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Valeria Riccieri,
Massimiliano Vasile,
Nicoletta Iannace,
Katia Stefanantoni,
Iliana Sciarra,
Carmine D Vizza, Roberto Badagliacca,
Roberto Poscia,
Silvia Papa,
Mario Mezzapesa,
Martina Nocioni,
Guido Valesini
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ABSTRACT: Objective. Pulmonary arterial hypertension (PAH) is a complication of SSc due to increased vascular resistance, and abnormal vascularity is a well-known feature of the disease as shown by nailfold videocapillaroscopy (NVC). This study investigated for specific NVC changes in SSc patients with and without PAH to assess any useful difference.Methods. Twenty-four SSc patients, 12 with PAH and 12 without, entered the study. Evidence of PAH was defined as increased systolic pulmonary artery pressure (PAP) (≥35 mmHg), indirectly assessed by echocardiography and confirmed by right heart catheterization (mPAP > 25 mmHg). NVC was performed, and a semi-quantitative rating scale, a rating system for avascular areas and a specific NVC pattern evaluation, namely early, active and late, were used.Results. An NVC score >1 was more frequently found in patients with PAH than those without, 11 cases (92%) vs 5 cases (42%) (P = 0.03); an avascular areas grade >1 was present in 10 (83%) and 2 (17%) cases, respectively (P = 0.003); and a more severe NC pattern (active/late) was described in 11 (92%) and 5 (42%) patients, respectively (P = 0.03). When we compared the mPAP with NVC parameters, we found significant correlations between mPAP values and the NVC score (P < 0.005) and with the avascular areas score (P < 0.001).Conclusion. Our results underline the relevance of early microvascular assessment in patients at risk of developing a severe complication such as PAH that can amplify the systemic microvascular impairment in SSc. More severe NVC abnormalities should lead to strict cardiopulmonary surveillance and a complete NVC study is indicated.
Rheumatology (Oxford, England) 05/2013; · 4.24 Impact Factor
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Roberto Badagliacca,
Roberto Poscia,
Beatrice Pezzuto,
Silvia Papa,
Alfred Nona,
Massimo Mancone,
Mario Mezzapesa,
Martina Nocioni,
Susanna Sciomer,
Gabriele Valli,
Nadia Cedrone,
Francesco Fedele,
Carmine Dario Vizza
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ABSTRACT: Pulmonary arterial dilatation is considered a consequence of chronic pulmonary hypertension (PH), but despite its relatively common detection, its prevalence and prognostic impact have not yet been systematically investigated. The aim of the study was to investigate these factors in a relatively large cohort of severe PH patients.
One hundred and forty-one consecutive patients diagnosed with PH were monitored for a mean of 957 days. Data including functional class, exercise capacity, invasive hemodynamics and pulmonary artery (PA) echo/CT scan measurement were performed and outcomes prospectively collected.
PA dilatation is a common feature, present in the 76.6% of cases in this cohort of severe PH patients. Survival at 1, 2 and 3 years was 83, 71 and 58%, respectively. On univariate analysis, the baseline variables associated with a poor outcome were related to pulmonary arterial hypertension associated with connective tissue disease (CDT-PAH), New York Heart Association (NYHA) functional class, 6-min walk test and right atrial pressure. On multivariate analysis only CDT-PAH and NYHA functional class remained independently associated with poor survival.
PA dilatation is commonly detected in severe PH patients and is not associated with an increased risk of death.
Cardiology 03/2012; 121(2):76-82. · 1.71 Impact Factor
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Roberto Badagliacca,
Beatrice Pezzuto,
Roberto Poscia,
Massimo Mancone,
Silvia Papa,
Serena Marcon,
Gabriele Valli,
Gennaro Sardella,
Fabio Ferrante,
Carlo Iacoboni,
Daniela Parola,
Francesco Fedele,
Carmine Dario Vizza
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ABSTRACT: Oral drugs have made the treatment of pulmonary hypertension (PH) feasible in non-expert centers, which could delay patient access to prostanoid therapy.
Fifty-seven consecutive patients with precapillary PH received a prostanoid in our center. Data at prostanoid initiation included modality of center referral, medical history, New York Heart Association [NYHA] class, exercise capacity, echocardiographic parameters, and hemodynamics.
Overall survival at 1, 2, and 3 years was 85%, 69%, 55%, respectively. Non-survivors had worse NYHA class III/IV (17/12) than survivors (27/1; p < 0.01) and exercise capacity on 6-minute-walk distance (254 ± 114 vs 354 ± 91 meters; p < 0.01). Non-survivors were more frequently referred on oral therapy (83% vs 36%; p < 0.01) and had a higher rate of urgent prostanoid treatment (69% vs 17%; p < 0.0001). Multivariate analysis (hazard ratio [95% confidence interval]) found the independent prognostic factors were urgent prostanoid therapy (2.0 [1.1-3.9]) and NYHA class (3.5 [1.5-8.2]). Survivors had a significant response to prostanoid, improving NYHA class from 2.8 ± 0.4 to 2.3 ± 0.5 (p = 0.002), 6-minute walk distance from 354 ± 91 to 426 ± 82 meters (p = 0.0001), and pulmonary hemodynamics (pulmonary artery pressure from 56 ± 13 to 44 ± 18 mm Hg [p < 0.05]; cardiac index from 2.0 ± 1.2 to 3.1 ± 1.2 liters/min/m(2) [p = 0.002], and pulmonary vascular resistance from 17 ± 10 to 8 ± 6 WU [p = 0.001]).
Referral of patients on oral treatment to a tertiary PH center is delayed and significantly affects prognosis.
The Journal of heart and lung transplantation: the official publication of the International Society for Heart Transplantation 01/2012; 31(4):364-72. · 3.54 Impact Factor
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Carmine Dario Vizza,
Claudio Letizia, Roberto Badagliacca,
Roberto Poscia,
Beatrice Pezzuto,
Cristina Gambardella,
Alfred Nona,
Silvia Papa,
Serena Marcon,
Massimo Mancone,
Carlo Iacoboni,
Valeria Riccieri,
Maurzio Volterrani,
Francesco Fedele
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ABSTRACT: OBJECTIVES: To address if baseline endothelin-1 (ET-1) plasma levels might predict clinical worsening (CW) in patients with idiopathic pulmonary hypertension (IPAH) treated with bosentan. METHODS: Forty-four consecutive patients with IPAH (WHO classes II-III) were included in this study. After an initial assessment (clinical status, pulmonary hemodynamics, samples for adrenomedullin (ADM), ET-1 and brain natriuretic peptide (BNP) plasma levels), patients were treated with bosentan and followed-up for CW. RESULTS: We observed CW in 24 patients. Actuarial rates of freedom from CW were 74% at 1year, 56% at 2years, and 43% at 3years. Patients with CW had a worse WHO functional class (II/III; no-CW 14/6 vs CW 5/19, p=0.002), six-minute walk-test distance (no-CW 439+94m vs CW 385+82m, p=0.04), mean pulmonary artery pressure (no-CW 47.4+10.6mm Hg vs CW 56+12.6mm Hg, p=0.02) and pulmonary vascular resistance (PVR no-CW 12.5+4.8 WU vs CW 16.4+6.3 WU, p=0.03) than the no-CW group. Moreover ET-1 (no-CW 14.1+4.2pg/ml vs CW 21.3+6.3pg/ml, p=0.0001), ADM (no-CW 14.9+7pg/ml vs CW 21.5+10.4pg/ml p=0.002) and BNP (no-CW 82.8+35.3pg/ml vs CW 115.4+39.6pg/ml, p=0.007) plasma levels were significantly higher in the CW group than in the no-CW group. The multivariate Cox proportional hazards model identified WHO class III (RR 4.6, 95%CI 14.6-1.45), ET-1 plasma levels (RR 1.1, 95%CI 2.05-1.01) and PVR (RR 1.2, 95%CI 1.3-1.03) as independent risk factors for CW. CONCLUSIONS: These data confirm the high rate of CW in patients with IPAH treated with bosentan and document the impact of the endothelin system on CW of these patients.
International journal of cardiology 01/2012; · 7.08 Impact Factor
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Paolo Calabrò,
Giuseppe Limongelli,
Valeria Maddaloni,
Carmine Dario Vizza,
Michele D'Alto,
Raffaella D'Alessandro,
Roberto Poscia,
Paola Argiento,
Brunella Ziello, Roberto Badagliacca,
Emanuele Romeo,
Giuseppe Pacileo,
Maria Giovanna Russo,
Francesco Fedele,
Raffaele Calabrò
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ABSTRACT: This study analyses the frequency and the potential role of two polymorphisms, the +134del/insA, located in the gene encoding for Endothelin-1 (EDN1), and the His323His in the gene encoding for Endothelin receptor type A (EDNRA) in a cohort of 98 consecutive patients with pulmonary arterial hypertension from two different Cardiology Units (Mid-South of Italy), and in 100 healthy Caucasian subjects randomly recruited from the same area. Cardiac anatomy and function were analysed by non invasive diagnostic imaging techniques (Echocardiography standard m-mode, 2D, colour-Doppler) and by invasive studies (cardiac catheterization). Molecular screening of the region of interest was performed by automated sequencing. At univariate analysis, patients with the His323His TT genotype show a lower cardiac index (2 ± 0.6 vs. 2.3 ± 0.6; p = 0.05) and a higher indexed pulmonary vascular resistance (18.8 ± 9.6 vs. 14.2 ± 6.9; p = 0.01) at cardiac catheterization. A logistic multivariate model shows idiopathic disease (p = 0.01; OR = 3.8; CI = 1.3-11) and indexed pulmonary vascular resistances (p = 0.01; OR = 1.1; CI = 1-1.2) as independent predictors of TT genotype. Our findings may suggest a potential link between specific genotypes in the EDNRA gene and susceptibility for PAH.
Internal and Emergency Medicine 07/2011; 7(5):425-30. · 2.06 Impact Factor
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ABSTRACT: In ST-segment elevation myocardial infarction (STEMI) impairment of microcirculatory function is a negative independent predictor of myocardial function recovery. In the Impact of Thrombectomy with EXPort Catheter in Infarct-Related Artery during Primary Percutaneous Coronary Intervention (PCI; EXPIRA) trial we found that manual thrombectomy resulted in a better myocardial reperfusion expressed by an improved procedural outcome and a decrease of infarct size compared to conventional PCI. The aim of the present study was to investigate whether the early efficacy of thrombus aspiration translates into very long-term clinical benefit. We randomized 175 patients with STEMI with occlusive thrombus at baseline undergoing primary PCI to thromboaspiration with a manual device (Export Medtronic, n = 88) or standard PCI (n = 87). No differences in baseline, clinical, and angiographic preprocedural findings were observed between the 2 groups except for incidence of hypertension and cholesterol levels. After 24 months major adverse cardiac events were 13.7% versus 4.5% (p = 0.038, log-rank test) and cardiac death was 6.8% versus 0% (p = 0.012, log-rank test). A strict correlation was observed between cardiac death incidence and tissue reperfusion parameters (postprocedural myocardial blush grade and ST-segment resolution). In conclusion, manual thrombus aspiration before stenting of the infarct-related artery in selected patients with STEMI improving myocardial reperfusion significantly decrease cardiac death and major adverse cardiac events at 2 years.
The American journal of cardiology 09/2010; 106(5):624-9. · 3.58 Impact Factor
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Carmine Dario Vizza,
Claudio Letizia,
Luigi Petramala, Roberto Badagliacca,
Roberto Poscia,
Enrico Zepponi,
Eleonora Crescenzi,
Alfred Nona,
Giulia Benedetti,
Fabio Ferrante,
Susanna Sciomer,
Francesco Fedele
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ABSTRACT: Bosentan, an endothelin (ET) ETA-ETB receptors antagonist, is an effective therapy for idiopathic pulmonary arterial hypertension (PAH) and for PAH related to connective tissue disease (CTD). The aim of this study was to evaluate the behaviour of ET-1 and brain natriuretic peptide (BNP) venous plasma levels during a 6-month dual ET-1 receptor blockade and the potential influence of baseline ET-1 venous plasma levels on the clinical efficacy of bosentan.
Twenty-five patients with PAH (idiopathic n=16, CTD n=9) in WHO functional class II-III were included in this study. After initial evaluation, patients' WHO class, 6-minute walking-test (6MWT), ET-1 and BNP venous plasma levels were assessed at baseline and after 6-month bosentan therapy. To evaluate whether the ET-1 levels could influence the clinical response to bosentan, data were analyzed for the whole population which was stratified according to high and low ET-1 plasma levels (on the basis of the baseline median value of ET-1 plasma: Gr.1<18.7 pg/ml, Gr.2>18.7 pg/ml).
Study population included patients with moderate-severe PAH. After 6-month of treatment we observed a significant increase in 6MWT distance (from 435+/-85) m to 467+/-77 m, p>0.001) and an improvement in WHO class (from 2.4+/-0.5 to 2+/-0.6 p>0.01), with a significant decrease in BNP (from 87+/-33 pg/ml to 67+/-41 pg/ml, p=0.006) and a trend towards lower ET-1 plasma levels (from 17.7+/-5 pg/ml to 16+/-6 pg/ml, p=ns). Improvement in effort tolerance (Delta distance) was not correlated to modification in ET-1 (DeltaET-1) and BNP (DeltaBNP) plasma levels, while we found a significant correlation between DeltaET-1 and DeltaBNP (r=0.63, p=0.0006). Analyzing the subpopulation, Gr.2 patients were older (Gr.1: 41+/-10 years vs Gr.2: 50+/-9 years, p=0.04), had less effort capacity (6MWT distance, Gr.1: 469+/-76 m, vs Gr.2: 398+/-82 m, p=0.03), and showed a trend towards higher BNP values (Gr.1: 82+/-41 pg/ml vs Gr.2: 92+/-23 pg/ml, p=0.051), but no significant differences in pulmonary hemodynamics. After the 6-month treatment both groups showed a significant improvement in 6MWT (Gr.1: +32+/-24 m, Gr.2: +32+/-21 m p=0.05) without differences between groups. WHO class had a trend towards lower class (Gr.1: -0.5+/-0.5, Gr.2: -0.3+/-0.4 p=0.15) in both groups. BNP plasma levels showed a significant decrease only in Gr.2 (Gr.1: -6+/-41 pg/ml, Gr.2: -34+/-19 pg/ml p=0.02); similarly ET-1 plasma levels showed a trend towards a decrease only in Gr.2 (Gr.1: 0.2+/-4.6 pg/ml, Gr.2: -3.8+/-6.6 pg/ml p=0.09).
Our data confirm that bosentan is an effective therapy for patients with PAH. Its clinical efficacy (effort tolerance and NYHA) seems to be independent from baseline venous ET1 plasma levels. Bosentan therapy seems to elicit different patterns in ET-1 and BNP plasma levels, with decrease of the peptides only in patients with higher activation of the systemic endothelin system. Further studies are warranted to explore the potential impact of baseline ET-1 levels on the long-term effects (clinical worsening) of bosentan therapy.
Regulatory Peptides 09/2008; 151(1-3):48-53. · 2.11 Impact Factor
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ABSTRACT: Pulmonary hypertension (PH) is a clinical condition characterised by elevated pulmonary artery pressure (PAP) and vascular resistances. At the onset of the disease, symptoms are frequently atypical so that PH diagnosis is usually made when the disease is advanced, which often is too late for efficacious treatment. As a consequence the prognosis is poor. Echo-Doppler evaluation allows: (a) an early identification of patients with PH, (b) to establish a patient's prognosis and (c) to evaluate a proper patient's follow-up. In patients with PH echocardiography provides information about right heart dimensions, pulmonary artery pressures, right ventricle systolic and diastolic function and left and right ventricle interdependence. Most importantly Echo-Doppler evaluation has became a major diagnostic tool for PH allowing evaluation of changes with time and with different treatments which are aimed at reducing pulmonary artery pressure and right heart dimensions and at improving right heart function.
Pulmonary Pharmacology & Therapeutics 02/2007; 20(2):135-40. · 2.80 Impact Factor
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Carmine Dario Vizza,
Claudio Letizia, Roberto Badagliacca,
Susanna Sciomer,
Roberto Poscia,
Giorgio Della Rocca,
Carlo Iacoboni,
De Luca Leonardo,
Serena Quattrucci,
Cotesta Dario,
Petramala Luigi,
Francesco Fedele
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ABSTRACT: To study the role of endothelin (ET-1) and adrenomedullin (AM) on pulmonary vascular pressure/flow characteristic (pulmonary arterial pressure/cardiac output (Pap/CO)) during low-dose dobutamine infusion.
Case control study of 14 patients (12 men, 2 women) with severe lung disease (chronic obstructive pulmonary disease, COPD n=5; cystic fibrosis, CF n=9) and 5 control subjects (CTRL, 4 men, 1 woman). ET-1 and AM plasma levels in pulmonary artery (mixed venous blood, ven) and aorta or femoral artery (arterial, art), were measured at baseline and during dobutamine infusion (5-10-15 mcg kg(-1) min(-1)). The Ppa/CO coordinates obtained at baseline and during dobutamina infusion for each patients were used to calculate the Slope and Intercept by linear regression analysis.
Baseline hemodynamics measurements were similar in the three groups with a trend towards a mild elevation in Ppa in CF group (Ppa mm Hg: CTRL 19+/-3.5, COPD 19.4+/-5.5, CF 22.7+/-7.5). Baseline plasma ET-1(ET-1ven pg ml(-1): CTRL 13.9+/-6.7, COPD 20.1+/-14, CF 20.4+/-7.1; ET-1art pg ml(-1): CTRL 16.7+/-6.4, COPD 20.1+/-11.7, CF 18.1+/-3.9) and AM (AMven pg ml(-1): CTRL 15.8+/-5, COPD 31.8+/-17.6, CF 27.7+/-7.6; AMart pg ml(-1): CTRL 15.9+/-1.4, COPD 21.4+/-3.8, CF 27+/-7.6) showed a trend towards higher value among patients' groups compared to the controls. Baseline ET-1 pulmonary gradient did not show significant difference among the three groups as well AM pulmonary gradient. Dobutamine infusion caused a comparable increase of heart rate and CO in the three groups. Mean pulmonary pressure had a trend towards a greater increase in COPD and CF than in controls, consequently, pulmonary Pap/CO relationship showed a steeper slope in patients' groups (Slope mm Hg L(-1) min(-1): CTRL 0.9+/-0.3, COPD 2.1+/-0.8 p<0.02 vs. CTRL, CF 1.9+/-0.9 p<0.03 vs CTRL). During dobutamine plasma ET-1 and AM showed a great individual variability resulting in no significant difference among groups. ET-1 pulmonary gradient showed a trend towards pulmonary uptake in patients' groups (ET-1art-ven pg min(-1): CTRL 2.7+/-2.9, COPD-6.1+/-7.8, CF -4+/-4.8) while AM pulmonary gradient did not show any particular pattern. During dobutamine ET-1 was significantly correlated to Pap/CO characteristics (Slope and ET-1ven, r=-0.59, p<0.05; Slope and ET-1art-ven, r=-0.60, p<0.05; Intercept and ET-1art-ven, r=0.63, p<0.004), and ET-1art-ven was the only independent variable related to Slope and Intercept.
In patients with moderate pulmonary vascular impairment, ET-1 pulmonary gradient, but not AM pulmonary gradient, is inversely correlated with pulmonary incremental resistance, suggesting a role of ET-1 in the regulation of pulmonary vascular resistance.
Regulatory Peptides 10/2006; 136(1-3):85-91. · 2.11 Impact Factor
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ABSTRACT: Prostanoids are a well-established therapy for pulmonary arterial hypertension (PAH), and observational studies suggest their efficacy even in chronic thromboembolic pulmonary hypertension (CTEPH) patients.
To compare the effects of 6 months of treatment with beraprost, an orally-active prostacyclin analog, in patients with distal CTEPH and PAH.
Case-control study.
Sixteen patients with severe pulmonary hypertension (NYHA II-IV), eight with distal CTEPH matched with eight patients with idiopathic PAH for similar effort tolerance.
All patients were in stable clinical and hemodynamic condition for 3 months with maximal standard therapy. During the titration phase (4 weeks) beraprost was increased to maximal tolerated dose (mean daily dosage: CTEPH 275 +/- 47 microg, PAH 277 +/- 47 microg) in adjunction of standard therapy, patients were followed-up for 6 months.
World Heart Organization (WHO) functional class, exercise capacity measured by distance walked in 6 min, and systolic pulmonary pressure (echocardiography), were evaluated at baseline, and at 1-, 3- and 6-month interval.
At 6 months WHO class decreased significantly in both groups (CTEPH from 2.7 +/- 0.6 to 2.0 +/- 0.24, p < 0.05; PAH from 3.0 +/- 0.26 to 2.1 +/- 0.25, p < 0.05), similarly the 6-min walk distance increased significantly from baseline (CTEPH from 312 +/- 31 to 373 +/- 29 m, p < 0.003; PAH from 303 +/- 31 to 347 +/- 29, p < 0.0003). Systolic pulmonary artery pressure showed a trend toward lower value (CTEPH from 85 +/- 7 m to 81 +/- 6 mm Hg, p = NS; PAH from 89 +/- 7 to 82 +/- 5, p = NS). During the observation period we did not have any death. The drug was well-tolerated with minor side-effects.
In patients with CTEPH beraprost had similar mid-term clinical and hemodynamic improvements than in patients with PAH.
Cardiology 02/2006; 106(3):168-73. · 1.71 Impact Factor
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ABSTRACT: Pulmonary arterial hypertension (PAH) is a clinical condition characterized by elevated vascular resistance, associated with a poor prognosis and usually diagnosed in late stage. Echocardiographic assessment of PAH includes early disease detection and functional heart evaluation, in order to introduce a more accurate surveillance at an early stage of the disease and to contribute to prognostic stratification of advanced disease. Detection involves pulmonary artery systolic pressure (PASP) estimation. There is no clear consensus on defining normal distribution, but a PASP of 36 mmHg has been widely assumed as a cut-off value for mild PAH, requiring a more aggressive surveillance to detect further progression. Functional heart evaluation requires an accurate characterization of morphologic and hemodynamic changes, secondary to PAH development, which involves description of dimensional parameters, ventricular interdependency, intracardiac flow patterns, and right ventricular systolic performance. A valid assessment of these issues results in a useful evaluation of cardiac function, supporting clinical context in defining heart failure condition.
Italian heart journal: official journal of the Italian Federation of Cardiology 11/2005; 6(10):840-5.
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ABSTRACT: Human herpesvirus 8 (HHV-8) antibodies were detected in 1 of 33 patients with pulmonary hypertension (including in 1 of 16 with idiopathic pulmonary arterial hypertension), 5 of 29 with cystic fibrosis, and 3 of 13 with interstitial lung disease. No relationship between HHV-8 infection and pulmonary hypertension was found.
Emerging infectious diseases 10/2005; 11(9):1480-2. · 6.17 Impact Factor
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ABSTRACT: The natural history of aortic stenosis is well defined. There is overwhelming evidence that patients with this disease who develop symptoms require prompt aortic valve replacement, as average survival rapidly falls. Once surgery has been performed age-corrected rates of survival approach the rate in the normal population. Conversely, asymptomatic patients with severe aortic stenosis have an excellent clinical prognosis. Nevertheless, there is a low risk of sudden death or rapid rate of progression to the symptomatic state. This low risk while patients remain asymptomatic does not outweigh the risk associated with valve replacement surgery or the complications of artificial prostheses, so surgery is not recommended for the entire group of asymptomatic patients. Therefore, therapeutic decisions in patients with aortic stenosis are based on the definition of symptomatic status and of hemodynamic severity, so accurate evaluation of these two issues is mandatory. However, establishing symptomatic status and severity of valve disease can be challenging because assessment of subjective symptoms and functional capacity is sometimes ambiguous, particularly in the elderly. Furthermore, it is well recognized that assessment of hemodynamic obstruction defined by echocardiographic indexes such as transvalvular pressure gradient and aortic valve area, is suboptimal because of technical difficulties and poor correlation with symptoms. Hence, aortic stenosis evaluation should be also performed introducing in clinical practice new simple indexes, such as function- and pressure-corrected indexes and energy loss index, that could provide a different estimate of disease severity, based on prognostic indication of adverse clinical outcome. Indeed, clinical outcome represents the real endpoint for defining severity and should be incorporated in clinical assessment and used to aid patient management in unclear situations. The development of heart failure in patients with aortic stenosis is associated with a high mortality rate and requires a careful management that includes an initial evaluation of the severity of the stenosis and the functional state of the left ventricle. Left ventricular dysfunction is usually due to afterload mismatch, but as end stage develops, decline in the intrinsic myocardial contractility becomes the most relevant mechanism. However, separating the effect of myocardial contractile dysfunction from that of afterload mismatch on pump performance is difficult. Dobutamine echocardiography can be useful both by testing myocardial contractile reserve and by separating true from relative aortic stenosis. Unfortunately the optimal management of patients with severe aortic stenosis and left ventricular dysfunction remains controversial, and we still have missing data to determine which patients are more likely to benefit from aortic valve replacement, by improving survival and functional status, with an acceptable perioperative mortality rate.
Italian heart journal. Supplement: official journal of the Italian Federation of Cardiology 07/2004; 5(6):457-65.
