ABSTRACT
Granulomatosis with polyangiitis is a rare systemic inflammatory disorder mainly affecting the small vessels. Cardiac involvement is rare, conduction delay being the most rare one. This case reports on a middle-aged male patient with heart failure symptoms due to a 1st degree atrioventricular block with a marked PR prolongation of 480 ms on electrocardiography (ECG). Because of heart failure symptoms as well as elevated N-terminal pro-B-type natriuretic peptide and no other relevant findings in the blood test it was initially planned to treat the conduction disorder with a pacemaker. During further investigations a certain diagnosis of granulomatosis with polyangiitis was determined. After administration of high-dose steroids a complete clinical remission of heart failure symptoms and normal conduction on ECG were demonstrated, so that no pacemaker therapy was needed.
ABSTRACT
BACKGROUND: Transcatheter aortic valve implantation (TAVI) has been shown to improve prognosis of high-risk patients. Data, however, concerning the impact of TAVI on regional and global left atrial (LA) and left ventricular (LV) mechanics in varying entities of severe aortic stenosis (AS) are sparse, particularly in patients with paradoxical low-flow (PLF) AS or with reduced LV ejection fraction (LVEF). This study evaluated the effects of TAVI on LA and LV mechanics in varying entities of AS 12 months after implantation. METHODS AND RESULTS: A total of 54 consecutive patients with severe AS (24 with a normal LVEF and normal flow, 16 with PLF, and 14 with a reduced LVEF) were included. Speckle tracking echocardiography was performed before and 12 months after TAVI to determine LV global and regional longitudinal deformation as well as LA function (reservoir function, conduit phase, and active contraction). In all the three entities of AS, there was a significant improvement in global and regional LV longitudinal function (average global longitudinal strain: -14.1 ± 3.9% at baseline vs. -16.5 ± 4.0% after TAVI, P < 0.001). Interestingly, the beneficial effects were most pronounced in patients with PLF (-14.0 ± 2.9 vs. -17.0 ± 4.4%, P < 0.031). Moreover, the atrial reservoir and conduit function recovered significantly after TAVI in all patients. CONCLUSION: In conclusion, regardless of the underlying AS entity, TAVI improves global and regional LV and LA mechanics within 12 months.
Subject(s)
Aortic Valve Stenosis/diagnostic imaging , Atrial Function, Left , Echocardiography, Three-Dimensional , Transcatheter Aortic Valve Replacement , Ventricular Function, Left , Aged , Aged, 80 and over , Aortic Valve Stenosis/mortality , Aortic Valve Stenosis/surgery , Echocardiography, Three-Dimensional/methods , Female , Follow-Up Studies , Humans , Male , Observer Variation , Predictive Value of Tests , Prospective Studies , Risk Assessment , Risk Factors , Sensitivity and Specificity , Severity of Illness Index , Transcatheter Aortic Valve Replacement/adverse effectsABSTRACT
BACKGROUND: Aortic stenosis (AS) leads to remodeling of the left heart. Strain measurements enable the assessment of left atrial (LA) mechanics. The goal of this study was to evaluate the short-term effects of transcatheter aortic valve implantation (TAVI) on LA myocardial deformation as well as left ventricular (LV) diastolic function. METHODS: Thirty-two patients with severe AS were prospectively enrolled and examined before and 8.2 ± 3.3 days after TAVI. Speckle-tracking echocardiography of the basal septal and lateral segments of the left atrium was performed to determine peak positive strain (R(LA)), strain during early diastole (E(LA)), and, if feasible, strain during atrial contraction (A(LA)). Assessment of LV diastolic function included standard indices, the atrial fraction, and LA volumes. RESULTS: Compared with baseline, the mean atrial reservoir (R(LA)) (24.0 ± 11.2% vs 32.2 ± 14.0%, P < .001) and conduit function (R(LA) - E(LA)) (13.9 ± 5.5% vs 20.8 ± 8.1%, P < .001) improved significantly after TAVI. There was a significant reduction in deceleration time (242 ± 56 vs 195 ± 65 msec, P < .001) and an improvement of pulsed-wave tissue Doppler-derived E' (5.5 ± 1.8 vs 7.3 ± 2.3 cm/sec, P = .01). Regarding LA volumes, only the minimal LA volume index changed significantly. In contrast, there was no improvement in atrial contraction, that is, contractile function (E(LA) - A(LA)) and atrial fraction. Moreover, the E/E' ratio remained unchanged. CONCLUSIONS: 8.2 ± 3.3 days after TAVI, only the reservoir and conduit function of the left atrium improved, whereas LA contraction and LA volumes, except for the systolic volume index, remained unchanged. This was accompanied by improvement of early LV diastolic function, indicating acute recovery of LV relaxation and LA function.
Subject(s)
Aortic Valve Stenosis/surgery , Atrial Function, Left/physiology , Cardiac Catheterization , Heart Atria/physiopathology , Heart Valve Prosthesis Implantation/methods , Myocardial Contraction , Ventricular Function, Left/physiology , Aged , Aortic Valve Stenosis/diagnostic imaging , Aortic Valve Stenosis/physiopathology , Diastole , Echocardiography, Doppler, Color , Female , Follow-Up Studies , Heart Atria/diagnostic imaging , Heart Atria/surgery , Humans , Male , Prospective Studies , Time FactorsABSTRACT
AIMS: Transcatheter aortic valve implantation (TAVI) is a new therapy for severe aortic stenosis in high-risk patients. So far, no reference values for the echocardiographic assessment of this new class of heart valves have been established. The aim of our study was to determine Doppler haemodynamics and the effective orifice area (EOA). METHODS AND RESULTS: We retrospectively analysed the earliest transthoracic echocardiographic examinations of 146 stable patients after successful TAVI (median 8±20 days). Doppler examinations were analysed for peak instantaneous velocity, peak, and the mean systolic gradient. EOA was determined using the continuity equation. Patients with severe paravalvular aortic or mitral valve regurgitation were excluded. The overall peak instantaneous velocity (n=146) was 2.0±0.4 m/s with a peak systolic gradient of 17.1±7.4 mmHg and a mean gradient of 9.3±4.5 mmHg. The mean EOA was 1.82±0.43 cm2 with an indexed EOA of 1.0±0.27 cm2/m2. In general, all prostheses showed similar values-with the exception of the Edwards Sapien 23 mm which was associated with higher velocities and peak pressure gradients. CONCLUSION: Our study establishes the normal range for Doppler haemodynamics of four transcatheter aortic valve prostheses. Compared with previously published data of surgically implanted bioprostheses percutaneous valves tend to have similar EOA values but lower mean peak velocities and pressure gradients. In comparison with physiological haemodynamics; however, this new class of heart valves is still associated with a mild obstruction.
