Svend Aakhus

Aortic valve replacement (AVR) improves survival and quality of life in patients with severe aortic stenosis (AS), but despite clear indications for surgical treatment a significant proportion of patients do not undergo AVR. The study aim was to identify clinical variables associated with the decision to perform AVR, and to assess the prognostic effect of surgery versus medical treatment in patients with severe AS adjusted for significant confounders and effect modifiers. A prospective observational study of consenting patients aged >18 years who were under consideration for AVR at the authors' tertiary teaching hospital was conducted. The main outcomes of the study were treatment decisions and survival. Among 480 patients with severe AS who were evaluated, 351 had surgical AVR, 38 had transcatheter AVR, and 91 were declined operative treatment. Typically, non-operated patients were older, were in a lower NYHA class, had fewer symptoms, a lower peak aortic jet velocity, a higher NT-proBNP level, and a lower physical summary score (SF-36). Higher age showed the strongest correlation against AVR (OR 0.91; 95% CI 0.87-0.94). One-, three-, and five-year cumulative survival rates, respectively, were 95%, 87%, and 73% among operated patients, and 82%, 47%, and 27% among non-operated patients. The median survival time was 1,604 days (95% CI 1,554-1,655) in operated patients versus 1,090 days (95% CI 954-1,226) in non-operated patients (p <0.001). The effect of operation on mortality was shown to depend on the interaction with diabetes, when adjusted for significant confounders (i.e., age, atrial fibrillation, NT-proBNP, hs-Troponin T, and NYHA class). An effect of AVR on mortality was found in patients without diabetes (HR 0.29; 95% CI 0.19-0.468; p <0.001), but not among patients with diabetes. Supplemental and better parameters to improve patient selection are warranted. Surgical AVR shows a greater prognostic effect in patients without diabetes.

In recipients with type 1 diabetes, we aimed to determine whether long-term normoglycemia achieved by successful simultaneous pancreas and kidney (SPK) transplantation could beneficially affect progression of coronary artery disease (CAD) when compared with transplantation of a kidney-alone from a living donor (LDK). In 42 kidney transplant recipients with functioning grafts who had received either SPK (n = 25) or LDK (n = 17), we studied angiographic progression of CAD between baseline (pretransplant) and follow-up at 7 years or older. In addition, computed tomography scans for measures of coronary artery calcification and echocardiographic assessment of left ventricular systolic function were addressed at follow-up. During a median follow-up time of 10.1 years (interquartile range [IQR], 9.1-11.5) progression of CAD occurred at similar rates (10 of 21 cases in the SPK and 5 of 14 cases in the LDK group; P = 0.49). Median coronary artery calcification scores were high in both groups (1767 [IQR, 321-4035] for SPK and 1045 [IQR, 807-2643] for LDK patients; P = 0.59). Left ventricular systolic function did not differ between the 2 groups. The SPK and LDK recipients were similar in age (41.2 ± 6.9 years vs 40.5 ± 10.3 years; P = 0.80) and diabetes duration at engraftment but with significant different mean HbA1c levels of 5.5 ± 0.4% for SPK and 8.3 ± 1.5% for LDK patients (P Conclusions In patients with both type 1 diabetes and end-stage renal disease, SPK recipients had similar progression of CAD long-term compared with LDK recipients. Calcification of coronary arteries is a prominent feature in both groups long-term posttransplant.

Diastolic dysfunction is a major cause of morbidity in heart transplant recipients. A reliable, non-invasive marker of left ventricular (LV) filling pressure would simplify follow-up in these patients. We aimed to test the validity of echocardiographic indices of LV filling pressure in a contemporary population of heart transplant recipients. Eighty-three patients were examined by right-sided heart catheterisation and echocardiography one year after heart transplantation. We explored the association between echocardiographic parameters of LV filling pressure and invasively measured pulmonary capillary wedge pressure (PCWP). Peak early mitral flow velocity divided by septal early mitral relaxation velocity (E/e'(septal)) was the echocardiographic parameter that best correlated with PCWP (r = 0.47; p < 0.001). At a cut-off value of 22, E/e'(septal) could identify patients with a PCWP above 12 mm Hg with a sensitivity of 56% and a specificity of 95%. The E/e' index was moderately associated with LV filling pressure in heart transplant recipients. Echocardiographic parameters of diastolic function should be interpreted with caution when estimating left ventricular filling pressures in this population.

Transcatheter aortic valve implantation involves percutaneously implanting a biomechanical aortic valve to treat severe aortic stenosis. In order to select a proper device, precise sizing of the aortic valve annulus must be completed.

Objectives To evaluate maternal left ventricular (LV) systolic and diastolic function during normal pregnancy by non‐invasive measures of LV contractility incorporating loading conditions. METHODS Sixty‐five women were examined using echocardiography, including tissue Doppler and two‐dimensional speckle tracking, and subclavian artery pulse trace recordings at gestational weeks 14–16, 22–24 and 36, and at 6 months postpartum. Results The mean ± SD age of the women was 32.0 ± 4.6 years. Cardiac output and LV end‐diastolic volume were on average 20% and 23% higher, respectively, during pregnancy, compared to that at 6 months postpartum (both, P < 0.01). LV ejection fraction, global peak systolic strain and rate‐corrected LV velocity of circumferential fiber shortening (Vcfc) were 11%, 6% and 6% lower, respectively, at 36 weeks' gestation compared to at 6 months postpartum (all, P < 0.01). Afterload, measured as LV end‐systolic wall stress (ESWS) increased by 10% between 14–16 and 36 weeks' gestation (P < 0.01). Analysis of the relationship between Vcfc and ESWS revealed that LV contractility was lower during pregnancy than at 6 months postpartum. Changes in diastolic function were demonstrated by 11% lower mitral early diastolic (E) wave velocity, 8% lower tissue Doppler early diastolic velocity (e′) and 13% higher left atrial area (all P < 0.01) during pregnancy. Tissue Doppler E/e′ remained unaltered (P = 0.78). Conclusions During normal pregnancy, LV contractility is lower than it is at 6 months postpartum. This is associated with increased LV and left atrial area, whereas filling pressures are unchanged. These findings suggest that pregnancy exerts a larger load on the cardiovascular system than previously assumed. Copyright © 2012 ISUOG. Published by John Wiley & Sons Ltd.

Novel and robust cardiovascular (CV) markers are needed to improve CV morbidity and mortality risk prediction in type 2 diabetes (T2D). We assessed the long term predictive value of 4 novel CV risk markers for major CV events and mortality.

Approximately 30% of patients treated with cardiac resynchronization therapy (CRT) do not respond. We evaluated response to CRT at six and 12 months, tested a novel response criterion and evaluated different clinical and echocardiographic predictors of response. Eighty one patients were enrolled. A definition of response to CRT was predefined as a combination of 1) a reduction of LV end-systolic volume of ≥10% and 2) either an improvement in NYHA class by ≥1 or an increase in peak oxygen consumption of ≥1 ml/kg/min. Pre-and postoperatively at six and 12 months we also evaluated the most commonly employed definitions of response in our material: NYHA class, quality of life, left ventricular (LV) performance and functional capacity. After six and 12 months of CRT, 42 (52%) and 48 patients (59%) were responders, respectively. Employing different criteria, response ranged from 33-96% and 31-94% at six and 12 months, respectively. In our material a large pre-operative interventricular motion delay (IVMD) was a predictor of response to CRT (p<0.05). Fifty two percent and 59% were responders to CRT at six months and one year given a predefined novel endpoint. Different response criteria to CRT gave response rates ranging from 33-96% and 31-94% at six and 12 months, respectively. A large IVMD predicts response to CRT at six and 12 months.