The patient with a systolic murmur: severe aortic stenosis may be missed during cardiovascular examination.
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Significant aortic stenosis is prevalent amongst elderly people. It may be subclinical, manifesting only as a murmur, but can still cause unexpected death with little warning after symptoms develop. Recent studies have highlighted the unreliability of the classical clinical signs of severe aortic stenosis, leading to concern that some patients may not be referred appropriately for echocardiography. Here, we review the evidence for the accuracy of each sign. We suggest that the assessment of the patient with a systolic murmur should be reappraised, and offer guidelines toward improving the recognition of aortic stenosis in the community. (+info)
Intravascular adenovirus-mediated VEGF-C gene transfer reduces neointima formation in balloon-denuded rabbit aorta.
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BACKGROUND: Gene transfer to the vessel wall may provide new possibilities for the treatment of vascular disorders, such as postangioplasty restenosis. In this study, we analyzed the effects of adenovirus-mediated vascular endothelial growth factor (VEGF)-C gene transfer on neointima formation after endothelial denudation in rabbits. For comparison, a second group was treated with VEGF-A adenovirus and a third group with lacZ adenovirus. Clinical-grade adenoviruses were used for the study. METHODS AND RESULTS: Aortas of cholesterol-fed New Zealand White rabbits were balloon-denuded, and gene transfer was performed 3 days later. Animals were euthanized 2 and 4 weeks after the gene transfer, and intima/media ratio (I/M), histology, and cell proliferation were analyzed. Two weeks after the gene transfer, I/M in the lacZ-transfected control group was 0. 57+/-0.04. VEGF-C gene transfer reduced I/M to 0.38+/-0.02 (P:<0.05 versus lacZ group). I/M in VEGF-A-treated animals was 0.49+/-0.17 (P:=NS). The tendency that both VEGF groups had smaller I/M persisted at the 4-week time point, when the lacZ group had an I/M of 0.73+/-0.16, the VEGF-C group 0.44+/-0.14, and the VEGF-A group 0. 63+/-0.21 (P:=NS). Expression of VEGF receptors 1, 2, and 3 was detected in the vessel wall by immunocytochemistry and in situ hybridization. As an additional control, the effect of adenovirus on cell proliferation was analyzed by performing gene transfer to intact aorta without endothelial denudation. No differences were seen in smooth muscle cell proliferation or I/M between lacZ adenovirus and 0.9% saline-treated animals. CONCLUSIONS: Adenovirus-mediated VEGF-C gene transfer may be useful for the treatment of postangioplasty restenosis and vessel wall thickening after vascular manipulations. (+info)
Aortic valve replacement with and without concomitant coronary artery bypass surgery in the elderly: risk factors related to long-term survival.
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AIM: Preoperative coronary angiography often reveals significant coronary artery lesions in elderly people (>75 years of age) referred to hospital for aortic valve replacement (AVR). However, the possible benefit of concomitant coronary artery bypass grafting (CABG) in elderly is still under debate. In an effort to contribute to this discussion, we evaluated our data on elderly patients after aortic valve replacement. METHODS: Between January 1990 and December 1993, 219 patients, aged 75 years and older, underwent AVR with or without concomitant CABG at our Department. There were 121 patients in the AVR group and 98 patients in the AVR+CABG group. There was no significant difference between the two groups in their age, sex valve type, valve size, and presence of diabetes. Five variables (concomitant CABG, age, sex, and type and size of prosthesis) were investigated with regard to long-term survival assessed by the Kaplan-Meier analysis. Group comparisons of survival were made with the Cox-Mantel log-rank test. RESULTS: Early mortality (<30 days) was 0.8% in the AVR group and 4.1% in the AVR+CABG group. Overall actuarial survival was 77.7+/-4.4% at 52 months. There was significantly longer survival in patients with mechanical valve implant in the AVR group. None of the other 5 investigated variables had a significant influence on the long-term survival. CONCLUSION: Our results suggest that AVR done in elderly is a treatment with excellent surgical results. We could not identify concomitant CABG as a predictor of poor long-term surgical outcome. (+info)
Bicuspid aortic valves are associated with aortic dilatation out of proportion to coexistent valvular lesions.
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BACKGROUND: Bicuspid aortic valves (BAVs) are associated with premature valve stenosis, regurgitation, and ascending aortic aneurysms. We compared aortic size in BAV patients with aortic size in control patients with matched valvular lesions (aortic regurgitation, aortic stenosis, or mixed lesions) to determine whether intrinsic aortic abnormalities in BAVs account for aortic dilatation beyond that caused by valvular hemodynamic derangement alone. METHODS AND RESULTS: Diameters of the left ventricular outflow tract, sinus of Valsalva, sinotubular junction, and proximal aorta were measured from transthoracic echocardiograms in 118 consecutive BAV patients. Annular area was measured by planimetry, and BAV eccentricity was expressed as the ratio of the right leaflet area to the total annular area. Seventy-seven control patients with tricuspid aortic valves were matched for sex and for combined severity of regurgitation and stenosis. BAV patients (79 men and 39 women, aged 44.1+/-15.5 years) had varying degrees of regurgitation (84 patients [71%]) and stenosis (48 patients [41%]). Within the bicuspid group, multivariate analysis demonstrated that aortic diameters increased with worsening aortic regurgitation (P:<0.001) and advancing age (P:<0.05) but not with the severity of aortic stenosis. BAV patients had larger aortic diameters than did control patients at all ascending aortic levels measured (P:<0.01), despite advanced age in the control patients. CONCLUSIONS: Aortic dimensions are larger in BAV patients than in control patients with comparable degrees of tricuspid aortic valve disease. Although more severe degrees of aortic regurgitation are associated with aortic dilatation in BAV patients, intrinsic pathology appears to be responsible for aortic enlargement beyond that predicted by hemodynamic factors. (+info)
Coronary flow reserve improves after aortic valve replacement for aortic stenosis: an adenosine transthoracic echocardiography study.
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OBJECTIVES: The goal of this study was to assess coronary flow reserve (CFR) before and after aortic valve replacement (AVR). BACKGROUND: Coronary flow reserve is impaired under conditions of left ventricular (LV) hypertrophy. It is not known whether CFR improves with regression of LV hypertrophy in humans. METHODS: We investigated 35 patients with pure aortic stenosis, LV hypertrophy and normal coronary arteriograms. Patients underwent adenosine transthoracic echocardiography on two occasions--immediately before AVR and six months postoperatively. Left ventricular mass, distal left anterior descending coronary artery (LAD) diameter, flow and CFR were assessed on each occasion. RESULTS: Distal LAD diameter was successfully imaged in 30 patients (86%), and blood flow was successfully imaged in 27 (77%). Paired data were subsequently available in 24 patients, of whom 14 were men, mean age 68.1+/-12.5 years, body mass index 24.5+/-2.0 kg/m2, aortic valve gradient 93+/-32 mm Hg. Pre- to post-AVR a significant decrease was seen in LV mass (271+/-38 vs. 236+/-32g, p<0.01) and LV mass index (154+/-21 vs. 134+/-21 g/m2, p< 0.01). Distal LAD diameter fell from 2.27+/-0.37 to 2.23+/-0.35 mm, p = 0.08). Pre- to post-AVR there was no significant change in resting parameters of peak diastolic velocity (0.43+/-0.16 vs. 0.41+/-0.11 m/s), distal LAD flow 23.3+/-10.1 vs. 20.9+/-5.2 ml/min or distal LAD flow scaled for LV mass (8.7+/-3.8 vs. 9.0+/-2.5 ml/min/100 g LV mass), but there was significant increase in hyperemic peak diastolic velocity (0.71+/-0.26 vs. 1.08+/-0.24 m/s; p<0.01), distal LAD flow (37.8+/-11.3 vs. 53.5+/-16.1 ml/min; p<0.01) and distal LAD flow scaled for LV mass (14.3+/-5.0 vs. 23.3+/-8.5 ml/min/100 g LV mass; p<0.01). Coronary flow reserve, therefore, increased from 1.76+/-0.5 to 2.61+/-0.7. CONCLUSIONS: Coronary flow reserve increases after AVR for aortic stenosis. This increase occurs in tandem with regression of LV hypertrophy. (+info)
Pathophysiology of subendocardial ischaemia.
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Most forms of heart disease cause myocardial damage which often is confined to the deep (subendocardial) layer of left ventricular muscle. Much clinical and experimental evidence suggests that subendocardial muscle is prone to ischaemic damage, and a physiological mechanism for this vulnerability is described. Furthermore, experiments suggest that pressures recorded at cardiac catheterization can help to assess if there is subendocardial ischaemia in a variety of lesions in man. (+info)
Effect of left renal vein division during aortic surgery on renal function.
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A total of 398 consecutive patients underwent surgery for an aneurysm or occlusive disease of the aorta at Norfolk and Norwich Hospital between December 1994 and October 1998. It was necessary to divide the left renal vein in 58 (14.6%) cases. We examined the effect of this division on the mortality rate and renal function. Renal function was assessed by measuring serum creatinine pre-operatively, peri-operatively and long-term postoperatively. There was no significant difference in the mortality rate between patients who had the left renal vein divided (LRVD) and in whom the left renal vein remained intact (LRVI)--31% versus 32%, P = 0.83. There was no significant difference in the pre-operative serum creatinine level between both groups (107 +/- 21 mumol/l in LRVD versus 103 +/- 29 mumol/l in LRVI, P = 0.14). There was an insignificant rise in the mean serum creatinine 7 days postoperatively (111 +/- 21 mumol/l in LRVD versus 107 +/- 31 mumol/l in LRVI, P = 0.05). The mean serum creatinine returned back to the pre-operative level at 30 days postoperatively (106 +/- 16 mumol/l in LRVD and 105 +/- 29 mumol/l, P = 0.20). After 1 month, there was no significant difference in the number of patients who had a sustained elevation of serum creatinine level (7.5% in LRVD versus 2.7% in LRVI, P = 0.11). We feel that division of the left renal vein is a safe and helpful procedure during juxtarenal aortic surgery. (+info)
Extreme pulmonary hypertension caused by mitral valve disease. Natural history and results of surgery.
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Five hundred and eighty six patients with mitral valve disease were studied with cardiac catheterization between 1961 and 1972; 48 (8.2%) had extreme pulmonary hypertension (resting systolic pulmonary artery pressure of 80 mmHg or above and pulmonary vascular resistance of 10 units or greater) and of these patients, 27 underwent cardiac surgery. The operative mortality for mitral valvotomy was 11 per cent and for mitral valve replacement 56 per cent. The overall mortality was 31 per cent. The risks of operation were increased in those with a long history of cardiac symptoms, those over 50 years of age, and in the presence of associated aortic valve disease. The mean survival for those patients not having operation was only 2.4 plus or minus 0.5 years. The mean follow-up period for those surviving operation has been 5.8 plus or minus 0.6 years, and symptomatic improvement has been good. (+info)