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31 results

Page 1 of 2

  • Chapter 13 - Diagnosis and Management of Heart Disease

  • from Section III - Care of the Elderly by Organ System
  • Edited by Jan Busby-Whitehead, University of North Carolina, Chapel Hill, Samuel C. Durso, The Johns Hopkins University, Maryland, Christine Arenson, Thomas Jefferson University, Philadelphia, Rebecca Elon, The Johns Hopkins University School of Medicine, Mary H. Palmer, University of North Carolina, Chapel Hill, William Reichel
  • Book:
    Reichel's Care of the Elderly
    Published online:
    30 June 2022
    Print publication:
    21 July 2022, pp 139-172

  • Summary

    This chapter addresses the major cardiovascular conditions faced by clinicians caring for older adults: ischemic heart disease, heart failure, valvular disease, arrhythmias and conduction system disorders, and pericardial diseases. After a brief review of the global burden of heart disease and the effects of aging on the cardiovascular system, each subsequent section of the chapter provides a consistent approach to the description of these disease processes. Beginning with a summary of the epidemiology and clinical presentations relevant to older adults, pharmacologic and procedural recommendations are then presented based on clinical trial data and practice guidelines specific to this patient population. Each section also highlights the importance of individualized care for patients with advanced age or substantial medical comorbidities, including commentary about prognosis and palliative care, when appropriate. With clinically relevant treatment recommendations, comprehensive trial review and data tables, and several illustrative figures, this chapter provides evidence-based guidance to assist with the daily clinical care of our aging population with cardiovascular diseases.

  • Comparison of early-stage stenosis and regurgitation results among patients who underwent aortic valve repair

  • Berra Zumrut Tan-Recep, Ali Can Hatemi, Yasemin Yavuz, Ayse Inci Yildirim, Hakan Ceyran
  • Journal:
    Cardiology in the Young / Volume 33 / Issue 6 / June 2023
    Published online by Cambridge University Press:
    17 June 2022, pp. 904-909
    • Article
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  • Introduction:

    This study aimed to analyse the results of paediatric aortic valve repairs in our institution.

    Method:

    The data of 57 patients under 18 years of age who underwent aortic valve repair between 2014 and 2019 were retrospectively analysed. Early postoperative reoperation and hospital mortality rates were evaluated based on the ages of the patients, their preoperative diagnoses, and the surgical techniques used. Survival curves for groups of patients were calculated by Kaplan–Meier analysis.

    Results:

    The rate of reoperation was 14% (n = 8), and there were no significant differences regarding valve pathologies and preoperative diagnoses (p > 0.05). Among the repair techniques, tricuspidisation was considered to be a risk factor for reoperation (p < 0.05). Augmentation, the material used (0.1 PTFE or pericardium), and the number of cusps were not found to have significant effects on reoperation or mortality. The mean follow-up period was 29.86 ± 21.30 months. The survival rates of the patients were 88%, 100%, and 88.2% for those with aortic stenosis, aortic insufficiency, and mixed disease, respectively, and no significant difference was found when these rates were evaluated with the log-rank test (p > 0.05). The mortality rate was 8.8% (n = 5), and undergoing surgery before the age of 1 year was found to be significant in terms of mortality (p = 0.032, p < 0.05). The bicuspid aortic valve group had the lowest mortality risk, while the Shone complex group had the highest.

    Conclusion:

    With its acceptable reoperation and mortality rates, aortic valve repair should be the first choice of treatment in the paediatric age group. Early results were satisfactory in all groups.

  • 3.1.4 - Valvular Heart Disease

  • from Section 3.1 - Cardiac and Circulatory Failure
  • Edited by Ned Gilbert-Kawai, The Royal Liverpool Hospital, Debashish Dutta, Princess Alexandra Hospital NHS Trust, Harlow, Carl Waldmann, Royal Berkshire Hospital, Reading
  • Book:
    Intensive Care Medicine
    Published online:
    27 July 2023
    Print publication:
    01 December 2021, pp 96-104

  • Summary

    Key Learning Points

    1. 1. The most common cause of aortic stenosis (AS) in patients aged <70 years is bicuspid aortic valve; aortic sclerosis is the most common precursor in the elderly. Surgical valve replacement is the best option for many patients, but transcatheter replacement is now available for patients at high and intermediate surgical risk.

    2. 2. The primary causes of acute aortic regurgitation (AR) are infective endocarditis and dissection of the ascending aorta; chronic AR in adults is most often caused by degeneration of the aortic valve or root. Acute AR requires prompt aortic valve replacement or repair.

    3. 3. Chronic AR requires aortic valve replacement or repair when symptoms or left ventricular (LV) dysfunction develops.

    4. 4. Common causes of mitral regurgitation (MR) include mitral valve prolapse, rheumatic fever and LV dilation or infarction. Valve repair is the preferred treatment to valve replacement in symptomatic patients.

    5. 5. Mitral stenosis is almost always caused by rheumatic fever. Pulmonary hypertension and atrial fibrillation may develop. Severely symptomatic patients and those with evidence of pulmonary hypertension require commissurotomy or valve replacement.

  • Chapter 8 - Fetal Cardiac Intervention

  • from Section 2
  • Edited by Olutoyin A. Olutoye
  • Book:
    Anesthesia for Maternal-Fetal Surgery
    Published online:
    19 November 2021
    Print publication:
    11 November 2021, pp 103-118

  • Summary

    Fetal cardiac intervention provides fetuses with certain cardiac anomalies, a greater likelihood of biventricular circulation and/or treatment options after delivery. Anesthesia care for mothers undergoing fetal cardiac intervention has evolved over the years and more recently involves the use of neuraxial anesthesia with sedation. The maternal fetal anesthesiologist caring for the patient undergoing fetal cardiac intervention should be conversant with the diagnosis, pathophysiology, and planned intervention. This is important for appropriate anticipation and treatment of hemodynamic changes that may occur in the fetus immediately following intervention.

  • Chapter 20 - Shone Complex

  • from Section 3 - Left-Sided Obstructive Lesions
  • Edited by Laura K. Berenstain, James P. Spaeth
  • Book:
    Congenital Cardiac Anesthesia
    Published online:
    09 September 2021
    Print publication:
    16 September 2021, pp 129-136

  • Summary

    Shone’s complex is a group of left-sided, typically obstructive, lesions of the heart, also referred to as Shone’s syndrome, disorder, or anomaly. Shone’s complex was first described in 1963 as four left-sided heart lesions consisting of a supravalvular ring of the left atrium, a “parachute” mitral valve, muscular or membranous subaortic stenosis, and a coarctation of the aorta. These anomalies cause a progressive limitation of inflow into the left ventricle and outflow obstruction from the left ventricle and aorta. There is also an association with a smaller left ventricular size and decreased left ventricular function. Lesions may progressively worsen over time, causing significant heart failure symptoms, pulmonary hypertension, and arrhythmias. Surgical intervention may range from a single intervention such as aortic arch repair to a combination of multiple procedures such as repair of aortic coarctation along with mitral valve repair and aortic valvotomy. This chapter details the perioperative management of a child with multilevel left-sided obstructive lesions presenting for noncardiac surgery.

  • Chapter 15 - Aortic Stenosis

  • from Section 3 - Left-Sided Obstructive Lesions
  • Edited by Laura K. Berenstain, James P. Spaeth
  • Book:
    Congenital Cardiac Anesthesia
    Published online:
    09 September 2021
    Print publication:
    16 September 2021, pp 90-96

  • Summary

    Aortic stenosis occurs in almost 5% of patients with congenital heart disease. Valvular aortic stenosis results from narrowing of the orifice size due to aberrant valve leaflets and is frequently associated with other cardiac lesions. Echocardiography is used to diagnose and quantify the degree of aortic stenosis. Neonates with critical aortic stenosis can present in congestive heart failure requiring urgent intervention, often a percutaneous balloon valvuloplasty. Infants, children, and adults are often asymptomatic, even in the setting of severe aortic stenosis. Surgical interventions for aortic stenosis include aortic valve repair, aortic valve replacement with a pulmonary autograft, or replacement with a mechanical valve. The Ross procedure describes using a pulmonary autograft in the left ventricular outflow tract and pulmonary homograft in the right ventricular outflow tract while the Konno procedure widens a stenotic left ventricular outflow tract. Aortic regurgitation and, less commonly, pulmonary homograft dysfunction can be seen after the Ross procedure.

  • Chapter 16 - Subvalvular Aortic Stenosis

  • from Section 3 - Left-Sided Obstructive Lesions
  • Edited by Laura K. Berenstain, James P. Spaeth
  • Book:
    Congenital Cardiac Anesthesia
    Published online:
    09 September 2021
    Print publication:
    16 September 2021, pp 97-104

  • Summary

    Subvalvular aortic stenosis is a progressive left-sided obstructive lesion, usually consisting of a discrete membrane, fibromuscular ridge, or tunnel. Surgical intervention is preferred over catheter intervention when the gradient across the lesion is greater than 40 mm Hg or aortic insufficiency has developed across the aortic valve. Perioperative anesthetic goals include maintaining adequate preload, afterload, and a low to normal heart rate.

  • Variation in management of paediatric isolated bicuspid aortic valve: current practice survey

  • Part of
  • Jesse M. Boyett Anderson, John S Hokanson
  • Journal:
    Cardiology in the Young / Volume 32 / Issue 1 / January 2022
    Published online by Cambridge University Press:
    04 May 2021, pp. 24-30
    • Article
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  • Background:

    Prior to the recent release of appropriate use criteria for imaging valvulopathies in children, follow-up of valvular lesions, including isolated bicuspid aortic valve, was not standardised. We describe current follow up, treatment, and intervention strategies for isolated bicuspid aortic valve with varying degrees of stenosis, regurgitation, and dilation in children up to 18 years old and compare them with newly released appropriate use criteria.

    Methods:

    Online survey was sent to members of the American Academy of Pediatrics Section on Cardiology and Cardiac Surgery and PediHeartNet.

    Results:

    Totally, 106 responses with interpretable data were received. For asymptomatic patients with isolated BAV without stenosis, regurgitation, or dilation follow-up-intervals increased from 7+/−4 months in the newborn period to 28 +/− 14 months at 18 years of age. Respondents recommended more frequent follow-up for younger patients and those with greater disease severity. More than 80% of respondents treat aortic regurgitation or aortic dilation in the setting of bicuspid aortic valve medically. In general, intervention was recommended once stenosis or regurgitation became severe (stenosis of >4 m/s; regurgitation with LV Z score 4) regardless of age, but was not routinely recommended for younger children (newborn – age 6 years) with severe dilation. Exercise was restricted at 38+/−11 mmHg echocardiographic mean gradient.

    Conclusions:

    Current follow-up, treatment, and intervention strategies for isolated bicuspid aortic valve deviate from appropriate use criteria. Differences between the two highlight the need to better delineate the disease course, clarify recommendations for care, and encourage wider adoption of guidelines.

  • The association between pro-arrhythmic agents and aortic stenosis in young adults: is it sufficient to clarify the sudden unexpected deaths?

  • Bojana Radnic, Nemanja Radojevic, Jelena Vucinic, Natasa Duborija-Kovacevic
  • Journal:
    Cardiology in the Young / Volume 27 / Issue 5 / July 2017
    Published online by Cambridge University Press:
    08 November 2016, pp. 929-935

  • Most young patients with mild-to-moderate aortic stenosis show no symptoms, and sudden death appears only occasionally. We hypothesised that malignant ventricular arrhythmias could be responsible for the high incidence of sudden death in such patients. If multiple factors such as asymptomatic aortic stenosis in association with arrhythmia-provoking agents are involved, could it be sufficient to account for sudden unexpected death? In this study, eight cases of sudden death in young adults, with ages ranging from 22 to 36 years, who had never reported any symptoms that could be related to aortic stenosis, were investigated. Full autopsies were performed, and congenital aortic stenosis in all eight cases was confirmed. DNA testing for channelopathies was negative. Comprehensive toxicological analyses found an electrolyte imbalance, or non-toxic concentrations of amitriptyline, terfenadine, caffeine, and ethanol. Collectively, these results suggest that congenital asymptomatic aortic stenosis without cardiac hypertrophy in young adults is not sufficient to cause sudden death merely on its own; rather, an additional provoking factor is necessary. According to our findings, the provoking factor may be a state of physical or emotional stress, a state of electrolyte imbalance, or even taking a therapeutic dose of a particular drug.

  • Exercise-induced ventricular re-polarisation changes in moderate congenital aortic valve stenosis

  • Louis-Simon Beauséjour, Hugo Gravel, Wadi Mawad, Nagib Dahdah, Daniel Curnier
  • Journal:
    Cardiology in the Young / Volume 26 / Issue 2 / February 2016
    Published online by Cambridge University Press:
    23 February 2015, pp. 298-305
  • Introduction

    Pressure overload increases in patients with moderate aortic valvular stenosis during exercise. In the absence of symptoms, it remains difficult, however, to discriminate patients for surgery based only on pressure overload. Other parameters, such as the dispersion of ventricular re-polarisation (d-QT), which reportedly increases with the transvalvular pressure gradient, have not been fully studied in this condition.

    Objective

    To determine the pattern of QT and d-QT response to exercise testing in children with moderate aortic valve stenosis in order to evaluate the impact of pressure overload from an electrophysiological perspective.

    Materials and methods

    In all, 15 patients were compared with 15 controls paired for age (14.8±2.5 versus 14.2±1.5 years old) and gender (66.7% male). All the patients underwent exercise stress testing with 12-lead electrocardiograph recording. QT was measured from the onset of QRS to the apex (QTa) at rest, at peak exercise, and at 1 and 3 minutes upon recovery. QT was corrected using the Fridericia equation, and d-QT was calculated.

    Results

    Resting QTc was similar among the study groups, but increased significantly in study patients compared with the control group at maximal effort (p=0.004) and after 1 (p<0.001) and 3 (p<0.001) minutes of recovery. A significant association was identified between groups for d-QT (p=0.034), and post-hoc tests revealed a significant difference only at rest (p=0.001).

    Conclusions

    Ventricular re-polarisation abnormalities can be unmasked and highlighted by the assessment of electrical re-polarisation during exercise challenge in patients with asymptomatic moderate aortic valve stenosis. Using QT response to exercise could be beneficial for better optimisation of risk stratification in these patients.

  • Abnormal myocardial blood flow in children with mild/moderate aortic stenosis

  • Erin Madriago, Ronald Wells, David J. Sahn, Brian S. Diggs, Stephen M. Langley, Daniel J. Woodward, Michael Jerosch-Herold, Michael Silberbach
  • Journal:
    Cardiology in the Young / Volume 25 / Issue 7 / October 2015
    Published online by Cambridge University Press:
    10 February 2015, pp. 1358-1366
  • Objective

    To quantify myocardial blood flow in infants and children with mild or moderate aortic stenosis using adenosine-infusion cardiac magnetic resonance.

    Background

    It is unclear whether asymptomatic children with mild/moderate aortic stenosis have myocardial abnormalities. In addition, cardiac magnetic resonance-determined normative myocardial blood flow data in children have not been reported.

    Methods

    We studied 31 infants and children with either haemodynamically normal hearts (n=20, controls) or mild/moderate aortic stenosis (n=11). The left ventricular myocardium was divided into six segments, and the change in average segmental signal intensity during contrast transit was used to quantify absolute flow (ml/g/minute) at rest and during adenosine infusion by deconvolution of the tissue curves with the arterial input of contrast.

    Results

    In all the cases, adenosine was well tolerated without complications. The mean pressure gradient between the left ventricle and the ascending aorta was higher in the aortic stenosis group compared with controls (24 versus 3 mmHg, p<0.001). Left ventricular wall mass was slightly higher in the aortic stenosis group compared with controls (65 versus 50 g/m2, p<0.05). After adenosine treatment, both the absolute increase in myocardial blood flow (p<0.0001) and the hyperaemic flow significantly decreased (p<0.001) in children with mild/moderate aortic stenosis compared with controls.

    Conclusion

    Abnormal myocardial blood flow in children with mild/moderate aortic stenosis may be an important therapeutic target.

  • Transcatheter management of neonatal aortic stenosis*

  • Gary E. Stapleton
  • Journal:
    Cardiology in the Young / Volume 24 / Issue 6 / December 2014
    Published online by Cambridge University Press:
    29 December 2014, pp. 1117-1120

  • Neonatal aortic valvar stenosis can be challenging to treat because of the varied morphology of the valve, the association with hypoplasia of other left heart structures, and the presence of left ventricular systolic dysfunction or endomyocardial fibroelastosis. Balloon valvuloplasty and surgical valvotomy have been well described in the literature for the treatment of neonatal aortic stenosis. Transcatheter therapy for neonatal aortic stenosis is the preferred method at many centres; however, some centres prefer a surgical approach. Balloon valvuloplasty for neonatal aortic stenosis is reviewed in this manuscript, including the history of the procedure, technical aspects, and acute and long-term outcomes.

  • 41 - Abdominal compartment syndrome

  • from Section 6 - Gastrointestinal emergencies
  • Edited by Kaushal Shah, Jarone Lee, Kamal Medlej, American University of Beirut, Scott D. Weingart
  • Book:
    Practical Emergency Resuscitation and Critical Care
    Published online:
    05 November 2013
    Print publication:
    24 October 2013, pp 274-277

  • Summary

    This chapter discusses the diagnosis, evaluation and management of valvular diseases including aortic stenosis (AS), aortic regurgitation (AR), mitral stenosis (MS) and mitral regurgitation (MR). Patients with AS are particularly sensitive to changes in cardiac output due to the pressure gradient across the aortic valve. Evaluation of any valvular pathology begins with the history and physical examination, and paying attention to whether valvular defect has been previously noted. If a new acute AR is discovered, the diagnosis of aortic dissection should be ruled out with a CTA or a transthoracic or transesophageal echocardiogram. Blood culture and antibiotics may be indicated if endocarditis or a perivalvular abscess is suspected. Characterization of valve dysfunction in the emergency department is not imperative if patients are hemodynamically stable. Echocardiography should be considered in patients who are hemodynamically unstable. Acute valvular dysfunction is usually secondary to a precipitating critical problem.

  • Chapter 9.3 - Structural heart disease

  • from Section 2 - Fetal disease
  • Edited by Mark D. Kilby, Anthony Johnson, Baylor College of Medicine, Texas, Dick Oepkes
  • Book:
    Fetal Therapy
    Published online:
    05 February 2013
    Print publication:
    13 December 2012, pp 123-127

  • Summary

    This chapter summarizes the current state of trans-catheter fetal cardiac interventions (FCI) for a select group of congenital heart defects (CHDs). The ethical issues and risks that pertain to the mother, as the healthy patient and innocent bystander are non-trivial. However, there are other situations in medical therapy that involve procedures to a healthy patient for the sake of another. Therapy for FCI involves ultrasound-guided uterine and fetal cardiac puncture with an 18- or 19-gauge cannula, predominantly percutaneous, and can be performed with the mother awake. The fetal cardiac lesion that has been the main focus of FCI over the past two decades is severe aortic stenosis (AS) in early and mid-gestation that has been shown in several publications to evolve into HLHS at birth. Hypoplastic left heart syndrome (HLHS) with highly restrictive or intact atrial septum (IAS) is one of the most challenging lesions in managing patients with CHD.

  • Aortic stenosis: current treatment options for a common condition in old age

  • D Tiwari, J Radvan, SC Allen
  • Journal:
    Reviews in Clinical Gerontology / Volume 22 / Issue 3 / August 2012
    Published online by Cambridge University Press:
    27 March 2012, pp. 195-203
    Print publication:
    August 2012

  • Degenerative-calcific aortic stenosis is mainly a disease of old age. Patients with mild to moderate stenosis without symptoms and those with aortic valve sclerosis do not require mechanical intervention. There is no firm evidence that the rate of progression can be modified by medical therapies, though statins might have some effect. Patients who develop severe stenosis with symptoms have a very poor prognosis if managed medically. Surgical aortic valve replacement greatly improves symptoms and mortality rates and remains the treatment of choice for those fit for major surgery, even above the age of 80 years. For those not suitable for surgery, or who are unwilling to have an operation, outcomes can be significantly improved by trans-catheter aortic valve replacement, which has become an important option for frail elderly patients. Balloon aortic valvuloplasty improves symptoms and short-term survival, but has a less clear impact on mortality beyond 1 year. It is useful as a palliative treatment and as a bridging procedure for patients who are not ready for valve replacement. There is less agreement on the best approach to patients with asymptomatic severe aortic stenosis. Trials indicate that early valve replacement results in outcomes that are comparable to those seen in symptomatic patients, though guidelines advocate delaying surgery until symptoms occur or left ventricular function begins to decline rapidly. All elderly patients with severe aortic stenosis should be considered for a mechanical intervention unless there is a properly considered reason for not doing so, or they are not willing to receive such treatment.

  • 14 - Ischemic heart disease

  • from Section 2 - Practical issues in transesophageal echocardiography
  • Edited by Robert Feneck, John Kneeshaw, Marco Ranucci
  • Book:
    Core Topics in Transesophageal Echocardiography
    Published online:
    10 May 2010
    Print publication:
    15 April 2010, pp 225-246

  • Summary

    Aortic valve (AV) disease is very common in Western populations. Aortic sclerosis is diagnosed when there is an ejection systolic murmur present in the AV region due to calcification in the ascending aorta, with associated turbulent flow. Aortic stenosis (AS) is differentiated from sclerosis when significant restriction of cusp movement and a raised transaortic peak velocity is seen on echocardiography. Transesophageal echocardiography (TEE) evaluation of AS starts with a 2D examination of the mid-esophageal short-axis (ME SAX) and long-axis (LAX) views of the valve. Continuous-wave Doppler (CWD) is applied to measure flow velocity across the valve and then calculate a pressure gradient using the Bernoulli equation. Aortic regurgitation (AR) results from a primary valve lesion, an abnormal aortic root and/or ascending aorta, or a combination of both. TEE is valuable in revealing important aspects of AV disease.

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