholesterolemia were not. Event-free survival for patients with no or mild valvular calcification was 92+/-5 percent at one year, 84+/-8 percent at two years, and 75+/-9 percent at four years, as compared with 60+/-6 percent, 47+/-6 percent, and 20+/-5 percent, respectively, for those with moderate or severe calcification. The rate of progression of stenosis, as reflected by the aortic-jet velocity, was significantly higher in patients who had cardiac events (0.45+/-0.38 m per second per year) than those who did not have cardiac events (0.14+/-0.18 m per second per year, P<0.001), and the rate of progression of stenosis provided useful prognostic information. Of the patients with moderately or severely calcified aortic valves whose aortic-jet velocity increased by 0.3 m per second or more within one year, 79 percent underwent surgery or died within two years of the observed increase.nnnCONCLUSIONSnIn asymptomatic patients with aortic stenosis, it appears to be relatively safe to delay surgery until symptoms develop. However, outcomes vary widely. The presence of moderate or severe valvular calcification, together with a rapid increase in aortic-jet velocity, identifies patients with a very poor prognosis. These patients should be considered for early valve replacement rather than have surgery delayed until symptoms develop.

Outcome of Watchful Waiting in Asymptomatic Severe Mitral Regurgitation

Background— The management of asymptomatic severe mitral regurgitation remains controversial. The aim of this study was to evaluate the outcome of a watchful waiting strategy in which patients are referred to surgery when symptoms occur or when asymptomatic patients develop left ventricular (LV) enlargement, LV dysfunction, pulmonary hypertension, or recurrent atrial fibrillation. Methods and Results— A total of 132 consecutive asymptomatic patients (age 55±15 years, 49 female) with severe degenerative mitral regurgitation (flail leaflet or valve prolapse) were prospectively followed up for 62±26 months. Patients underwent serial clinical and echocardiographic examinations and were referred for surgery when the criteria mentioned above were fulfilled. Overall survival was not statistically different from expected survival either in the total group or in the subgroup of patients with flail leaflet. Eight deaths were observed. Thirty-eight patients developed criteria for surgery (symptoms, 24; LV criteria, 9; pulmonary hypertension or atrial fibrillation, 5). Survival free of any indication for surgery was 92±2% at 2 years, 78±4% at 4 years, 65±5% at 6 years, and 55±6% at 8 years. Patients with flail leaflet tended to develop criteria for surgery slightly but not significantly earlier. There was no operative mortality. Postoperative outcome was good with regard to survival, symptomatic status, and postoperative LV function. Conclusions— Asymptomatic patients with severe degenerative mitral regurgitation can be safely followed up until either symptoms occur or currently recommended cutoff values for LV size, LV function, or pulmonary hypertension are reached. This management strategy is associated with good perioperative and postoperative outcome but requires careful follow-up.

Statins but not angiotensin-converting enzyme inhibitors delay progression of aortic stenosis

Background—Recently, statins and angiotensin-converting enzyme inhibitors (ACEIs) have been shown to slow aortic valve calcium accumulation. Although several studies also suggest that statins may reduce the hemodynamic progression of aortic stenosis (AS), no data are available for ACEIs or the combination of both. Methods and Results—A total of 211 consecutive patients (aged 70±10 years, 104 females) with native AS, defined by a peak velocity >2.5 m/s (valve area 0.84±0.23 cm2, mean gradient 42±19 mm Hg), with normal left ventricular function and no other significant valvular lesion who were examined between 2000 and 2002 and who had 2 echocardiograms separated by at least 6 months were included. Of these, 102 patients were treated with ACEIs, 50 patients received statins, and 32 patients received both. Hemodynamic progression of AS was assessed and related to medical treatment. Annualized increase in peak aortic jet velocity for the entire study group was 0.32±0.44 m · s−1 · y−1. Progression was significantly lower in patients treated with statins (0.10±0.41 m · s−1 · y−1) than in those who were not (0.39±0.42 m · s−1 · y−1; P<0.0001). This effect was observed both in mild-to-moderate and severe AS. ACEI use, however, did not significantly affect hemodynamic progression (P=0.29). Furthermore, ACEIs had no additional effect on AS progression when given in combination with statins (0.11±0.42 versus 0.08±0.43 m · s−1 · y−1 for combination versus statin only; P=0.81). Cholesterol levels did not correlate with hemodynamic progression either in the group receiving statins or in the group that did not. Conclusions—ACEIs do not appear to slow AS progression. However, statins significantly reduce the hemodynamic progression of both mild-to-moderate and severe AS, an effect that may not be related to cholesterol lowering.

Natural History of Very Severe Aortic Stenosis

Background— We sought to assess the outcome of asymptomatic patients with very severe aortic stenosis. Methods and Results— We prospectively followed 116 consecutive asymptomatic patients (57 women; age, 67±16 years) with very severe isolated aortic stenosis defined by a peak aortic jet velocity (AV-Vel) ≥5.0 m/s (average AV-Vel, 5.37±0.35 m/s; valve area, 0.63±0.12 cm2). During a median follow-up of 41 months (interquartile range, 26 to 63 months), 96 events occurred (indication for aortic valve replacement, 90; cardiac deaths, 6). Event-free survival was 64%, 36%, 25%, 12%, and 3% at 1, 2, 3, 4, and 6 years, respectively. AV-Vel but not aortic valve area was shown to independently affect event-free survival. Patients with an AV-Vel ≥5.5 m/s had an event-free survival of 44%, 25%, 11%, and 4% at 1, 2, 3, and 4 years, respectively, compared with 76%, 43%, 33%, and 17% for patients with an AV-Vel between 5.0 and 5.5 m/s (P<0.0001). Six cardiac deaths occurred in previously asymptomatic patients (sudden death, 1; congestive heart failure, 4; myocardial infarction, 1). Patients with an initial AV-Vel ≥5.5 m/s had a higher likelihood (52%) of severe symptom onset (New York Heart Association or Canadian Cardiovascular Society class >II) than those with an AV-Vel between 5.0 and 5.5 m/s (27%; P=0.03). Conclusions— Despite being asymptomatic, patients with very severe aortic stenosis have a poor prognosis with a high event rate and a risk of rapid functional deterioration. Early elective valve replacement surgery should therefore be considered in these patients.

ESC Working Group on Valvular Heart Disease Position Paper: assessing the risk of interventions in patients with valvular heart disease

AIMSnRisk scores provide an important contribution to clinical decision-making, but their validity has been questioned in patients with valvular heart disease (VHD), since current scores have been mainly derived and validated in adults undergoing coronary bypass surgery. The Working Group on Valvular Heart Disease of the European Society of Cardiology reviewed the performance of currently available scores when applied to VHD, in order to guide clinical practice and future development of new scores.nnnMETHODS AND RESULTSnThe most widely used risk scores (EuroSCORE, STS, and Ambler score) were reviewed, analysing variables included and their predictive ability when applied to patients with VHD. These scores provide relatively good discrimination, i.e. a gross estimation of risk category, but cannot be used to estimate the exact operative mortality in an individual patient because of unsatisfactory calibration.nnnCONCLUSIONnCurrent risk scores do not provide a reliable estimate of exact operative mortality in an individual patient with VHD. They should therefore be interpreted with caution and only used as part of an integrated approach, which incorporates other patient characteristics, the clinical context, and local outcome data. Future risk scores should include additional variables, such as cognitive and functional capacity and be prospectively validated in high-risk patients. Specific risk models should also be developed for newer interventions, such as transcatheter aortic valve implantation.

ESC Working Group on Valvular Heart Disease Position Paper—heart valve clinics: organization, structure, and experiences

BACKGROUNDnWith an increasing prevalence of patients with valvular heart disease (VHD), a dedicated management approach is needed. The challenges encountered are manifold and include appropriate diagnosis and quantification of valve lesion, organization of adequate follow-up, and making the right management decisions, in particular with regard to the timing and choice of interventions. Data from the Euro Heart Survey have shown a substantial discrepancy between guidelines and clinical practice in the field of VHD and many patients are denied surgery despite having clear indications. The concept of heart valve clinics (HVCs) is increasingly recognized as the way to proceed. At the same time, very few centres have developed such expertise, indicating that specific recommendations for the initial development and subsequent operating requirements of an HVC are needed.nnnAIMSnThe aim of this position paper is to provide insights into the rationale, organization, structure, and expertise needed to establish and operate an HVC. Although the main goal is to improve the clinical management of patients with VHD, the impact of HVCs on education is of particular importance: larger patient volumes foster the required expertise among more senior physicians but are also fundamental for training new cardiologists, medical students, and nurses. Additional benefits arise from research opportunities resulting from such an organized structure and the delivery of standardized care protocols.nnnCONCLUSIONnThe growing volume of patients with VHD, their changing characteristics, and the growing technological opportunities of refined diagnosis and treatment in addition to the potential dismal prognosis if overlooked mandate specialized evaluation and care by dedicated physicians working in a specialized environment that is called the HVC.

Gender differences in clinical presentation and surgical outcome of aortic stenosis

Background Little is known about the gender differences of patients undergoing aortic valve replacement (AVR) for isolated severe aortic stenosis. Methods and Results 408 consecutive patients (215 women and 193 men; p=0.9) were analysed. At presentation, women were older (73.7±9.3u2005years vs men 66.5±11.5u2005years; p<0.001), more symptomatic (New York Heart Association (NYHA) class: women 2.3±0.7 vs men 2.0±0.65; p<0.001), and presented with smaller valve areas (women 0.6±0.2u2005cm2 vs men 0.7±0.2u2005cm2; p<0.001) and higher mean pressure gradients (women 67.3±19.2u2005mmu2002Hg vs men 62.2±20.0u2005mmu2002Hg, p=0.001). Despite older age and more advanced disease in women, operative mortality did not differ. Survival after AVR by Kaplan–Meier analysis tended to be even better in women (92.8%, 89.8%, 81.4% vs men 89.1%, 86.6%, 76.3% at 1, 2 and 5u2005years, p=0.31). After division into age quintiles, the outcome of women was significantly better in patients older than 79u2005years (p=0.005). After adjustment for clinical characteristics, gender did not predict operative mortality and late outcome. Despite physical improvement in both groups after surgery, women remained more symptomatic (NYHA class: women 1.6±0.7 vs men 1.3±0.4; p=0.001). Conclusion Although women referred to AVR are older and more symptomatic, operative and long-term mortality are not increased. In the oldest age group of 79u2005years and older, women even have a better outcome, presumably due to a longer mean life expectancy.

Linee guida ESC 2015 per il trattamento dell'endocardite infettiva: Task Force per il Trattamento dell'Endocardite Infettiva della Società Europea di Cardiologia (ESC): Con il patrocinio dell'Associazione Europea di Chirurgia Cardiotoracica (EACTS) e dell'Associazione Europea di Medicina Nucleare (EANM)

Authors/Task Force Members: Gilbert Habib* (Chairperson) (France), Patrizio Lancellotti* (co-Chairperson) (Belgium), Manuel J. Antunes (Portugal), Maria Grazia Bongiorni (Italy), Jean-Paul Casalta (France), Francesco Del Zotti (Italy), Raluca Dulgheru (Belgium), Gebrine El Khoury (Belgium), Paola Anna Erba (Italy), Bernard Iung (France), Jose M. Miro (Spain), Barbara J. Mulder (The Netherlands), Edyta Plonska-Gosciniak (Poland), Susanna Price (UK), Jolien Roos-Hesselink (The Netherlands), Ulrika Snygg-Martin (Sweden), Franck Thuny (France), Pilar Tornos Mas (Spain), Isidre Vilacosta (Spain), and Jose Luis Zamorano (Spain)Autori/Membri della Task Force Gilbert Habib (Chairperson) (Francia), Patrizio Lancellotti (co-Chairperson) (Belgio), Manuel J. Antunes (Portogallo), Maria Grazia Bongiorni (Italia), Jean-Paul Casalta (Francia), Francesco Del Zotti (Italia), Raluca Dulgheru (Belgio), Gebrine El Khoury (Belgio), Paola Anna Erbaa (Italia), Bernard Iung (Francia), Jose M. Mirob (Spagna), Barbara J. Mulder (Olanda), Edyta Plonska-Gosciniak (Polonia), Susanna Price (UK), Jolien Roos-Hesselink (Olanda), Ulrika Snygg-Martin (Svezia), Franck Thuny (Francia), Pilar Tornos Mas (Spagna), Isidre Vilacosta (Spagna), Jose Luis Zamorano (Spagna)

Benefit of atrial septal defect closure in adults: impact of age

AIMSnTo evaluate the effect of age on the clinical benefit of atrial septal defect (ASD) closure in adults.nnnMETHODS AND RESULTSnFunctional status, the presence of arrhythmias, right ventricular (RV) remodelling, and pulmonary artery pressure (PAP) were studied in 236 consecutive patients undergoing transcatheter ASD closure [164 females, mean age of 49 ± 18 years, 78 younger than 40 years (Group A), 84 between 40 and 60 years (Group B) and 74 older than 60 years (Group C)]. Defect size [median 22 mm (inter-quartile range, 19, 26 mm)] and shunt ratio [Qp:Qs 2.2 (1.7, 2.9)] did not differ among age groups. Older patients had, however, more advanced symptoms and both, PAP (r = 0.65, P < 0.0001) and RV size (r = 0.28, P < 0.0001), were significantly related to age. Post-interventionally, RV size decreased from 41 ± 7, 43 ± 7, and 45 ± 6 mm to 32 ± 5, 34 ± 5, and 37 ± 5 mm for Groups A, B, and C, respectively (P < 0.0001), and PAP decreased from 31 ± 7, 37 ± 10, and 53 ± 17 mmHg to 26 ± 5, 30 ± 6, and 43 ± 14 mmHg (P < 0.0001), respectively. Absolute changes in RV size (P = 0.80) and PAP (P = 0.24) did not significantly differ among groups. Symptoms were present in 13, 49, and 83% of the patients before and in 3, 11, and 34% after intervention in Groups A, B, and C. Functional status was related to PAP.nnnCONCLUSIONSnAt any age, ASD closure is followed by symptomatic improvement and regression of PAP and RV size. However, the best outcome is achieved in patients with less functional impairment and less elevated PAP. Considering the continuous increase in symptoms, RV remodelling, and PAP with age, ASD closure must be recommended irrespective of symptoms early after diagnosis even in adults of advanced age.