A NOVEL MOBILE SCREENING PROGRAM FOR VALVULAR HEART DISEASE

2019 AATS/ACC/ASE/SCAI/STS expert consensus systems of care document: A proposal to optimize care for patients with valvular heart disease: A joint report of the American Association for Thoracic Surgery, American College of Cardiology, American Society of Echocardiography, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons

Multisociety (AATS, ACCF, SCAI, and STS) Expert Consensus Statement: Operator and Institutional Requirements for Transcatheter Valve Repair and Replacement, Part 1: Transcatheter Aortic Valve Replacement

ACC/AATS/AHA/ASE/ASNC/HRS/SCAI/SCCT/SCMR/STS 2017 Appropriate Use Criteria for Multimodality Imaging in Valvular Heart Disease: A Report of the American College of Cardiology Appropriate Use Criteria Task Force, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic

ACC/AATS/AHA/ASE/ASNC/HRS/SCAI/SCCT/SCMR/STS 2017 Appropriate Use Criteria for Multimodality Imaging in Valvular Heart Disease: A Report of the American College of Cardiology Appropriate Use Criteria Task Force, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic

Background There is ongoing discussion regarding the terminology used when atrial fibrillation (AF) is present alongside either valvular heart disease (VHD) or non-valvular heart disease (NVHD). Warfarin has been used for decades for stroke (S) and systemic embolism (SE) prophylaxis in atrial fibrillation (AF) patients. However, due to its drug and food interactions, pharmacogenetic approach via VKORC1, narrow therapeutic window, frequent monitoring, and high risk of intracranial hemorrhage (ICH), it is not preferred as a first-line anticoagulant for AF patients. Is it time to retire warfarin and replace it with dabigatran? Aim and objectives We conducted this meta-analysis to assess the effectiveness and safety of dabigatran compared to warfarin and find out how likely it could be used instead of warfarin in AF patients with VHD and NVHD. Methods PubMed, SCOPUS, Web of Science, and Cochrane CENTRAL were searched online from inception till June 2023, and eligible randomized controlled trials (RCTs) were selected. The outcomes were analyzed and calculated using the risk ratio (RR), and its confidence interval (CI) using STATA software. The Cochrane Risk of Bias 2.0 tool (ROB2) was used to assess the included studies. Results In the NVHD subgroup, dabigatran 150 mg showed a significantly low risk of S and SE (RR 0.74, 95% CI: [0.62,0.88]), ICH (RR 0.38, 95% CI: [0.26,0.56]), death (RR 0.85, 95% CI: [0.74,0.99]), and high risk of gastrointestinal bleeding (GIB) (RR 1.47, 95% CI: [1.17,1.85]) compared to Warfarin. Dabigatran 110 mg showed a low risk of ICH (RR 0.31, 95% CI: [0.21,0.47]), and no significant differences in S/SE (RR 1.02, 95% CI: [0.87,1.19]) and death (RR 0.94, 95% CI: [0.82,1.09]) compared to warfarin. In the VHD subgroup, dabigatran showed no significant differences in S/SE (RR 2.57, 95% CI: [0.57,11.56]), major bleeding (RR 1.14, 95% CI: [0.35,3.68]), and death (RR 0.35, 95% CI: [0.07,1.81]) compared to warfarin. In the catheter ablation subgroup, dabigatran showed a significant reduction only in groin hematoma (RR 0.19, 95% CI: [0.05,0.73]), compared to warfarin. Conclusion Dabigatran 150 mg was superior to warfarin in AF patients with NVHD; except with GIB; otherwise, Dabigatran 110 mg was superior only to warfarin in reducing ICH. In catheter ablation, dabigatran only reduced the groin hematoma. In AF patients with VHD, dabigatran did not show either superiority or inferiority to warfarin, further studies are needed. “Non-valvular AF” term is outdated and should be replaced with “type II VHD” to differentiate it from other valvular heart diseases that are accompanied by AF.

Differences in Clinical Profile and Survival After Heart Transplantation According to Prior Heart Disease

Introduction Data about the epidemiology of valvular heart disease (VHD) is scarce. The increasing aging of the population may cause an augmented prevalence of VHD, with a great number of comorbidities that conveys a higher surgical risk. The aim of this study was to describe the prevalence of VHD in the patients attended at our institution from 2007 until 2017 and to describe the main characteristics of this population. Methods We used a new tool based on EHRead Technology to extract clinical relevant information from Electronic Health Records, designed for descriptive and predictive big data analysis. All medical reports generated at the outpatient clinic, ER or hospitalization ward were examined. Patients with a diagnosis of moderate or severe VHD were selected. The prevalence of VHD was also estimated in 2 quintiles, from 2008 until Feb 2013 and from March 2013 until Dec 2017. Results The total prevalence of VHD in our population was 1.04% (n=3431). Mitral regurgitation was the most frequent valvular lesion (0.4%, n=1318), followed by aortic stenosis (0.3%, n=967) and aortic regurgitation (0.28%, n=938). There was a clear female predominance (63%), and the median age was 76.4. In the 1st quintile the prevalence of VHD was 0.25%, and increased to 0.79% in the 2nd. This trend was consistent in all type of valvular lesions. The prevalence of comorbidities was higher than in other epidemiological studies (Table). Prevalence of comorbidities Severe MR Severe AS Severe AR Euro Heart Valve Survey Hypertension 54,5% 69,1% 47,9% 49% Dyslipidemia 32,2% 40,6% 27,4% 35% Diabetes Mellitus 28,0% 31,5% 16,4% 15% Smoking (current) 5,6% 5,4% 13,7% 39% Coronary heart disease 12,0% 17,0% 12,3% 13% Stroke 7,0% 8,9% 5,5% 7% Chronic kidney disease 18,9% 16,9% 20,5% 15% Chronic obstructive pulmonary disease 11,2% 9,9% 11,0% 15% MR: Mitral regurgitation, AS: aortic stenosis, AR: aortic regurgitation, MS: mitral stenosis. Sex Distribution Conclusions The older age and greater number of comorbidities seen in our series over the past ten years, compared to the Euroheart Valve Survey reinforce the idea that the percutaneous valvular therapies should play a major role in the treatment of patients with VHD. Although, the prevalence of VHD may be underestimated in our population, due to the methodology, it reflects an ever-growing pathology in an older and sicker population.

Background Cardiac auscultation, an essential bedside diagnostic tool, often identifies significant valvular heart disease through murmurs. However, its accuracy is contingent upon the clinician's expertise, leading to a growing dependence on expensive imaging techniques. This study aimed to develop and validate a machine learning model for detecting valvular heart disease from cardiac auscultation. Methods The digital cardiac auscultation and associated echocardiograms were prospectively collected from three sites between May 1, 2022, and Dec 31, 2022. We trained, validated, and externally tested a machine learning based model to classify aortic stenosis, mitral stenosis, aortic regurgitation, mitral regurgitation, tricuspid regurgitation, oveall valvular heart disease from cardiac auscultation, age, sex, and comorbidity. We condcted training, and internal testing using datasets for eXtreme Gradient Boosting (XGBoost) machine learning model from hospital one and hospital two. The dataset from hospital three was employed for external testing. We evaluated the area under the receiver operating characteristic curve (AUROC), area under the precision recall curve (AUPRC), accuracy, sensitivity, specificity. Result We selected the cardiac auscultation and echocardiograms of a total of 4,321 patients, excluding those without valvular heart disease information, congenital heart disease, a history of valvular operation, and cardiac auscultation could not be interpreted. The diagnostic performance of heart murmurs for valvular heart disease across the three datasets generally demonstrated high sensitivity and PPV. Specifically, the sensitivity for aortic stenosis was 89.1%, mitral stenosis 88.8%, aortic regurgitation 88.5%, mitral regurgitation 89.8%, tricuspid regurgitation 90.1%, and for any valvular heart disease, it was 95.0%. However, the NPV was consistently lower, with values of 16.4%, 14.2%, 12.2%, 23.1%, 26.2%, and 65.3% for the respective conditions. In XGBoost machine learning model, the AUROC values for internal testing (N=1,403), along with their 95% confidence intervals, were as follows: aortic stenosis (0.93, 0.88–0.97), mitral stenosis (0.91, 0.81–0.97), aortic regurgitation (0.84, 0.79–0.90), mitral regurgitation (0.94, 0.90–0.98), tricuspid regurgitation (0.81, 0.75–0.87), and overall valvular heart disease (0.86, 0.82–0.89). For external testing (N=814), the AUROC values were: aortic stenosis (0.90, 0.83–0.96), mitral stenosis (0.88, 0.79–0.95), aortic regurgitation (0.94, 0.93–0.96), mitral regurgitation (0.93, 0.92–0.95), tricuspid regurgitation (0.89, 0.87–0.91), and overall valvular heart disease (0.92, 0.90–0.94). Conclusion The machine learning based model can accurately classify valvular heart diseases using information from digital cardiac auscultation.Figure 1.Study FlowFigure 2.AUC curve

Controversy exists over the use of direct oral anticoagulants (DOACs) in patients with nonvalvular atrial fibrillation (NVAF) and concurrent valvular heart disease (VHD), given their labeled indication for NVAF only. However, a closer examination reveals that the landmark clinical trials of each DOAC enrolled patients with certain types of VHD including mitral regurgitation, aortic stenosis, and aortic regurgitation. Our recently published review article in Clinical Cardiology, “Direct Oral Anticoagulant Use in Nonvalvular Atrial Fibrillation With Valvular Heart Disease–A Systematic Review,” highlighted this discrepancy, focusing on the VHD subanalyses published regarding dabigatran, rivaroxaban, and apixaban.1 Apart from an increased bleed risk noted with rivaroxaban in patients with VHD, these 3 DOACs exhibited similar safety and efficacy outcomes to the overall population regardless of the presence of VHD. At the time of submission, there was a lack of information regarding the VHD population with edoxaban. This letter serves as an addendum to the original review article, highlighting 2 recent edoxaban abstracts from the Effective Anticoagulation with Factor Xa Next Generation in Atrial Fibrillation-Thrombolysis in Myocardial Infarction Study 48 (ENGAGE AF-TIMI 48) trial comparing edoxaban vs warfarin.2 Regarding the ENGAGE AF-TIMI 48 VHD population, investigators excluded patients with moderate-to-severe mitral stenosis and mechanical valve prosthesis. When examining the overall population, 2824 (13.4%) patients with VHD were identified and defined as having mitral or aortic valve surgery or moderate-to-severe mitral regurgitation, aortic stenosis, or aortic insufficiency.3 However, the incidence of different types of VHD within the population were not fully distinguished. Of note, valve surgery included not only valve repair or valvuloplasty, but bioprosthetic valve patients (n = 191) as well. Outcomes were similar to the overall trial results regardless of VHD status concerning rates of stroke or systemic embolism (SE) (hazard ratio [HR] = 0.69 [95% confidence interval [CI]: 0.44-1.08] VHD vs HR = 0.91 [95% CI: 0.77-1.08] no VHD) and major bleeding (HR = 0.74 [95% CI: 0.53-1.03] VHD vs HR = 0.82 [95% CI: 0.71-0.95] no VHD). However, rates of the composite outcome (stroke or SE, major bleeding, or death) were significantly higher for patients with VHD overall (HR = 1.42 [95% CI: 1.31-1.54], P < 0.001). Aortic stenosis (n = 165) was also noted to display the highest impact on mortality in the VHD population. A separate abstract examined the 191 patients with bioprosthetic valves (69% mitral, 31% aortic), comprised of 63.4% males with a median CHA2DS2-VASc (congestive heart failure, hypertension, age [≥65: 1 point, ≥75: 2 points], diabetes, stroke/transient ischemic attack [2 points], vascular disease, sex category [female]) score of 5.4 The bioprosthetic valve population comprised 6.8% of the VHD group and 0.9% of the total population. The investigators compared outcomes in patients with bioprosthetic valves to those with VHD without bioprosthetic valves, and found bioprosthetic valve patients to have a higher risk of stroke or SE (HR = 1.84, P = 0.027). Major bleeding was unaffected by the presence of bioprosthetic valves. When comparing outcomes in those receiving higher-dose edoxaban to warfarin, no differences in treatment effects were noted based upon the presence or absence of a bioprosthetic valve. However, bioprosthetic valve patients had a more favorable net outcome (stroke or SE, major bleeding, or cardiovascular death) when treated with higher-dose edoxaban compared to those VHD patients without a bioprosthetic valve (HR = 0.45 [95% CI: 0.23-0.90] bioprosthetic valve vs. HR = 1.01 [95% CI: 0.84-1.22] VHD, P = 0.03). Overall, outcomes for VHD patients treated with edoxaban appear to mimic the total population results observed in ENGAGE AF-TIMI 48. However, these results should be interpreted with caution given the post hoc nature of the analyses and the fact that these data are currently only available in abstract form. Although larger, randomized prospective trials comparing DOACs to warfarin in VHD patients are needed for definitive conclusions, these preliminary data show that patients should not be ruled inappropriate edoxaban candidates based solely on the presence of VHD. As with the other DOACs, individual assessments of patient-specific factors, including both thromboembolic and bleed risk, should be performed to determine appropriate edoxaban candidates in the setting of concurrent VHD. It is important to note that along with the exclusion of moderate-to-severe mitral stenosis and mechanical heart valves, mild mitral stenosis was also not included in the definition of VHD by investigators for analysis. Therefore, these subsets of patients should not be considered for edoxaban therapy. However, based upon these subanalyses results, patients with previous mitral or aortic valve surgery, bioprosthetic valve, moderate-to-severe mitral regurgitation, aortic stenosis, or aortic insufficiency may qualify for edoxaban therapy.

It has been reported that Kawasaki syndrome is accompanied with mitral regurgitation or aortic regurgitation in some cases. To elucidate the incidence and the natural history of valvular heart disease in Kawasaki syndrome, we analyzed the patients who were detected to have a new heart murmur after the onset of Kawasaki syndrome. From 1973 to 1988, we have experienced 13 cases with valvular heart disease in 1215 cases of Kawasaki syndrome, 12 cases with mitral regurgitation (1.0%) and one with aortic regurgitation (0.1%). Valvular lesions were confirmed by angiography or pulsed Doppler echocardiography. The age at onset of Kawasaki syndrome, the duration of fever, the maximum erythrocyte sedimentation rate, and the incidence of coronary artery lesions in these cases were compared with the same variables in 30 cases of without valvular lesion in Kawasaki syndrome. There were no statistical difference between the cases with valvular heart disease and without valvular heart disease about the age of onset (mean +/- SD 10.2 +/- 12.7 months vs 20.8 +/- 18.4 months; N.S.) and the maximum erythrocyte sedimentation rate (87.7 +/- 29.0 mm/h vs 87.2 +/- 35.6 mm/h; N.S.). Whereas the duration of fever in cases of valvular heart disease was more extended than those without valvular heart disease (20.3 +/- 8.1 days vs 10.3 +/- 4.3 days; p less than 0.001), and the incidence of coronary artery lesions in the cases of valvular heart disease was significantly higher than those without valvular heart disease (12/13 cases vs 7/30 cases; p less than 0.001), thus suggesting that the cases of valvular heart disease were subject to a severe case of Kawasaki syndrome. All valvular heart disease appeared within 1 month after the onset of Kawasaki syndrome, except in one case whose heart murmur was noticed 5 years after the onset. The heart murmur disappeared within 2 months after the onset of valvular heart disease in 5 cases, however in another 7 cases, the heart murmur persisted more than 2 years (mean; 5.3 years to date) or one has died of acute congestive heart failure due to mitral regurgitation. All cases with persistent valvular disease revealed mitral or aortic valve prolapse. Our data suggest that the cause of valvular heart disease might be different by the time of onset and duration of valvular heart disease.(ABSTRACT TRUNCATED AT 400 WORDS)

Ultrasonography is a non-invasive imaging modality widely used to evaluate and diagnose many diseases. The purpose of this article is to provide a more detailed overview of the use of ultrasound in the diagnosis of heart and liver disease. In addition to a basic introduction to heart and liver disease, this article will explore specific applications of ultrasound in specific heart and liver diseases. In terms of heart disease, ultrasound plays an important role in the diagnosis of coronary atherosclerotic heart disease, valvular heart disease and congenital heart disease. Ultrasound can assess the degree of narrowing and blood flow in coronary arteries to help determine a patient's cardiovascular risk. For valvular heart disease, ultrasound can detect and evaluate the function and abnormality of the heart valves, providing information about valve stenosis or regurgitation. For congenital heart disease, ultrasound can reveal structural abnormalities and hemodynamic changes in the heart, helping to determine the type and severity of the lesion. In liver disease, ultrasound plays an important role in the evaluation of pathologies such as cirrhosis and hepatocellular carcinoma. Ultrasound can assess the shape, size, and texture of the liver, help detect and diagnose cirrhosis, and assess liver function and disease progression. In addition, ultrasound is also of great significance for the early diagnosis and monitoring of hepatocellular carcinoma, which can reveal the location, size and blood flow of the tumor. The role of ultrasound in diagnosing and monitoring disease will expand further with advances in technologies such as artificial intelligence and elastography. In conclusion, ultrasound plays a key role in the assessment, diagnosis and monitoring of heart and liver diseases and has many advantages. With the further development of technology and the expansion of application, the position of ultrasound in clinical practice will be further strengthened.

BACKGROUND:Cardiac valve disease is observed in 2.5% of the general population and 10% of the elderly people. Effective pharmacological treatments are currently not available, and patients with severe cardiac valve disease require surgery. PROX1 (prospero-related homeobox transcription factor 1) and FOXC2 (Forkhead box C2 transcription factor) are transcription factors that are required for the development of lymphatic and venous valves. We found that PROX1 and FOXC2 are expressed in a subset of valvular endothelial cells (VECs) that are located on the downstream (fibrosa) side of cardiac valves. Whether PROX1 and FOXC2 regulate cardiac valve development and disease is not known.METHODS:We used histology, electron microscopy, and echocardiography to investigate the structure and functioning of heart valves from Prox1ΔVEC mice in which Prox1 was conditionally deleted from VECs. Isolated valve endothelial cells and valve interstitial cells were used to identify the molecular mechanisms in vitro, which were tested in vivo by RNAScope, additional mouse models, and pharmacological approaches. The significance of our findings was tested by evaluation of human samples of mitral valve prolapse and aortic valve insufficiency.RESULTS:Histological analysis revealed that the aortic and mitral valves of Prox1ΔVEC mice become progressively thick and myxomatous. Echocardiography revealed that the aortic valves of Prox1ΔVEC mice are stenotic. FOXC2 was downregulated and PDGF-B (platelet-derived growth factor-B) was upregulated in the VECs of Prox1ΔVEC mice. Conditional knockdown of FOXC2 and conditional overexpression of PDGF-B in VECs recapitulated the phenotype of Prox1ΔVEC mice. PDGF-B was also increased in mice lacking FOXC2 and in human mitral valve prolapse and insufficient aortic valve samples. Pharmacological inhibition of PDGF-B signaling with imatinib partially ameliorated the valve defects of Prox1ΔVEC mice.CONCLUSIONS:PROX1 antagonizes PDGF-B signaling partially via FOXC2 to maintain the extracellular matrix composition and prevent myxomatous degeneration of cardiac valves.

In adults with valvular aortic stenosis (AS), valve replacement is recommended in the presence of symptoms and severely reduced aortic valve area (AVA).1 In such patients, valve replacement improves symptoms and survival, even in the setting of left ventricular (LV) dysfunction. LV dysfunction in severe AS is usually due to afterload mismatch; valve replacement relieves the afterload excess imposed by the stenotic valve and improves LV performance. 2 However, a subset of patients with “ severe” AS, LV dysfunction, and low-transvalvular gradient has been reported to have a relatively high operative mortality and poor prognosis.2–4⇓⇓ This clinical scenario has been termed “low-flow, low-gradient AS.” Accurate assessment of AVA in such patients is difficult because (1) calculated AVA is directly proportional to forward stroke volume, and (2) the Gorlin constant varies at low-flow states. 5–7⇓⇓ Some patients with low-flow, low-gradient AS have a reduced AVA as a result of inadequate forward stroke volume rather than anatomic stenosis, a situation analogous to reduced anterior mitral leaflet excursion in dilated cardiomyopathy where there is not enough forward flow to fully open the valve. For example, Cannon et al 8 showed that some patients with low-gradient AS were found to have only mild AS at surgery despite a Gorlin AVA indicating critical AS. Obviously, surgical therapy is unlikely to benefit such patients because their primary pathology is a cardiomyopathy. On the other hand, patients with severe anatomic AS may benefit from valve replacement despite the increased operative risk associated with a low-flow, low-gradient hemodynamic state. The recent American College of Cardiology/American Heart Association (ACC/AHA) guidelines for managing valvular heart disease recommends hemodynamic evaluation of low-flow, low-gradient AS using dobutamine echocardiography to distinguish patients with fixed anatomic AS from those with flow-dependent (“ relative”) AS in patients with LV …

Objectives: To determine the prevalence of isolated left ventricular noncompaction (IVNC) as a cause of heart failure and heart transplantation. Methods: There were 960 patients seen in the heart failure clinic from 1987 to 2005, with a complete evaluation including echocardiography at our center (study population, 82% men, mean age 52 years). The following data were collected: type of heart disease, age at echocardiography and at heart transplantation, and frequency of heart transplantation. Echocardiographic diagnosis of IVNC was based on our published criteria. Results: The etiologies of heart failure were coronary artery disease (CAD; 37%), idiopathic dilated cardiomyopathy (33%), valvular heart disease (11%), congenital heart disease (5%), IVNC (3%), hypertensive heart disease (3%), hypertrophic cardiomyopathy (2%), myocarditis (1%), and <1% other diagnoses. Heart transplantation was performed in 253 patients (26%) due to idiopathic dilated cardiomyopathy (42%), CAD (39%), valvular heart disease (5%), congenital heart disease (5%), IVNC (2%), or other etiologies (≤1% each). Conclusions: The most common causes for heart failure remain idiopathic dilated cardiomyopathy, CAD and valvular heart disease. Strictly using the criteria for the definition of IVNC, IVNC is a rare underlying cardiomyopathy for both, heart failure (2.7%) and heart transplantation (2%) in our center.

Hemolysis and Acute Kidney Failure