Role of echocardiography in aortic stenosis.

Aortic stenosis is a valve disorder that includes not only valve narrowing but also changes in the left ventricle and intracardiac hemodynamics. Older patients with aortic stenosis often have co-existing pathologic disorders, which influence the pathophysiology, symptom expression and prognosis. There is also increasing awareness that severe aortic stenosis could be associated with low transvalvular pressure gradient caused by a variety of mechanisms. Surgical and transcutaneous valve replacements are currently available interventions for patients with severe aortic stenosis. This article reviews the role of echocardiography in the comprehensive assessment of aortic stenosis, its severity and associated pathophysiologic abnormalities.

Artifacts in three-dimensional transesophageal echocardiography.

Three-dimensional (3D) transesophageal echocardiography (TEE) is subject to the same types of artifacts encountered on two-dimensional TEE. However, when displayed in a 3D format, some of the artifacts appear more "realistic," whereas others are unique to image acquisition and postprocessing. Three-dimensional TEE is increasingly used in the setting of percutaneous catheter-based interventions and ablation procedures, and 3D artifacts caused by the metallic components of catheters and devices are particularly frequent. Knowledge of these artifacts is of paramount relevance to avoid misinterpretation of 3D images. Although artifacts and pitfalls on two-dimensional echocardiography are well described and classified, a systematic description of artifacts in 3D transesophageal echocardiographic images and how they affect 3D imaging is still absent. The aim of this review is to describe the most relevant artifacts on 3D TEE, with particular emphasis on those occurring during percutaneous interventions for structural heart disease and ablation procedures.

Doppler markers of elevated left atrial and ventricular filling pressure in a critically ill patient.

Accurate assessment of intracardiac flows by Doppler echocardiography may add important hemodynamic information in the critically ill patient. Detailed analysis of flow gradients through different sites and their correlation with timing of cardiac events may help us in better understanding the pathophysiology of the underlying disease. We report the clinical case of a 78-year-old patient with septic shock, in whom an A-dip of aortic regurgitation, shortening of diastolic filling, and diastolic mitral regurgitation were detected by Doppler analysis. Pathophysiologic explanation of these phenomena and their evolution after inotropic drug infusion are reported.

The syndrome of degenerative calcific aortic stenosis: prevalence of multiple pathophysiologic disorders in association with valvular stenosis and their implications.

BACKGROUND: We hypothesized that degenerative calcific aortic stenosis (DCAS) is a syndrome influenced by factors beyond aortic valve stenosis (AS). The aim of this study was to assess how frequently DCAS is complicated by increased vascular load, systolic and/or diastolic left ventricular (LV) dysfunction, and comorbid disorders. METHODS: In 215 consecutive patients > 60 years of age with severe and moderate AS, we analyzed systemic arterial compliance, global hemodynamic load, LV ejection fraction (EF), the presence of diastolic dysfunction, and other valvular or systemic disorders. RESULTS: A total of 164 patients had severe AS and 51 had moderate AS. In patients with severe AS, the prevalence of increased vascular load was 42%; LV systolic and diastolic dysfunction was present in 27% and 42%; other valve diseases in 23%; and comorbid disorders in 82%. In the moderate AS group, abnormal vascular load was found in 52%; LV systolic and diastolic dysfunction was prevalent in 26% and 31%; other valve diseases in 17%; and comorbid disorders in 78% patients. More than half the patients in both groups had symptoms. In both severe and moderate AS groups, the prevalence of increased vascular load and systolic dysfunction was higher in the symptomatic group. CONCLUSION: Considerable number of patients with DCAS have abnormal vascular load, abnormal LV function, and significant coexisting disorders. These could influence the total pathophysiologic burden on the heart and symptom expression. Thus, DCAS should not be considered just as valvular stenosis, but a syndrome of DCAS because of the diagnostic, prognostic, and therapeutic implications of various factors associated with it.

Eroded valves, recurrent pleural effusions, and ultimately heart-liver transplant.

A patient with eroded tricuspid and pulmonic valves, who eventually developed elevated right atrial and systemic venous pressure that led to hepatic cirrhosis and recurrent pleural effusion, is presented. The complex issues involved over a long period in this patient, who ultimately required combined heart and liver transplant, are discussed.

A case of aortic stenosis and hypertrophic cardiomyopathy.

A patient with severe aortic valvular stenosis and coexisting obstructive hypertrophic cardiomyopathy, in whom diagnostic difficulties and management dilemmas arose, is presented. The complex issues involved in such a combination are discussed.