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Aortic valve morphology predicts progression of valve dysfunction in bicuspid aortic valve: Echo-Doppler follow-up of 52 patients
J o u m a l o f the American Society o f Echocardiography Volume 8 Number 3
4-VIII
Eehoeardiographic Assessment of Valvular Function in Patients Undergoing Replacement of the Aortic Valve with a Pulmonary Autograft
Abstracts 353
6-VIII
Gregory B. Clarke, Robert K Salley, Peter M. Sapin, Gong-Yuan Xie, David R. Gross, Mikel D. Smith, University o f Kentucky Lexington, K Y
Carlos X. PimenteL MD, Marie J. Garcia, MD, Leonardo Rodriguez, MD, Pieter M. Vandervoott, MD, James D. Thomas, MD, Brian P, Griffin, MD. Cleveland Clinic Foundation, Cleveland, OH.
One form of surgical treatment for severe aortic valve disease includes the use o f a patients (pts) own pulmonary valve as an autograft in the aortic position (A-Aut) with placement of a cryopreserved allogratt in the pulmonary position (P-All). Advantages of this method include elimination of the need for long term anticoagulation as well as providing the potential for growth of the A-Aut when used in young pts. The purpose o f this study was to evaluate the immediate and long term valvular hemodynamics in pls undergoing this procedure. Methods: Valvular function of 25 consecutive pts (mean age = 35.6 +/- 15 yrs) undergoing this procedure were studied intraoperatively with transesophageal echo (TEE) and in follow up (flu) using transthoracic echo (TTE). Mean duration o f f / u was 11.3 mos with a range of 1-24 mos. Results: The A-Aut was well visualized by TEE in all 22 pts studied intraoperatively. Mild A-Aut insufficiency (AAut-I) was detected by TEE in 19 o f 22 pts at the time o f surgery. Three o f these pts progressed to moderate AAttt-I during flu by T T E None progressed further. The average mean gradient across the A-Aut during f/u TTE was 4.0 mrn H g (range - 1-10). Six pts developed increased P-All gradients (peak gradient >20ram Hg, mean gradient >10mm Hg) during f/u TTE. Eleven pts developed new onset or worsened tricuspid regurgitation (TR) following surgery including 4 classified as severe T R during f/u T T E Conclusions: 1 ) This "aortic-pulmonary autografi" procedure results in excellent A-Aut hemodynamics with no progression o f valvular regurgitation during flu to 24 rodS. 2.) A small number o f pts develop right heart complications including worsened T R and increased P-All gradients greater than 10 m m H g . Continued follow up and study is needed to determine the significance of these findings.
5-VIII
AORTIC VALVE MORPHOLOGY PREDICTS PROGRESSION OF VALVE DYSFUNCTION IN BICUSPID AORTIC VALVE: ECHO-DOPPLER FOLLOW-UP OF 52 PATIENTS. Brian M McClements MD, Dan Gilon MD, Miohae; J Williams MB, Christian Breburda MD, Mar'/Etta King MD. Michael H Pieard MD, Robert A Levine MD. Massachusetts General Hospital, Boston, MA An understanding of the natural history of bicuspid aortic valve (BAY) disease is important to the clinical management of this condition. However, only limited data are available concerning the rate and echocardiographie determinants of progression of valve dysfunction in BAV. To elucidate this 19roblem, 52 patients with BAV who underwent 2D and Doppler eehocardiography on two occasions separated by at least 12 months were identified from our laboratory database. The mean age was 30• years and 34 (65%) were male. All studies were reviewed to assess the morphological characteristics of the aortic valve including cusp orientation (horizontal v vertical), thickening (score 0-5), presence of cusp prolapse, lndex o! eccentricity of the coaptation line, regurgitation (AR)(04), peak systolic gradient corrected for the subvalvular velocity and grade of stenosis (AS)(1-3). Aortic and left ventricular dimensions were also obtained. Results: The median foLlow-up period was 37 months. Thirty-three (63%) valves were horizontal and there was evidence of prolapse in 18 (35%). In the total population the mean AR grade increased from 1.5 t 1.2 to t.9 ~ 1.3 (p=0,000t) and in 15 (29%) pts the grade of AR Inerease~ by zt. In the total population the mean corrected peak systotic gradient (mmHg I increased from 24.4 ~ 21.0 to 307 _. 25.6 (p=0.0002). In 13 (25%) the peak systolic gradient increased by ~10mmHg and in 8 (15%) the grade of AS increased by M; in these progressive patients, peak systolic gradient increased by 26 • 11 mmHg over 34 9 22 months. Multiple regression analysis identified the aortic valve thickness score at baseline as the only predictor of progression of AS (p=0.0026); cusp orientation and degree of prolapse were not predictive. Markers of progression of AR identified by the model were duration of followup (p=0.00017), the coaptation eccentricity index (p=0.0006) and the left ventrieular end-systolic dimension at baseline (p=0.0001). Conclusion: Morphologic characteristics of the bicuspid aortic valve at baseline study, specifically the degree of thickening and the eccentricity of leaflet coaptation, are the major predictors of progression of AS and AR in these patients.
Predictors of Improvement in Pulmonary Hypertension After Correction of Severe Mitral Regurgitation: An Echocardiographic Study.
Although pulmonary hypertension (PHTN) is a recognized complication of isolated mitral regurgitation (MR), little is known of the effects of corrective surgery on pulmonary artery pressures (PAP) in this condition. We used Doppler echocardiography to determine the magnitude, time course and predictors of change in the PA pressures following corrective surgery in 4 4 patients {mean age 64+__13 yrsl with significant PHTN l > 45 mm Hg systolic) complicating severe isolated MR. Methods Pts undergoing mitral valve repair ( n = 2 6 ) or replacement ( n = 1 8 ) for > 3 + MR were included. Pts with mitral stenosis or significant aortic valve disease or residual MR postop were excluded. All p t s were studied preoperatively (preop) and early (mean 10 days) postoperatively (postop); 22 (50%) were studied later (mean 3 4 2 days) postop. PA pressure was calculated from the tricuspid regurgitant velocity (v) as 4v s + 10 mm Hg. Left atrial, left ventricular diastolic and systolic diameters (LVIDS) and fractional shortening were measured from M-mode. Stepwise linear regression analysis was used to determine the independent predictors among echo and demographic variables of change in PAP. Data are expressed as mean + SD. Results: Preoperative PAP fell from 59__+15 mmHg to 43-t-9 mmHg postoperatively (p < 0.001). A > 2 0 % fall in PAP was seen in 29 pts (66%). Male sex (p = 0.022), higher preoperative PAP (p < O.001l and smatter preoperative LVIDS {p = 0 . 0 1 5 ) were independent predictors of a fall in PAP postoperatively, whereas type of surgery, LV or RV function were not, PAP did not change significantly from early (41-I-11 mm Hg) to late postop ( 4 2 • )mm Hg. Conclusions: 11 There is a significant improvement in PHTtV. early after surgical correction of MR. 2) Reduction in PAP is most likely in men, pts with smaller preoperative LVIDS and higher preoperative PAP.
7-VIII
TRANS-MITRAL FLOW VELOCITY PROFILES IN THE DIAGNOSIS OF SEVERE MITRAL REGURGITATION Arzu Ilerci[ MD, Anna Maria Municino MD, Jose Santiago MD, Ying Zhu MS, Myung-Ho Lee MD, David Rubinstein MD, MicheleNanna MD. Montefiore Medical Center, AECOM, Bronx, NY Eehocardiographic grading of mitral regargitalion (MR) can be challenging at times We hypothesize that the presence of severe MR, by influencing loading conditions, may affect the transmittal flow velocity profile (TMFVP) We used a lumped parameter computer model of the cardiovascular system to predict the effect of MR on the E/A ratio in the setting of abnormal left ventricular (LV) relaxation. To further evaluate our hypothesis, echocardiograms of 96 patients with varying degrees of MR were reviewed and TMFVP were analyzed. Patients were placed in three groups based on color Doppler severity of MR: I-mild II= moderate and lIl= severe. Patients with mitral stenosis, atrial fibrillation and greater than mild aortic insufficiency were excluded. Results:Figure l shows a normal TMFVP generated by the computer model. Figure 2 show the TMFVP after introducing abnormal LV relaxation, figures 3 & 4 are under the same conditions as 2 except the addition of mild and severe MR
1
2
3
4
z,mr162162
l=Normal 2=Abnormal LV relaxation 3=Abnormal relaxation and mild MR 4=Abnormal relaxation and severe MR Summary of echocardiographic findings in 96 patients: Group I Group II Group II1 # of Patients 36 30 30 # Patients with E/A (peak) < 1 20 11" 0? E/A (peak)(mean+/-SD) 1.1+/-0.6 1.3+/-0.5* 1.9+L0.St E/A (Velocity time integral) 1.6+/-0.8 1.7+/-0.8" 3.3+L1 4? ~=p<0.003 vs Group I & II *-NS vs Group 1 . There was no statistically significant difference in age or heart rate of patients in group III as compared with groups I and II. Conclnsion: Patients with severe MR have a higher E/A ratio than patients with lesser degrees of MR. Reversal of the E/A ratio was not found in any patient with severe MR. In addition, computer modelingpredicted pseudonomzalizationof a reversed E/A ratio in the presence of severe MR. A reversed E/A ratio, therefore, appears to exclude the gresence of severe MR.
4-VIII
Eehoeardiographic Assessment of Valvular Function in Patients Undergoing Replacement of the Aortic Valve with a Pulmonary Autograft
Abstracts 353
6-VIII
Gregory B. Clarke, Robert K Salley, Peter M. Sapin, Gong-Yuan Xie, David R. Gross, Mikel D. Smith, University o f Kentucky Lexington, K Y
Carlos X. PimenteL MD, Marie J. Garcia, MD, Leonardo Rodriguez, MD, Pieter M. Vandervoott, MD, James D. Thomas, MD, Brian P, Griffin, MD. Cleveland Clinic Foundation, Cleveland, OH.
One form of surgical treatment for severe aortic valve disease includes the use o f a patients (pts) own pulmonary valve as an autograft in the aortic position (A-Aut) with placement of a cryopreserved allogratt in the pulmonary position (P-All). Advantages of this method include elimination of the need for long term anticoagulation as well as providing the potential for growth of the A-Aut when used in young pts. The purpose o f this study was to evaluate the immediate and long term valvular hemodynamics in pls undergoing this procedure. Methods: Valvular function of 25 consecutive pts (mean age = 35.6 +/- 15 yrs) undergoing this procedure were studied intraoperatively with transesophageal echo (TEE) and in follow up (flu) using transthoracic echo (TTE). Mean duration o f f / u was 11.3 mos with a range of 1-24 mos. Results: The A-Aut was well visualized by TEE in all 22 pts studied intraoperatively. Mild A-Aut insufficiency (AAut-I) was detected by TEE in 19 o f 22 pts at the time o f surgery. Three o f these pts progressed to moderate AAttt-I during flu by T T E None progressed further. The average mean gradient across the A-Aut during f/u TTE was 4.0 mrn H g (range - 1-10). Six pts developed increased P-All gradients (peak gradient >20ram Hg, mean gradient >10mm Hg) during f/u TTE. Eleven pts developed new onset or worsened tricuspid regurgitation (TR) following surgery including 4 classified as severe T R during f/u T T E Conclusions: 1 ) This "aortic-pulmonary autografi" procedure results in excellent A-Aut hemodynamics with no progression o f valvular regurgitation during flu to 24 rodS. 2.) A small number o f pts develop right heart complications including worsened T R and increased P-All gradients greater than 10 m m H g . Continued follow up and study is needed to determine the significance of these findings.
5-VIII
AORTIC VALVE MORPHOLOGY PREDICTS PROGRESSION OF VALVE DYSFUNCTION IN BICUSPID AORTIC VALVE: ECHO-DOPPLER FOLLOW-UP OF 52 PATIENTS. Brian M McClements MD, Dan Gilon MD, Miohae; J Williams MB, Christian Breburda MD, Mar'/Etta King MD. Michael H Pieard MD, Robert A Levine MD. Massachusetts General Hospital, Boston, MA An understanding of the natural history of bicuspid aortic valve (BAY) disease is important to the clinical management of this condition. However, only limited data are available concerning the rate and echocardiographie determinants of progression of valve dysfunction in BAV. To elucidate this 19roblem, 52 patients with BAV who underwent 2D and Doppler eehocardiography on two occasions separated by at least 12 months were identified from our laboratory database. The mean age was 30• years and 34 (65%) were male. All studies were reviewed to assess the morphological characteristics of the aortic valve including cusp orientation (horizontal v vertical), thickening (score 0-5), presence of cusp prolapse, lndex o! eccentricity of the coaptation line, regurgitation (AR)(04), peak systolic gradient corrected for the subvalvular velocity and grade of stenosis (AS)(1-3). Aortic and left ventricular dimensions were also obtained. Results: The median foLlow-up period was 37 months. Thirty-three (63%) valves were horizontal and there was evidence of prolapse in 18 (35%). In the total population the mean AR grade increased from 1.5 t 1.2 to t.9 ~ 1.3 (p=0,000t) and in 15 (29%) pts the grade of AR Inerease~ by zt. In the total population the mean corrected peak systotic gradient (mmHg I increased from 24.4 ~ 21.0 to 307 _. 25.6 (p=0.0002). In 13 (25%) the peak systolic gradient increased by ~10mmHg and in 8 (15%) the grade of AS increased by M; in these progressive patients, peak systolic gradient increased by 26 • 11 mmHg over 34 9 22 months. Multiple regression analysis identified the aortic valve thickness score at baseline as the only predictor of progression of AS (p=0.0026); cusp orientation and degree of prolapse were not predictive. Markers of progression of AR identified by the model were duration of followup (p=0.00017), the coaptation eccentricity index (p=0.0006) and the left ventrieular end-systolic dimension at baseline (p=0.0001). Conclusion: Morphologic characteristics of the bicuspid aortic valve at baseline study, specifically the degree of thickening and the eccentricity of leaflet coaptation, are the major predictors of progression of AS and AR in these patients.
Predictors of Improvement in Pulmonary Hypertension After Correction of Severe Mitral Regurgitation: An Echocardiographic Study.
Although pulmonary hypertension (PHTN) is a recognized complication of isolated mitral regurgitation (MR), little is known of the effects of corrective surgery on pulmonary artery pressures (PAP) in this condition. We used Doppler echocardiography to determine the magnitude, time course and predictors of change in the PA pressures following corrective surgery in 4 4 patients {mean age 64+__13 yrsl with significant PHTN l > 45 mm Hg systolic) complicating severe isolated MR. Methods Pts undergoing mitral valve repair ( n = 2 6 ) or replacement ( n = 1 8 ) for > 3 + MR were included. Pts with mitral stenosis or significant aortic valve disease or residual MR postop were excluded. All p t s were studied preoperatively (preop) and early (mean 10 days) postoperatively (postop); 22 (50%) were studied later (mean 3 4 2 days) postop. PA pressure was calculated from the tricuspid regurgitant velocity (v) as 4v s + 10 mm Hg. Left atrial, left ventricular diastolic and systolic diameters (LVIDS) and fractional shortening were measured from M-mode. Stepwise linear regression analysis was used to determine the independent predictors among echo and demographic variables of change in PAP. Data are expressed as mean + SD. Results: Preoperative PAP fell from 59__+15 mmHg to 43-t-9 mmHg postoperatively (p < 0.001). A > 2 0 % fall in PAP was seen in 29 pts (66%). Male sex (p = 0.022), higher preoperative PAP (p < O.001l and smatter preoperative LVIDS {p = 0 . 0 1 5 ) were independent predictors of a fall in PAP postoperatively, whereas type of surgery, LV or RV function were not, PAP did not change significantly from early (41-I-11 mm Hg) to late postop ( 4 2 • )mm Hg. Conclusions: 11 There is a significant improvement in PHTtV. early after surgical correction of MR. 2) Reduction in PAP is most likely in men, pts with smaller preoperative LVIDS and higher preoperative PAP.
7-VIII
TRANS-MITRAL FLOW VELOCITY PROFILES IN THE DIAGNOSIS OF SEVERE MITRAL REGURGITATION Arzu Ilerci[ MD, Anna Maria Municino MD, Jose Santiago MD, Ying Zhu MS, Myung-Ho Lee MD, David Rubinstein MD, MicheleNanna MD. Montefiore Medical Center, AECOM, Bronx, NY Eehocardiographic grading of mitral regargitalion (MR) can be challenging at times We hypothesize that the presence of severe MR, by influencing loading conditions, may affect the transmittal flow velocity profile (TMFVP) We used a lumped parameter computer model of the cardiovascular system to predict the effect of MR on the E/A ratio in the setting of abnormal left ventricular (LV) relaxation. To further evaluate our hypothesis, echocardiograms of 96 patients with varying degrees of MR were reviewed and TMFVP were analyzed. Patients were placed in three groups based on color Doppler severity of MR: I-mild II= moderate and lIl= severe. Patients with mitral stenosis, atrial fibrillation and greater than mild aortic insufficiency were excluded. Results:Figure l shows a normal TMFVP generated by the computer model. Figure 2 show the TMFVP after introducing abnormal LV relaxation, figures 3 & 4 are under the same conditions as 2 except the addition of mild and severe MR
1
2
3
4
z,mr162162
l=Normal 2=Abnormal LV relaxation 3=Abnormal relaxation and mild MR 4=Abnormal relaxation and severe MR Summary of echocardiographic findings in 96 patients: Group I Group II Group II1 # of Patients 36 30 30 # Patients with E/A (peak) < 1 20 11" 0? E/A (peak)(mean+/-SD) 1.1+/-0.6 1.3+/-0.5* 1.9+L0.St E/A (Velocity time integral) 1.6+/-0.8 1.7+/-0.8" 3.3+L1 4? ~=p<0.003 vs Group I & II *-NS vs Group 1 . There was no statistically significant difference in age or heart rate of patients in group III as compared with groups I and II. Conclnsion: Patients with severe MR have a higher E/A ratio than patients with lesser degrees of MR. Reversal of the E/A ratio was not found in any patient with severe MR. In addition, computer modelingpredicted pseudonomzalizationof a reversed E/A ratio in the presence of severe MR. A reversed E/A ratio, therefore, appears to exclude the gresence of severe MR.