AORTIC STENOSIS – ETIOLOGY, PATHOPHYSIOLOGY AND TREATMENT Edited by Masanori Hirota Aortic Stenosis – Etiology, Pathophysiology and Treatment Edited by Masanori Hirota Published by InTech Janeza Trdine 9, 51000 Rijeka, Croatia Copyright © 2011 InTech All chapters are Open Access articles distributed under the Creative Commons Non Commercial Share Alike Attribution 3.0 license, which permits to copy, distribute, transmit, and adapt the work in any medium, so long as the original work is properly cited. After this work has been published by InTech, authors have the right to republish it, in whole or part, in any publication of which they are the author, and to make other personal use of the work. Any republication, referencing or personal use of the work must explicitly identify the original source. Statements and opinions expressed in the chapters are these of the individual contributors and not necessarily those of the editors or publisher. No responsibility is accepted for the accuracy of information contained in the published articles. The publisher assumes no responsibility for any damage or injury to persons or property arising out of the use of any materials, instructions, methods or ideas contained in the book. Publishing Process Manager Alenka Urbancic Technical Editor Teodora Smiljanic Cover Designer Jan Hyrat Image Copyright Floris Slooff, 2011. Used under license from Shutterstock.com First published September, 2011 Printed in Croatia A free online edition of this book is available at www.intechopen.com Additional hard copies can be obtained from orders@intechweb.org Aortic Stenosis – Etiology, Pathophysiology and Treatment, Edited by Masanori Hirota p. cm. ISBN 978-953-307-660-7 free online editions of InTech Books and Journals can be found at www.intechopen.com Contents Preface IX Part 1 Introduction 1 Chapter 1 Aortic Stenosis - New Insights in Stenosis Progression and in Prevention 3 Parolari Alessandro, Trezzi Matteo, Merati Elisa, Filippini Sara and Alamanni Francesco Part 2 Etiology and Pathophysiology 23 Chapter 2 Aortic Stenosis: Geriatric Considerations 25 Petar Risteski, Andreas Zierer, Nestoras Papadopoulos, Sven Martens, Anton Moritz and Mirko Doss Chapter 3 Pathophysiologic Mechanisms of Age – Related Aortic Valve Calcification 33 Alexandros Alexopoulos, Nikolaos Michelakakis and Helen Papadaki Part 3 Diagnosis and Prognosis 49 Chapter 4 Asymptomatic Aortic Stenosis - Prognosis, Risk Stratification and Follow-Up 51 Paoli Ursula and Dichtl Wolfgang Chapter 5 Stress Testing in Patients with Asymptomatic Severe Aortic Stenosis 67 Asim M. Rafique, Kirsten Tolstrup and Robert J. Siegel Chapter 6 Analog Simulation of Aortic Stenosis 75 M. Sever, S. Ribarič, F. Runovc and M. Kordaš Part 4 Surgical and Interventional Treatments 89 Chapter 7 Minimally Invasive Aortic Valve Surgery - New Solutions to Old Problems 91 Juan Bustamante, Sergio Cánovas and Ángel L Fernández VI Contents Chapter 8 Technical Modifications for Patients with Aortic Stenosis and Calcified Ascending Aorta During Aortic Valve Replacement 115 Masanori Hirota, Joji Hoshino, Yasuhisa Fukada, Shintaro Katahira, Taichi Kondo, Kenichi Muramatsu and Tadashi Isomura Chapter 9 Transcatheter Aortic Valve Implantation: New Hope for Inoperable and High-Risk Patients 131 Kentaro Hayashida and Thierry Lefèvre Chapter 10 Management of Congenital Aortic Stenosis by Catheter Techniques 153 Mehnaz Atiq Part 5 Molecular Considerations in Aortic Stenosis 165 Chapter 11 Proteomics - A Powerful Tool to Deepen the Molecular Mechanisms of Aortic Stenosis Disease 167 Felix Gil-Dones, Fernando de la Cuesta, Gloria Alvarez-Llamas, Luis R. Padial, Luis F. López-Almodovar, Tatiana Martín-Rojas, Fernando Vivanco and Maria G. Barderas Chapter 12 The Inflammatory Infiltrate in Calcific Aortic Stenosis is Characterized by Clonal Expansions of T Cells and is Associated with Elevated Proportions of Circulating Activated and Effector Memory CD8 T Cells 187 Robert Winchester and Susheel Kodali Chapter 13 Natriuretic Peptides in Severe Aortic Stenosis - Role in Predicting Outcomes and Assessment for Early Aortic Valve Replacement 203 Aaron Lin and Ralph Stewart Chapter 14 Cellular and Neuronal Aspects in Aortic Stenosis 221 J. Ker and WFP Van Heerden Part 6 Associated Disorders with Aortic Stenosis 229 Chapter 15 Severe Calcific Aortic Valve Stenosis and Bleeding: Heyde's Syndrome 231 Giampaolo Zoffoli, Domenico Mangino, Andrea Venturini, Angiolino Asta, Alberto Terrini, Chiara Zanchettin, Francesco Battaglia and Elvio Polesel Chapter 16 Hybrid Procedure in Neonatal Critical Aortic Stenosis and Borderline Left Heart: Buying Time for Left Heart Growth 239 Ward Y. Vanagt, Stephen C. Brown and Marc Gewillig Preface At the moment, aortic stenosis (AS) is the most prevalent valvular disease in the developed countries. Pathological and molecular mechanisms of AS have been investigated in many aspects, and new therapeutic devices, such as trans-catheter aortic valve implantation, have been developed as a less invasive treatment for high- risk patients. Due to advanced prevalent age of AS, further research results and technology are required to treat elderly patients for longer life expectancy. This book is an effort to present an up-to-date account of existing knowledge, involving recent development in this field. There are 15 chapters written by several expert researchers and clinicians, including cardiologists, cardiac surgeons, pediatricians, physiologists, pathologists and immunologists. These opinion leaders described details of established knowledge, as well as newly recognized advances associated with diagnosis, treatment and mechanism in their speciality. This book will enable close intercommunication to another field and collaboration technology for new devices. We hope that it will be an important source, not only to clinicians, but also to general practitioners, contributing to development of better therapeutic adjuncts in the future. Masanori Hirota, MD, PhD Department of Cardiovascular Surgery, Hayama Heart Center, Kanagawa, Japan [...]... an early cartilage formation, and the aortic valve demonstrates the mineralized osteoblast phenotype,which follows the spectrum of normal skeletal bone formation The 6 Aortic Stenosis Etiology, Pathophysiology and Treatment calcified aortic valves express an osteoblast phenotype: bone in the aortic valve that is responsible for the stenosis present in symptomatic aortic stenosis requiring surgical valve... compared, with and without aortic stenosis, and significant differences between the two groups were observed in the genotype of the vitamin D receptors (27) Another study identified polymorphisms of the apolipoproteins AI, B and E as predisposing factors for development of calcification and valvular stenosis (28) Finally, a unique study by Garg et al 10 Aortic Stenosis Etiology, Pathophysiology and Treatment. .. of stenosis by ACC/AHA 2006 (20) and includes the following: Valve area 1 mild aortic stenosis: area > 1.5 cm2 2 moderate aortic stenosis: area 1 to 1.5 cm2 3 severe aortic stenosis: area < 1.0 cm2 Aortic velocity allows classification of stenosis as 1 mild (less than 3.0 m/s) 2 moderate (3 to 4 m/s) 3 severe (>4 m/s) but in the revision and the update of ACC/AHA guidelines (2006) the grading of aortic. .. to develop aortic sclerosis and those likely to progress to aortic stenosis Only a few studies have examined the relationship between CRP and aortic stenosis Galante et al (6) published the initial study demonstrating elevated CRP levels in association with calcific aortic stenosis In a surgical series, CRP levels were higher in severe aortic stenosis patients compared to patients with pure aortic regurgitation... is more turbulent, causing increased wear and tear on the valve leaflets Over time, excessive wear and tear leads to calcification, 4 Aortic Stenosis Etiology, Pathophysiology and Treatment scarring, and reduced mobility of the valve leaflets About 10% of bicuspid valves become significantly narrowed, resulting in the symptoms and heart problems of aortic stenosis The most common cause for AS in adults... mild aortic stenosis and every 12 years in those with moderate stenosis Prompt echocardiography should be performed anytime there is new symptom onset Infective endocarditis prophylaxis should be followed Patients with moderate-to-severe aortic stenosis should avoid athletics, which require high dynamic and Aortic Stenosis - New Insights in Stenosis Progression and in Prevention 11 static muscular demands... MedlinePlus: Aortic Stenosis [2] Rossebứ AB et al (2008) Intensive Lipid Lowering with Simvastatin and Ezetimibe in Aortic Stenosis N Engl J Med 10.1056 [3] Carabello BA, Paulus WJ (2009) Review Aortic stenosis The lancet vol 373,march 14, 2009 [4] Roberts WC, Ko JM (2005) Frequency by decades of unicuspid, bicuspid, and tricuspid aortic valves in adults having isolated aortic valve replacement for aortic stenosis, ... angiotensin II and the angiotensin II type-1 receptor, have been identified in aortic sclerotic lesions , which stimulate monocyte infiltration and macrophage uptake of modified LDL (34) Calcification, the hallmark characteristic of aortic valve stenosis, is also clearly a feature of the active inflammatory process, occurring in valve 12 Aortic Stenosis Etiology, Pathophysiology and Treatment regions... associated with aortic calcification and stenosis, OPN is the only molecule that is implicated in both inflammation and biomineralization processes, which lead to aortic valve calcification and subsequent stenosis Also Ferrari and Grau demonstrates a direct correlation of NT-proBNP, BNP, and osteopontin and the presence of calcific AS, while fetuin A showed an inverse correlation Plasma ADMA and homocysteine... calcific aorticvalve disease They observed that older age, male gender, hypertension, coronary artery disease, and renal insufficiency, but not CRP values, are associated with the presence of increasing calcific aortic valve abnormality and that CRP values are not related to the progression from a normal aortic valve to aortic sclerosis or stenosis, nor progression from aortic sclerosis to aortic stenosis . AORTIC STENOSIS – ETIOLOGY, PATHOPHYSIOLOGY AND TREATMENT Edited by Masanori Hirota Aortic Stenosis – Etiology, Pathophysiology and Treatment Edited. increased wear and tear on the valve leaflets. Over time, excessive wear and tear leads to calcification, Aortic Stenosis – Etiology, Pathophysiology and Treatment 4 scarring, and reduced. AI, B and E as predisposing factors for development of calcification and valvular stenosis (28). Finally, a unique study by Garg et al. Aortic Stenosis – Etiology, Pathophysiology and Treatment