Assessment of aortic valve disease--a clinician oriented review

Aortic valve disease [aortic stenosis(AS) and aortic regurgitation(AR)] represents an important global healthproblem; when severe, aortic valve disease carries poor prognosis. For AS, aortic valve replacement, either surgical or interventional, may provide definite treatment in carefully selected patients. For AR, valve surgery(either replacement or-in selected cases-aortic valve repair) remains the gold standard of care. To properly identify those patients who are candidates for surgery, the clinician has to carefully assess the severity of valve disease with an understanding of the potential pitfalls involved in these assessments. This review focuses on the practical issues concerning the evaluation of patients with AS and AR from a general cardiologist's perspective. The most important issues regarding the documentation of the severity of AS and AR are summarized. More specific issues, such as the role of stress echocardiography, other imaging techniques and details regarding the treatment options(medical, surgical, or interventional), are mentioned briefly.

Patient selection for transcatheter aortic valve replacement:A combined clinical and multimodality imaging approach

Transcatheter aortic valve replacement(TAVR) has been validated as a new therapy for patients affected by severe symptomatic aortic stenosis who are not eligible for surgical intervention because of major contraindication or high operative risk. Patient selection for TAVR should be based not only on accurate assessment of aortic stenosis morphology, but also on several clinical and functional data. Multi-Imaging modalities should be preferred for assessing the anatomy and the dimensions of the aortic valve and annulus before TAVR. Ultrasounds represent the first line tool in evaluation of this patients giving detailed anatomic description of aortic valve complex and allowing estimating with enough reliability the hemodynamic entity of valvular stenosis. Angiography should be used to assess coronary involvement and plan a revascularization strategy before the implant. Multislice computed tomography play a central role as it can give anatomical details in order to choice the best fitting prosthesis, evaluate the morphology of the access path and detect other relevant comorbidities. Cardiovascular magnetic resonance and positron emission tomography are emergent modality helpful in aortic stenosis evaluation. The aim of this review is to give an overview onTAVR clinical and technical aspects essential for adequate selection.

Estimating pressure gradients by auscultation:How technology(echocardiography)can help improve clinical skills

AIM To extend our previously-published experience in estimating pressure gradients(PG) via physical examination in a large patient cohort. METHODS From January 1, 1997 through December 31, 2009, an attending pediatric cardiologist compared clinical examination(EXAM) with Doppler-echo(ECHO), in 1193 patients with pulmonic stenosis(PS, including tetralogy of Fallot), aortic stenosis(AS), and ventricular septal defect(VSD). EXAM PG estimates were based primarily on a murmur's pitch, grade, and length. ECHO peak instantaneous PG was derived from the modified Bernoulli equation. Patients were 0-38.4 years old(median 4.8).RESULTS For all patients, EXAM correlated highly with ECHO: ECHO = 0.99(EXAM) + 3.2 mm Hg; r = +0.89; P < 0.0001. Agreement was excellent(mean difference =-2.9 ± 16.1 mm Hg). In 78% of all patients, agreement between EXAM and ECHO was within 15 mm Hg and within 5 mm Hg in 45%. Clinical estimates of PS PG were more accurate than of AS and VSD. A palpable precordial thrill and increasing loudness of the murmur predicted highergradients(P < 0.0001). Weight did not influence accuracy. A learning curve was evident, such that the most recent quartile of patients showed ECHO = 1.01(EXAM) + 1.9, r = +0.92, P < 0.0001; during this time, the attending pediatric cardiologist had been > 10 years in practice.CONCLUSION Clinical examination can accurately estimate PG in PS, AS, or VSD. Continual correlation of clinical findings with echocardiography can lead to highly accurate diagnostic skills.

Is there evidence for statins in the treatment of aortic valve stenosis?

Research revealed that the pathogenesis of aortic stenosis(AS) not merely comprises of a mechanical wear and tear process yet that active biological processes, similar to those of coronary artery disease are involved, a promising role for statins in disease-modifying therapy was suggested. However, recently, many prospective studies could not observe decreased progression nor regression of the disease. Here, we review the current knowledge on the pathomechanisms of AS and its similarities and differences with atherosclerosis. Moreover, we discuss whether there is still a place for statins in the treatment of particular AS patient subgroups.

Circulating CD14＋ monocytes in patients with aortic stenosis

BackgroundCalcific 大动脉的狭窄(作为) 是与动脉粥样硬化和长期的发炎分享类似的一个活跃过程。pathophysiology 这为三个最重要的部件是著名的：发炎，纤维变性和石灰化。单核白血球在每这些过程起一个作用。传播单核白血球在的角色这不是清楚的。现在的学习的目的是学习在传播 apoptotic 之间并且非的一个协会 apoptotic CD14 + 单核白血球并且当 features.MethodsWe 在 54 个病人估计了 CD14 + 单核白血球和 apoptotic 单核白血球的数字与作为重要(大动脉的阀门区域 0.74 ±；0.27 厘米 2) 并且把他们与类似的风险因素和没有瓣膜的疾病作比较到 33 个病人。CD14 + 单核白血球和 apoptotic 单核白血球的水平被流动 cytometry.ResultsThere 估计不是在风险因素侧面的差别并且知道在病人之间的冠或外部的脉管的疾病与作为并且控制。病人与是作为与控制相比展出了 CD14 + 单核白血球的增加的数字(9.9%±；4.9% 对 7.7%±；3.9% ， P = 0.03 ) 。CD14 + 单核白血球数字与年龄和存在和严厉有关作为。在病人与作为，两个 CD14 + 单核白血球和 apoptotic 单核白血球是相反地与大动脉的阀门 area.ConclusionsPatients 与有关作为重要增加了传播 CD14 + 单核白血球的数字，在单核白血球计数和大动脉的阀门区域之间有反的关联。这些调查结果可以建议那发炎在早阀门损害阶段是起作用的不仅，而且在象石灰化那样的以后的发达阶段什么时候同样是严重的。

Optimal C-arm angulation during transcatheter aortic valve replacement: Accuracy of a rotational C-arm computed tomography based three dimensional heart model

AIM To investigate the accuracy of a rotational C-arm CTbased 3D heart model to predict an optimal C-arm configuration during transcatheter aortic valve replacement(TAVR). METHODS Rotational C-arm CT(RCT) under rapid ventricular pacing was performed in 57 consecutive patients with severe aortic stenosis as part of the pre-procedural cardiac catheterization. With prototype software each RCT data set was segmented using a 3D heart model. From that the line of perpendicularity curve was obtained that generates a perpendicular view of the aortic annulus according to the right-cusp rule. To evaluate the accuracy of a model-based overlay we compared model- and expert-derived aortic root diameters. RESULTS For all 57 patients in the RCT cohort diameter measurements were obtained from two independent operators and were compared to the model-based measurements. The inter-observer variability was measured to be in the range of 0°-12.96° of angular C-arm displacement for two independent operators. The model-to-operator agreement was 0°-13.82°. The model-based and expert measurements of aortic root diameters evaluated at the aortic annulus(r = 0.79, P < 0.01), the aortic sinus(r = 0.93, P < 0.01) and the sino-tubular junction(r = 0.92, P < 0.01) correlated on a high level and the Bland-Altman analysis showed good agreement. The interobserver measurements did not show a significant bias. CONCLUSION Automatic segmentation of the aortic root using an anatomical model can accurately predict an optimal C-arm configuration, potentially simplifying current clinical workflows before and during TAVR.