Degenerative Aortic Stenosis, Dyslipidemia and Possibilities of Medical Treatment.

Degenerative aortic stenosis (DAS) is the most frequently diagnosed heart valve disease in Europe and North America. DAS is a chronic progressive disease which resembles development of atherosclerosis. Endothelial dysfunction, lipid infiltration, calcification and ossification are evidenced in both diseases. The same risk factors such as older age, male sex, smoking, and elevated levels of lipids are identified. The effect of smoking, visceral obesity, metabolic syndrome, hypercholesterolemia, low-density lipoprotein, high-density lipoprotein, lipoprotein(a), adiponectin and apolipoprotein(a) on development of DAS are being studied. The search for genetic ties between disorders of lipid metabolism and DAS has been started. DAS is characterized by a long symptom-free period which can last for several decades. Aortic valve replacement surgery is necessary when the symptoms occur. The lipid-lowering therapy effect on stopping or at least slowing down the progression of DAS was studied. However, the results of the conducted clinical trials are controversial. In addition, calcium homeostasis, bone metabolism and calcinosis-reducing medication are being studied. Although prospective randomized clinical trials have not demonstrated any positive effect of statins used for slowing progression of the disease, statins are still recommended for patients with dyslipidemia. Recent study has suggested that a specific modification of treatment, based on severity of disease, may have a beneficial effect in patients with aortic sclerosis and mild DAS. New clinical studies analyzing new treatment possibilities which could correct the natural course of the disease and reduce the need for aortic valve replacement by surgery or transcatheter treatment interventions are needed.

Impact of Left Ventricular Diastolic Dysfunction and Biomarkers on Pulmonary Hypertension in Patients with Severe Aortic Stenosis.

Background: Severe aortic stenosis (AS) complicated by pulmonary hypertension (PH) is associated with poor outcomes after surgical aortic valve replacement (AVR). There is still scarce information about predictors of secondary PH in this group of patients. Objectives: The aim of this study was to investigate the prognostic impact of biomarkers together with conventional Doppler echocardiographic parameters of left ventricular diastolic function on elevated pulmonary systolic pressure (PSP) in severe AS patients before surgical AVR. Methods: Sixty patients with severe isolated AS (aortic valve area <1 cm²) underwent echocardiography, N-terminal pro B-type natriuretic peptide (NT-proBNP) and growth differentiation factor-15 (GDF-15) measurements before AVR. PSP, left ventricular ejection fraction (LV EF), parameters of LV diastolic function (E/E' ratio, mitral valve deceleration time (MV DT) and left atrial (LA) volume) were evaluated. PH was defined as an estimated PSP ≥ 45 mmHg. Results: Of the 60 patients, 21.7% with severe isolated AS had PH with PSP ≥ 45 mmHg (58.5 ± 11.2 mmHg). LV EF did not differ between groups and was not related to an elevated PSP (50 ± 8 vs. 49 ± 8%, p = 0.58). Parameters of LV diastolic dysfunction (E/E' ratio > 14 (OR 6.00; 95% CI, 1.41⁻25.48; p = 0.009), MV DT ≤ 177.5 ms (OR 9.31; 95% CI, 2.06⁻41.14; p = 0.001), LA volume > 100 mL (OR 9.70; 95% CI, 1.92⁻49.03; p = 0.002)) and biomarkers (NT-proBNP > 4060 ng/L (OR 12.54; 95% CI, 2.80⁻55.99; p < 0.001) and GDF-15 > 3393 pg/mL (OR 18.33; 95% CI, 2.39⁻140.39; p = 0.001)) were significantly associated with elevated PSP in severe AS. Conclusions: Left ventricular diastolic dysfunction and elevated biomarkers levels could predict the development of pulmonary hypertension in patients with severe aortic stenosis. Elevation of biomarkers paired with worsening of LV diastolic dysfunction could help to stratify patients for earlier surgical treatment before the development of pulmonary hypertension.

The predictive value of left ventricular myocardium mechanics evaluation in asymptomatic patients with aortic regurgitation and preserved left ventricular ejection fraction. A long-term speckle-tracking echocardiographic study.

BACKGROUND: The management of asymptomatic patients with aortic regurgitation (AR) and preserved left ventricular (LV) ejection fraction (LVEF) remains challenging. The purpose of the study was to assess the early changes of LV mechanics by 2D speckle-tracking echocardiography (2D-STE) in order to predict a decrease in LVEF. METHODS: Sixty-seven patients (age, 47 ± 15 years) with asymptomatic moderate (n = 27) and severe AR (n = 40) with preserved LVEF were prospectively followed for about 5 years. Sixty healthy age-matched controls were included in the study. Standard echocardiography and 2D-STE were performed at the baseline and follow-up. The primary endpoint was a deterioration of the LVEF (≤50%). RESULTS: At baseline, global LV longitudinal peak systolic strain (GLS) and strain rate (GLSRs) were decreased in patients with severe AR compared to controls (-18.9 ± 2.4 vs 20.0 ± 2.1%; -1.05 ± 0.19 vs -1.18 ± 0.15 1/s, P < .05, respectively). In the moderate AR group, GLS was not different from that of the control group, but GLSRs was significantly lower than in controls. The primary endpoint was reached in 12 patients with severe AR, while this was not observed in patients with moderate AR. In multivariate analysis, GLS was an independent predictor of LVEF. According to ROC curve analysis, probability of primary endpoint occurrence was significantly greater in patients with GLS values ≥-18.5% (AUC: 0.89, P < .01). CONCLUSIONS: The reduction of LV longitudinal deformation is a sign of early subclinical LV dysfunction. GLS is a prognostic predictor of LV dysfunction and may be potentially useful for optimal timing of surgery for patients with significant AR.

Risk of Pregnancy in Moderate and Severe Aortic Stenosis: From the Multinational ROPAC Registry.

BACKGROUND: Controversial results on maternal risk and fetal outcome have been reported in women with aortic stenosis (AS). OBJECTIVES: The authors sought to investigate maternal and fetal outcomes in patients with AS in a large cohort. METHODS: The Registry on Pregnancy and Cardiac Disease (ROPAC) is a global, prospective observational registry of women with structural heart disease, providing a uniquely large study population. Data of women with moderate (peak gradient 36 to 63 mm Hg) and severe AS (peak gradient ≥64 mm Hg) were analyzed. RESULTS: Of 2,966 pregnancies in ROPAC, the authors identified 96 women who had at least moderate AS (34 with severe AS). No deaths were observed during pregnancy and in the first week after delivery. However, 20.8% of women were hospitalized for cardiac reasons during pregnancy. This was significantly more common in severe AS compared with moderate AS (35.3% vs. 12.9%; p = 0.02), and reached the highest rate (42.1%) in severe, symptomatic AS. Pregnancy was complicated by heart failure in 6.7% of asymptomatic and 26.3% of symptomatic patients, but could be managed medically, except for 1 patient who was symptomatic before pregnancy and underwent balloon valvotomy. Children of patients with severe AS had a significantly higher percentage of low birth weight (35.0% vs. 6.0%; p = 0.006). CONCLUSIONS: Mortality in pregnant women with AS, including those with severe AS, appears to be close to zero in the current era. Symptomatic and severe AS does, however, carry a substantial risk of heart failure and is associated with high rates of hospitalization for cardiac reasons, although heart failure can nearly always be managed medically. The results highlight the importance of appropriate pre-conceptional patient evaluation and counseling.

Components of left ventricular ejection and filling in patients with aortic regurgitation assessed by speckle-tracking echocardiography.

The aim of our study was to evaluate left ventricular (LV) longitudinal, radial, and rotational function and its relationship with conventional LV parameters of systolic and diastolic function in patients with aortic regurgitation (AR) by speckle-tracking echocardiography. MATERIAL AND METHODS. A total of 26 asymptomatic patients with moderate AR, 34 patients with severe AR, and 28 healthy controls were included into the study. LV rotation and longitudinal and radial strain were measured offline using speckle-tracking imaging. RESULTS. The systolic longitudinal strain (-18.3% [SD, 2.18%] vs. -21.0% [SD, 2.52%], P<0.05) and strain rate (-1.08 s(-1) [SD, 0.13 s(-1)] vs. -1.27 s(-1) [SD, 0.15 s(-1)], P<0.05) were significantly lower and apical rotation (11.3° [SD, 4.99°] vs. 8.30° [SD, 4.34°], P<0.05) as well as rotation rate (82.72°/s [SD, 28.24 °/s] vs. 71.00°/s [SD, 28.04 °/s], P<0.05) were significantly higher in the patients with moderate AR compared with the control patients. The LV systolic basal rotation, systolic radial strain, and diastolic radial strain rate were significantly reduced in the patients with severe AR compared with the control patients. The global longitudinal, radial strain, and LV systolic diameter were the independent predictors of LV ejection fraction in the patients with AR (R(2)=0.77). The LV systolic basal rotation in the control patients, diastolic longitudinal strain rate and systolic longitudinal strain in the patients with moderate and severe AR, respectively, were independent predictors of LV diastolic filling. CONCLUSIONS. LV long-axis dysfunction with an increased apical rotation was present in the patients with moderate AR, while LV radial function and systolic basal rotation were found to be reduced in more advanced disease. LV diastolic filling depended on diastolic and systolic LV strain and rotation components in the patients with AR.

Strain value in the assessment of left ventricular function and prediction of heart failure markers in aortic regurgitation.

BACKGROUND: This study aimed to examine the relationship between biochemical heart failure markers and conventional left ventricular (LV) measurements and strain assessed by speckle-tracking echocardiography in chronic aortic regurgitation (AR) patients. METHODS AND RESULTS: LV strain, rotation assessed by speckle-tracking echocardiography, LV measurements, mitral annular plane excursion measured by M-mode, and systolic annular plane velocity measured by tissue Doppler echocardiography were analyzed in 64 controls and 65 chronic AR patients. Reduced LV longitudinal strain with increased apical rotation was seen in normal plasma NT-proBNP patients. Increased NT-proBNP (>400 pg/mL) was associated with reduced longitudinal and circumferential strain, diminished mitral annular plane excursions and systolic annular plane velocity. Global systolic longitudinal strain was an indepentent predictor of NT-proBNP level. Longitudinal strain less than 16.0% was the cutoff value for NT-proBNP>400 pg/mL (P<0.05). CONCLUSIONS: LV strain analysis in conjunction with NT-proBNP evaluation is a useful tool in assessing LV function in AR patients.

Left ventricular mechanics in asymptomatic normotensive and hypertensive patients with aortic regurgitation.

BACKGROUND: The aims of this study were to detect subclinical left ventricular (LV) dysfunction and to determine the impact of arterial hypertension on LV systolic function using speckle-tracking echocardiography in patients with chronic aortic regurgitation (AR). METHODS: Sixty-eight patients with AR and 47 healthy controls were included in the study. LV rotation and longitudinal, radial, and circumferential strain were measured using speckle-tracking imaging. RESULTS: Longitudinal axis dysfunction was found in patients with moderate AR with hypertension but was not present in patients with moderate AR without hypertension. Radial strain in patients with moderate AR was unchanged, but reduced levels were noted at the apical level in patients with severe AR without hypertension and preserved in those with severe hypertensive AR. LV basal rotation was reduced in patients with severe AR, whereas apical rotation was increased in those with moderate AR. LV torsion was reduced in patients with severe AR. CONCLUSIONS: Patients with asymptomatic AR show subclinical LV longitudinal axis dysfunction, with more attenuation demonstrated in hypertensive than in normotensive patients.

[Clinical forms of infective endocarditis in Kaunas University of Medicine Hospital in 2002-2005]. / Infekcinio endokardito klinikines formos Kauno medicinos universiteto klinikose 2002-2005 m.

OBJECTIVES: To determine the incidence and distribution of clinical forms of infective endocarditis and to compare these data with data of 1983-1993. MATERIAL AND METHODS: A retrospective analysis of clinical data of 116 patients with infective endocarditis treated in Kaunas University of Medicine Hospital in 2002-2005 was performed. The data were compared with analogical data of 1983-1993. RESULTS: During 2002-2005, 55 (47.4%) patients presented with classic symptoms of infective endocarditis. In 61 cases, atypical clinical manifestations were observed: 19 patients presented with heart failure symptoms, 14 patients with embolic symptoms, 9 with pulmonary manifestations, and 5 patients with septic manifestations. There were three cases of nephritic form, three cases of rheumatic form, three cases of meningoencephalitic form, and two cases of ophthalmic form. In three cases, pacemaker endocarditis was seen. During the period of 1983-1993, 15 patients with infective endocarditis were treated annually in Kaunas University of Medicine Hospital; in 2002-2005, this number increased to 29 cases per year. More cases of embolic and pulmonic clinical forms of infective endocarditis were diagnosed as compared to the data of 1983-1993 (P<0.05). There were more cases of primary endocarditis in 2002-2005 than in 1983-1993 (36.2% and 23.8%, respectively, P<0.05). CONCLUSIONS: Typically, infective endocarditis manifests as classical symptoms, but in more than half of cases, atypical forms were observed, the most common of which were heart failure form and embolic form. Primary infective endocarditis was detected more frequently.

[Successful treatment of degenerative critical aortic stenosis at stage of valvular cardiomyopathy]. / Sekmingas kritines degeneracines aortos stenozes gydymas issivyscius voztuvinei kardiomiopatijai.

Degenerative aortic stenosis and mitral annulus calcification are the most common valvular abnormalities in elderly population. The incidence of these abnormalities has increased due to increased life expectancy. In recent years, new diagnostic techniques have improved the accuracy of diagnosis of valvular heart disease, however, cases of advanced critical aortic stenosis with valvular cardiomyopathy and severe heart failure still occur. A clinical case of critical degenerative aortic stenosis and mitral annulus calcinosis, mitral stenosis and regurgitation, subsequently significantly decreased ejection fraction (15%) accompanied by valvular cardiomyopathy and severe congestive heart failure is described. Ischemic heart disease was excluded. Cardiosurgery including implantation of aortic and mitral bioprosthesis and tricuspid annuloplasty was performed after intensive medical treatment and improvement of heart failure symptoms. After follow-up of six months, a 76-year-old female patient has just symptoms of mild left-ventricular dysfunction corresponding to New York Heart Association functional class II.

[Management of patients with prosthetic heart valves]. / Pacientu, kuriems protezuoti voztuvai, ambulatorine prieziura.

The amount of patients with prosthetic valves is increasing and their follow up is an actual problem. The aim of this study was to estimate postoperative complications after valve replacement and to give the follow up schedule for family doctors and cardiologist. The article demonstrates late postoperative results of valve replacements performed in Heart Centre of Kaunas University of Medicine during five years (1999-2003). Hemodynamics, auscultation of patients with prosthetic valves, antithrombotic treatment, specificity of anticoagulants use before noncardiac surgery are described according to the last practical guidelines (1998). The follow up schedule after valve replacement is recommended for practical purposes. A total of 766 valves were replaced in this period: 82, 180, 167, 135 and 202, respectively per year. There were seen these late postoperative complications: thromboembolism (3.8%), valve thrombosis (2%), hypocoagulation (1.1%) and infective endocarditis (3.2%). CONCLUSION. Postoperative complications such as thromboembolism, valve thrombosis, hypocoagulation and infective endocarditis were detected more often than it is described in literature. The follow up schedule will help to identify near and late postoperative complications and to improve patients' life quality.

Mitral valve prolapse: diagnosis, treatment and natural course.

This article analyzes data obtained from the medical records of the patients with primary mitral valve prolapse. The study population was the patients admitted to Kaunas University of Medicine Heart Center (KUMHC) between 1999 and 2003. The objective of our study was to analyze the natural course of mitral valve prolapse, complications and their frequency, treatment strategy in KUMHC, as well as to review the results of surgical treatment. We gathered data from the medical records of 160 patients and analyzed their age, medical history, complications, comorbidities, functional status and echocardiographic parameters. Patients who underwent mitral valve surgery were followed 7.9+/-8.4 months after procedure. On average, 32+/-14 patients with primary mitral valve prolapse were treated at KUMHC annually. Their mean age was 48.4+/-16.5 years, 44.4% of them were male. The most frequent complications of mitral valve prolapse were > or =II degrees mitral regurgitation (78.4%), various cardiac arrhythmias (68.1%) and heart failure of > or =II NYHA class (79%). Surgical treatment was recommended for 64 (40%) KUMHC patients with primary mitral valve prolapse. Surgical treatment was applied in 44 (28.1%) of study patients. The patients, who were recommended surgical treatment, were older (mean age 53.2+/-11.9 years, p<0.05) and predominantly male (62.5%, p<0.05) as compared to medically managed patients. The heart failure (62.5% had NYHA class III or IV), severe mitral regurgitation (95.3% had mitral regurgitation of > or =III degrees ) and worse left ventricle function (15% had ejection fraction of <50%) were more frequent in this group as compared to medically managed patients (all p<0.05). During the last five years the number of hospitalized patients with primary mitral valve prolapse increased 3.2 times, the number of mitral valve surgical procedures among these patients increased 2.8 times, and the number of mitral valve repair increased 15.8 times. 56.8% of patients had uncomplicated postoperative course. The most frequent postoperative complication was new arrhythmias and/or conduction disturbances. 1 patient died in early postoperative period. There was significant decrease in left ventricle and left atrium size and the severity of mitral regurgitation 2 to 6 months after mitral valve surgery. These positive changes remained during all study period. Taking in the consideration the large number of mitral valve repair procedures and good outcomes, the low postoperative mortality of the surgical mitral valve prolapse treatment in KUMHC, we can strongly recommend surgical treatment for the patients with severe mitral regurgitation secondary to mitral valve prolapse.

[Influence of surgery on survival in infective endocarditis]. / Infekcinio endokardito chirurginio gydymo itaka ligoniu isgyvenamumui.

An impact of surgery for infective endocarditis on survival and heart failure has been analyzed. A total of 131 patients with IE have been observed during 1999-2001. Eighty seven of them were male and 44 female, mean age - 50+/-16 years. Sixty three (48.1%) patients underwent surgery, remaining 68 (51.9%) were treated conservatively. The surgical patients had signs of remarkably worse heart failure (p=0.0001), higher grade aortic (p=0.0001) and mitral (p=0.001) valve regurgitation. Surgery resulted in significant improvement of heart failure (p=0.01). Hospital mortality was 25.2% and did not differ between the groups. Elimination of the influence of complications revealed reduced hospital mortality of all patients by 9.9% and mortality of NYHA III-IV patients by 23.9% (p=0.02) as a result of surgery.

[Arrhythmogenic dilated cardiomyopathy]. / Aritmogenine dilatacine kardiomiopatija.

Sustained or chronic tachyarrhythmia can produce reversible changes of atria or/and ventricles that induce systolic or/and diastolic disfunction, dilatation of heart chambers and progressive symptoms of heart failure. The changes regress after restoration of sinus rhythm. This is the clinical case, when at the beginning of the treatment, primary dilated cardiomyopathy is diagnosed to the patient having chronic atrial fibrillation and later after restoration of sinus rhythm and subsequent reduction of heart chambers as well as improvement of systolic function, past changes was assessed as reversible arrhythmogenic cardiomyopathy.

[Timing of surgery in infective endocarditis: impact on the outcome and recurrence]. / Infekcinis endokarditas: operacijos laiko rysys su hospitaline mirtimi ir ligos atkryciu.

Timing of surgery in infective endocarditis remains a challenge in the face of potential drug toxicity on one hand and recurrence of endocarditis on the other. The aim of the study was analysis of risk factors for hospital mortality and recurrent endocarditis. A total of 131 patients with infective endocarditis have been observed during 1999-2001. Eighty seven of them were male and 44 female with mean age of 50+/-16 years. Sixty three (48.1%) patients underwent surgery, remaining 68 (51.9%) were treated conservatively. Hospital mortality was 25.2%. Postoperative perivalvular leak was associated with culture negative endocarditis (p=0.09) as well as with positive valve culture (p=0.04). Recurrence was related to positive valve culture (p=0.08) and embolism (p=0.02). Increased risk of death was associated with neurologic, embolic, renal complications, myocardial abscess, NYHA IV f.cl. and extracardial surgery. According to the data obtained, optimal surgery time in the group appeared to be between 17 and 45 days after the diagnosis of infective endocarditis has been made (p=0.049).

[Effect of blood and valve cultures on complication rate and outcome of infective endocarditis (analysis of data of patients treated at Kaunas district hospitals, 1999-2001)]. / Infekcinio endokardito komplikacijos ir ligos baigtys esant skirtingiems kraujo ir sirdies voztuvu audinio mikrobiologiniu tyrimu duomenims (ligoniu, gydytu Kauno apskrities ligoninese 1999-2001 m., duomenu analize).

The objective of the study was to determine the current epidemiology of infective endocarditis (IE) and to evaluate correlation of blood and valve cultures with complication rates of the disease. During 1999-2001 138 patients, 91 (65.9%) males and 47 (34.1%) females with mean age of 50 +/- 16, were observed. The incidence of IE makes 0.0042% per year in Kaunas district, in-hospital mortality rate was 24.6%. Forty five patients had positive blood culture, 54.8%--negative blood cultures, 16.9% of valve tissue cultures were positive. Patients with positive blood culture had higher incidence of acute IE, vascular phenomena, peripheral abscess and toxic encephalopathy. Culture negative endocarditis presented itself with worse left ventricular function, more frequent immunologic phenomena, myocarditis, glomerulonephritis, cardiac operation and perivalvular leak. Positive valve culture was associated with more frequent perivalvular leak. Mortality rate did not differ in groups.