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Cardiovascular Ultrasound Dec 2019Left ventricular hypertrophy and diastolic dysfunction are common echocardiographic features of both aortic valve stenosis (AS) and cardiac amyloidosis (CA). These two...
BACKGROUND
Left ventricular hypertrophy and diastolic dysfunction are common echocardiographic features of both aortic valve stenosis (AS) and cardiac amyloidosis (CA). These two different entities therefore may mask each other. From recent years, there is a growing body of evidence about the relatively high incidence of wild-type transthyretin (wtTTR) amyloidosis in AS, but there are scarce data on the prevalence of AS in CA, particularly in AL-type amyloidosis. The echocardiographic approach to these patients is not obvious, and not evidence based. We aimed to study the prevalence, severity, and type of AS in patients with CA and also to evaluate the potential of echocardiography in the diagnostic process.
METHODS
Between January 2009 and January 2019, we retrospectively analyzed the clinical and echocardiographic data, and the echocardiographic work up of 55 consecutive CA patients.
RESULTS
80% of our CA patients had AL amyloidosis. We identified 5 patients (9%) with moderate to severe AS: two with moderate AS and three with low-flow, low-grade AS (LFLG AS). Further analysis of the latter three patients with dobutamine stress echocardiography revealed pseudo-severe LFLG AS in two, and true-severe AS in one patient.
CONCLUSION
The prevalence of moderate to severe AS is 9% in our population of CA patients, the majority of whom have AL amyloidosis. Dobutamine echocardiography seems to be appropriate for the further characterization of patients with LFLG AS, even with normal ejection fraction.
Topics: Aged; Amyloidosis; Aortic Valve Stenosis; Cardiomyopathies; Echocardiography; Female; Humans; Magnetic Resonance Imaging; Male; Middle Aged; Retrospective Studies
PubMed: 31878928
DOI: 10.1186/s12947-019-0182-y -
Heart, Lung & Circulation May 2020The choice of valve type for aortic valve replacement surgery is sometimes challenging. The main risk for bioprostheses is structural valve degeneration (SVD); however,... (Meta-Analysis)
Meta-Analysis
The choice of valve type for aortic valve replacement surgery is sometimes challenging. The main risk for bioprostheses is structural valve degeneration (SVD); however, little is known about what the most important risk factors are. We conducted a systematic review and meta-analysis to identify the risk factors and estimate their pooled effect sizes to aid the prosthesis choice for replacement. We followed PRISMA guidelines and systematically searched three electronic databases (PubMed, Scopus, and Web of Science) using appropriate key terms: 'aortic valve', 'bioprosthesis', 'degeneration', 'durability', 'prosthesis failure', etc. Hazard ratio (HR) and odds ratio (OR) and associated 95% confidence intervals (CI) were extracted. Pooled risk estimates were calculated using a random-effects model. Twenty-nine (29) observational studies were included with a total of 25,490 patients, 981 of whom developed SVD over a mean follow-up time of 18.5 years. Four (4) factors influencing bioprosthetic SVD were identified: increasing age was a protective factor (per 1-yr increase, HR: 0.91 [95% CI 0.89, 0.94], p<0.0001), whereas increased body surface area (HR 1.77 [1.04, 3.01], p=0.034), patient-prosthesis mismatch (HR 1.95 [1.56, 2.43], p<0.001), and smoking (HR 2.28 [1.37, 3.79], p=0.0015) were risk factors for SVD. We found younger age, patient-prosthesis mismatch, body surface area, and smoking, as risk factors for aortic SVD, which should be considered for valve selection. This study generates a further hypothesis that accelerated flow across the valve is a shared key component in the pathophysiology of SVD, thus future research should consider other high cardiac output states.
Topics: Aortic Valve; Bioprosthesis; Heart Valve Diseases; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Humans; Postoperative Complications; Prosthesis Design; Prosthesis Failure; Risk Factors
PubMed: 31839362
DOI: 10.1016/j.hlc.2019.09.013 -
Annals of Vascular Surgery Jan 2020Complications after thoracic endovascular aortic repair (TEVAR) are common. Even after a successful TEVAR, a late endoleak (>30 days) can occur. The objective of this...
BACKGROUND
Complications after thoracic endovascular aortic repair (TEVAR) are common. Even after a successful TEVAR, a late endoleak (>30 days) can occur. The objective of this study is to summarize the current evidence and, if lacking, the need of evidence regarding the incidence and predictive factors for type 1b endoleak in patients with aortic aneurysm treated with TEVAR.
METHODS
A systematic review of the literature was performed on endoleak type 1b, in patients with aortic aneurysm, after TEVAR. The PubMed and Embase databases were systematically searched for articles regarding endoleak type 1b up to January 2019. The main subjects discussed are the incidence, risk factors, treatment, and prognosis.
RESULTS
About 722 articles were screened, and 16 articles were included in this review. The reported incidence of endoleak is between 1.0% and 15.0%, with a mean follow-up duration of at least 1 year. Type 1b endoleak is associated with an increased aortic tortuosity index (>0.15 cm). No significant difference is found in relation to age and gender. Treatment is required in most cases (22/27) and is usually performed with distal extension of the stent graft (21/27). There are no data regarding stent graft oversizing, length of distal landing zone, and differences between devices or the prognosis for patients with type 1b endoleak.
CONCLUSIONS
Limited literature is available on the occurrence of type 1b endoleak after TEVAR. A tortuous aorta can be associated as a predictive factor for the occurrence of type 1b endoleak. Data clearly delineating the anatomic variables predicting type 1b endoleak should be examined and listed. Likewise, the impact of more recent conformable devices to prevent complications like type 1b endoleaks from occurring should be elucidated.
Topics: Aorta, Thoracic; Aortic Aneurysm, Thoracic; Blood Vessel Prosthesis; Blood Vessel Prosthesis Implantation; Endoleak; Endovascular Procedures; Female; Foreign-Body Migration; Humans; Incidence; Male; Risk Assessment; Risk Factors; Stents; Time Factors; Treatment Outcome
PubMed: 31449934
DOI: 10.1016/j.avsg.2019.06.030 -
Journal of Endovascular Therapy : An... Dec 2019To investigate the association between the bird-beak configuration (BBC), a wedge-shaped gap between the undersurface of a thoracic endograft and the lesser curvature... (Meta-Analysis)
Meta-Analysis
To investigate the association between the bird-beak configuration (BBC), a wedge-shaped gap between the undersurface of a thoracic endograft and the lesser curvature of the arch after thoracic endovascular aortic repair (TEVAR), and postoperative outcome after TEVAR. The study was performed according to the PRISMA guidelines. The PubMed, EMBASE, and Cochrane databases were searched to identify all case series reporting BBC after TEVAR between 2006 and April 2018. Data analysis was performed considering the difference in the risk of complications for presence vs absence of BBC. After screening 1633 articles, 21 studies were identified that matched the selection criteria; 12 of these reported detailed information to investigate the postoperative outcome using proportion meta-analysis with a random effects model. The pooled risk difference is reported with the 95% confidence interval (CI). Heterogeneity of the included studies was assessed with the statistic (low 25%, medium 50%, high 75%). Complications occurred within a range of 0 to 72 months in 14.7% (95% CI 7.4% to 27.3%) of patients with BBC and in 6.3% (95% CI 2.5% to 15.4%) of patients without BBC. A cumulative incidence could not be assessed. The summary risk difference was 11.1% (95% CI -0.1% to 22.3%, p=0.052). There was significant heterogeneity (=85.6%). The Egger test did not show evidence of publication bias (p=0.975). When specifically considering type Ia endoleak and endograft migration, the risk difference between BBC and non-BBC patients was 8.2% (95% CI 0.3% to 16.1%, p=0.042; =69.0%). The specific risk difference for endograft collapse/infolding and thrombosis was 3.7% (95% CI -3.5% to 11.1%, p=0.308; =10.2%). At present the literature does not provide statistical evidence to establish an overall prognostic value of the BBC. Nevertheless, the BBC appears to be associated with a high risk of type Ia endoleak and endograft migration, which warrants specific and long-term surveillance. Clinically relevant values for BBC grading should be established to perhaps define indications for preemptive treatment based on the presence of BBC only.
Topics: Aorta, Thoracic; Aortic Diseases; Blood Vessel Prosthesis; Blood Vessel Prosthesis Implantation; Endoleak; Endovascular Procedures; Foreign-Body Migration; Hemodynamics; Humans; Prosthesis Design; Risk Assessment; Risk Factors; Stents; Treatment Outcome
PubMed: 31364458
DOI: 10.1177/1526602819865906 -
Autoimmunity Reviews Sep 2019Immunoglobulin G4 (IgG4)-related disease is a systemic chronic fibroinflammatory disease that can affect almost every organ of the body. IgG4-related...
OBJECTIVE
Immunoglobulin G4 (IgG4)-related disease is a systemic chronic fibroinflammatory disease that can affect almost every organ of the body. IgG4-related periaortitis/periarteritis is a newly recognized subset of IgG4-related disease, and its characteristics and prognosis remain unclear. We investigated the clinical characteristics and prognosis of IgG4-related periaortitis/periarteritis.
METHODS
We performed a systematic literature review of IgG4-related periaortitis/periarteritis. Additionally, we have summarized the characteristics and prognosis of IgG4-related coronary arteritis.
RESULTS
We investigated 248 patients with IgG4-related periaortitis/periarteritis. All studies reported the condition in elderly patients, and male predominance was observed. The infra-renal abdominal aorta and iliac arteries were the most commonly affected sites. Most reports showed the serum C-reactive protein elevation in this disease entity, in contrast to non-vascular IgG4-related disease. Based on radiological findings observed in 27 patients with IgG4-related coronary arteritis, vasculitic lesions were classified into 3 types: stenotic (67% of patients), aneurysmal (42%), and diffuse wall thickening type (92%). Serum IgG4 level, but not C-reactive protein level, was associated with the number of affected organs in IgG4-related coronary arteritis. Corticosteroid treatment with or without cardiac surgery or percutaneous coronary intervention was effective in most patients with IgG4-related coronary arteritis; however, 33% of patients showed an unfavorable clinical course including disease progression, relapse, or death. Pre-treatment stenosis and/or aneurysms were associated with progression of stenosis or aneurysm after corticosteroid treatment.
CONCLUSION
Most clinical characteristics were similar between the IgG4-related periaortitis/periarteritis and the non-vascular IgG4-related disease groups; however, serum C-reactive protein level elevation was observed only in the former. Although corticosteroid treatment was effective, this disease can be life-threatening secondary to myocardial infarction, aortic dissection, and aneurysmal rupture. Pre-treatment evaluation of stenosis or aneurysms is important for predicting progression of stenosis or aneurysm after corticosteroid treatment.
Topics: Age Factors; Aged; Aged, 80 and over; Arteritis; Disease Progression; Female; Humans; Immunoglobulin G; Immunoglobulin G4-Related Disease; Male; Prognosis; Recurrence; Retroperitoneal Fibrosis; Sex Factors
PubMed: 31323364
DOI: 10.1016/j.autrev.2019.102354 -
European Journal of Vascular and... Aug 2019Low psoas muscle mass is associated with increased mortality and morbidity after surgery. Recent evidence has linked low psoas muscle mass with survival after abdominal... (Meta-Analysis)
Meta-Analysis
Effect of Low Skeletal Muscle Mass on Post-operative Survival of Patients With Abdominal Aortic Aneurysm: A Prognostic Factor Review and Meta-Analysis of Time-to-Event Data.
OBJECTIVE/BACKGROUND
Low psoas muscle mass is associated with increased mortality and morbidity after surgery. Recent evidence has linked low psoas muscle mass with survival after abdominal aortic aneurysm (AAA) repair. The aim of this study was to investigate the prognostic role of low skeletal muscle mass in survival of patients with AAA undergoing open or endovascular aneurysm repair (EVAR).
METHODS
A review of the literature was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (PROSPERO registration number: CRD42018107793). The prognostic factor of interest was degenerative loss of skeletal muscle. A time-to-event data meta-analysis was performed for all cause mortality using the inverse variance method and the results were reported as summary hazard ratio (HR) and 95% confidence interval (CI). Pooled estimates of peri-operative outcome data were calculated using the odds ratio (OR) or risk difference (RD) and 95% CI. Random-effects models of meta-analysis were applied.
RESULTS
Seven observational cohort studies reporting a total of 1,440 patients were eligible for quantitative synthesis. Patients with low skeletal muscle mass had a significantly higher hazard of mortality than those without low skeletal muscle mass (HR 1.66, 95% CI 1.15-2.40; p = .007). Subgroup analysis including only patients who underwent EVAR showed a marginal survival benefit for patients without low skeletal muscle mass (HR 1.86, 95% CI 1.00-3.43; p = .05). Meta-analysis of two studies found no significant difference in peri-operative mortality (RD 0.04, 95% CI -0.13 to 0.21) and morbidity (OR 1.58, 95% CI 0.90-2.76; p = .11) between patients with and without low skeletal muscle mass.
CONCLUSION
There is a significant link between low skeletal muscle mass and mortality in patients undergoing AAA repair. Prospective studies validating the use of body composition for risk prediction after aortic surgery are required before this tool can be used to support decision making and patient selection.
Topics: Aortic Aneurysm, Abdominal; Blood Vessel Prosthesis Implantation; Body Composition; Endovascular Procedures; Frailty; Health Status; Humans; Muscle, Skeletal; Risk Assessment; Risk Factors; Sarcopenia; Treatment Outcome
PubMed: 31204184
DOI: 10.1016/j.ejvs.2019.03.020 -
Journal of Vascular Surgery Nov 2019The objective was to characterize the growing body of literature regarding nonoperative management of blunt thoracic aortic injury (BTAI).
OBJECTIVE
The objective was to characterize the growing body of literature regarding nonoperative management of blunt thoracic aortic injury (BTAI).
METHODS
A systematic search of MedLine, Embase, and Cochrane Central was completed to identify original articles reporting injury characteristics and outcomes in patients with BTAI managed nonoperatively during their index hospitalization. Article title and abstract screening, full-text review, and data abstraction were performed in duplicate, with discrepancies resolved by a third reviewer. The quality of each study was evaluated using the Oxford Centre for Evidence-Based Levels of Evidence.
RESULTS
Of 2162 identified studies, 74 were included and reported on 8606 patients with BTAI who were managed nonoperatively between 1970 and 2016. Only one study was prospective. The median nonoperative sample size per study was 11 patients. The characterization of aortic injury grade differed across studies. Follow-up varied widely from 1 day to 118 months. Injury healing or improvement on follow-up imaging occurred in 34% (226 of 673 patients; reported in 37 studies), most often in the context of grade I intimal injury. Injury progression or requirement for a thoracic endovascular aneurysm repair for injury progression was 7.6% (66 of 873 patients; reported in 46 studies). A total of 37 studies reported aortic-related death, with an overall rate of 4.5% (37 of 827 patients) and a rate of 1% in grade I and II injuries (1 of 153 patients) and 18% in grade III and IV (9 of 50 patients).
CONCLUSIONS
An increasing number of reports support nonoperative management of grade I intimal injury, consistent with Society for Vascular Surgery guidelines. However, a retrospective interpretation of the determinants of management, heterogeneous injury characterization, and variable follow-up remain major limitations to the informed use of nonoperative management across all BTAI grades.
Topics: Aorta, Thoracic; Clinical Decision-Making; Conservative Treatment; Disease Progression; Endovascular Procedures; Humans; Injury Severity Score; Practice Guidelines as Topic; Societies, Medical; Specialties, Surgical; Treatment Outcome; Vascular System Injuries; Wounds, Nonpenetrating
PubMed: 31126762
DOI: 10.1016/j.jvs.2019.02.023 -
The International Journal of... Jun 2019Measures of sarcopenia, such as low muscle mass measured from the readily available preoperative computed tomography (CT) images, have been recently suggested as a... (Meta-Analysis)
Meta-Analysis
Usefulness of skeletal muscle area detected by computed tomography to predict mortality in patients undergoing transcatheter aortic valve replacement: a meta-analysis study.
Measures of sarcopenia, such as low muscle mass measured from the readily available preoperative computed tomography (CT) images, have been recently suggested as a predictor of outcomes in patients undergoing transcatheter aortic valve replacement (TAVR). However, results of these studies are variable and, therefore, we performed a systematic review of current literature to evaluate sarcopenia as a predictor of outcome post TAVR. The search was carried out in electronic databases between 2008 and 2018. We identified studies that reported CT-derived skeletal muscle area (SMA) and survival outcomes post TAVR. Studies were evaluated for the incidence of early (≤ 30 days) and late all-cause mortality (> 30 days) post TAVR. Eight studies with 1881 patients were included (mean age of 81.8 years ± 12, 55.9% men). Mean body mass index was (28.2 kg/m ± 1.1), mean Society of Thoracic Surgeons risk score (7.0 ± 0.6), and mean albumin level was (3.8 g/dL ± 0.1). Higher SMA was associated with lower long-term mortality [odds ratio (OR) 0.49, 95% confidence interval (CI) 0.28-0.83, p = 0.049], compared with low SMA. Also, higher SMA was associated with lower early mortality but was not statistically significant (OR 0.72; 95% CI 0.44-1.18; p = 0.285). CT-derived SMA provides value in predicting post-TAVR long-term outcomes for patients undergoing TAVR. This is a simple risk assessment tool that may help in making treatment decisions and help identifying and targeting high-risk patients with interventions to improve muscle mass prior to and following the procedures.
Topics: Age Factors; Aged; Aged, 80 and over; Aortic Valve; Aortic Valve Stenosis; Female; Geriatric Assessment; Humans; Male; Muscle, Skeletal; Predictive Value of Tests; Risk Assessment; Risk Factors; Sarcopenia; Time Factors; Tomography, X-Ray Computed; Transcatheter Aortic Valve Replacement; Treatment Outcome
PubMed: 30915667
DOI: 10.1007/s10554-019-01582-0 -
The Thoracic and Cardiovascular Surgeon Oct 2020Prosthesis-patient mismatch (PPM) after aortic valve replacement (AVR) may affect survival but data are conflicting. It is assessed by relating effective orifice area...
BACKGROUND
Prosthesis-patient mismatch (PPM) after aortic valve replacement (AVR) may affect survival but data are conflicting. It is assessed by relating effective orifice area (EOA) to body surface area (EOAi). EOA is patient-specific as the result of flow-velocity times area at the individual patient's outflow tract levels (LVOT) divided by trans-prosthetic flow velocity. However, some studies use projected EOAs (i.e., valve size associated EOAs from other patient populations) to assess how PPM affects outcome.
METHODS
We analyzed 76 studies addressing hemodynamic outcome and/or mortality after bioprosthetic AVR.
RESULTS
In 48 studies, projected or measured EOA for calculation of EOAi and PPM assessment was used (of which 25 demonstrated an effect on survival). We identified 28 additional studies providing measured EOA values and the corresponding Bernoulli's pressure gradients after AVR. Despite EOA being a patient-specific parameter, 77% of studies assessing a PPM impact on survival used projected EOAs. The 28 studies are providing measured EOA values and the corresponding Bernoulli's pressure gradients in patients after AVR showed a highly significant, linear relationship between EOA and Bernoulli's gradient. Considering this relationship, it is surprising that relating EOA to body surface area (BSA) (EOAi) is standard but relating pressure gradients to BSA is not.
CONCLUSION
We conclude that the majority of studies assessing PPM have used false assumptions because EOA is a patient-specific parameter and cannot be transferred to other patients. In addition, the use of EOAi to assess PPM may not be appropriate and could explain the inconsistent relation between PPM and survival in previous studies.
Topics: Aortic Valve; Aortic Valve Stenosis; Bioprosthesis; Body Surface Area; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Hemodynamics; Humans; Postoperative Complications; Prosthesis Design; Prosthesis Failure; Risk Factors; Treatment Outcome
PubMed: 30609446
DOI: 10.1055/s-0038-1676814 -
Seminars in Thoracic and Cardiovascular... 2019To assess the predictive value of preoperative cognitive impairment on postoperative in-hospital, short-term, and mid-term outcomes among patients undergoing surgical or...
To assess the predictive value of preoperative cognitive impairment on postoperative in-hospital, short-term, and mid-term outcomes among patients undergoing surgical or transcatheter aortic valve replacement. The review was conducted according to PRISMA guidelines. Articles were identified in EMBASE, Medline, and PubMed. Eligible articles compared the outcomes of patients with and without preoperative cognitive impairment who underwent aortic valve replacement and were published in English between January 1, 1997 and November 1, 2017. The quality of included observational studies was evaluated using the Newcastle-Ottawa scale. The strength of the body of evidence was also assessed. A total of 6163 abstracts were screened by 2 independent reviewers and 31 full-text articles were reviewed. Eight studies met inclusion criteria. The studies included 1 case-control, 5 prospective cohort, and 2 retrospective cohort studies. Given the paucity and heterogeneity of studies, meta-analysis was not possible. Five studies were of good quality. Preoperative cognitive impairment is a risk factor for postoperative delirium in 2 studies, increased mid-term mortality in 2 studies, and increased length of stay, risk of discharge to a health-care facility or progressive disability in 1 study. However, given the paucity and methodological flaws of the included studies, the body of evidence on the predictive value of preoperative cognitive impairment on postoperative outcomes remains weak. This systematic review highlights the need for more good quality studies to provide evidence regarding the incidence of cognitive impairment and associations with poor outcomes after aortic valve replacement.
Topics: Aged; Aortic Valve; Aortic Valve Stenosis; Cognition; Cognitive Dysfunction; Delirium; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Humans; Length of Stay; Middle Aged; Patient Discharge; Risk Assessment; Risk Factors; Severity of Illness Index; Transcatheter Aortic Valve Replacement; Treatment Outcome
PubMed: 30529383
DOI: 10.1053/j.semtcvs.2018.11.017