177 results found
Vrettos A, Panoulas V, 2021, Diagnosing STEMI in the presence of paced rhythm: dispelling the myth of the 'uninterpretable paced ECG'., BMJ Case Rep, Vol: 14
Monteagudo-Vela M, Panoulas V, Kourliouros A, et al., 2021, Is the quality-of-life improvement after transcatheter aortic valve implantation equivalent to that achieved by surgical aortic valve replacement?, Interact Cardiovasc Thorac Surg
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'is the quality-of-life (QoL) improvement after transcatheter aortic valve implantation (TAVI) equivalent to that achieved by surgical aortic valve replacement (sAVR)?' Literature search revealed 189 papers with reference to QoL after TAVI, of which 7 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers were tabulated. QoL plays a crucial role in the decision-making process for procedures such as TAVI and sAVR. Current evidence included and analysed in this review have shown a clear improvement in QoL after both TAVI and sAVR. TAVI offers a rapid improvement of QoL, evident within the first 30 days. There is no difference in QoL at 2- and 5-year follow-up between TAVI and sAVR. There are currently paucity of data on long-term QoL and the potential impact of structural valve degeneration following TAVI.
Basavarajaiah S, Athukorala S, Kalogeras K, et al., 2021, Mid-term clinical outcomes from use of Sirolimus coated balloon in coronary intervention; data from real world population., Catheter Cardiovasc Interv, Vol: 98, Pages: 57-65
BACKGROUND: Use of drug coated balloons (DCBs) in coronary intervention is escalating. There is a plethora of data on Paclitaxcel-DCB. However, when it comes of stents, Limus-drugs are preferred over Paclitaxel. There is very limited data on Sirolimus coated balloons (SCB). MagicTouch-SCB (Concept Medical, FL) elutes Sirolimus via nano-technology and have been used in our centers since March 2018. We report a mid-term follow-up with this relatively novel-technology. METHODS AND RESULTS: We retrospectively analyzed all patients treated with MagicTouch-SCB between March-2018 and February-2019. Results are reported as cardiac-death, target-vessel myocardial-infarction (TVMI), target lesion revascularization (TLR) and Major Adverse Cardiac Events (MACE). During the study period, 288-patients (373-lesions) with a mean age of 65.8 were treated with MagicTouch-SCB. 84% (n = 241) were male, 155 (54%) were in the setting of acute coronary syndrome, 38% (n = 110) had diabetes and 62% (n = 233) were in de-novo lesions. Most lesions treated were in the LAD/diagonal-system (n = 170; 46%). Pre-dilatation was performed in 92% (n = 345) of cases. Bailout stenting was required in 9% lesions (n = 35). The mean diameter and length of SCBs were 2.64 ± 0.56 mm and 24 ± 8.9 mm respectively. During a median follow-up of 363 days (IQR: 278-435), cardiac death and TVMI occurred in 5-patients (1.7%) and 10-patients (3.4%) respectively, TLR per-lesion was 12%. The MACE rate was 10%. There were no documented cases of acute vessel closure. CONCLUSIONS: The results from mid-term follow-up with this relatively new technology SCB is encouraging with a low rates of hard endpoints and acceptable MACE rates despite complex group of patients and lesion subsets.
Monteagudo-Vela M, Farmidi A, Panoulas V, et al., 2021, Use of Impella RP for Acute Right Ventricular Failure Post-Pericardiectomy., Cardiovasc Revasc Med, Vol: 28S, Pages: 176-179
Surgical pericardiectomy is the accepted treatment for patients with constrictive pericarditis. Right ventricular failure in patients that undergo pericardiectomy is a frequent complication due to sudden volume overload. Impella RP is used to bypass the right ventricle and tackle the transient right ventricular failure. It is implanted percutaneously and provides enough support to achieve haemodynamical stability and recover end-organ function. We report the case of a patient that developed acute right ventricular failure in the early postoperative period of a pericardiectomy. He underwent the implantation of an Impella RP in the setting of acute right ventricular failure and was successfully explanted after 6 days of support.
Panoulas V, Greenough N, Sulemane S, et al., 2021, The Role of Mechanical Circulatory Support in Patients With Severe Left Ventricular Impairment Treated With Transcatheter Aortic Valve Implantation and Percutaneous Coronary Intervention., Cardiovasc Revasc Med, Vol: 28S, Pages: 169-175
Transcatheter aortic valve implantation (TAVI) has become an established treatment for patients with severe aortic stenosis (AS) in an ever-growing patient population. It is not uncommon for patients who are undergoing TAVI to have technically difficult anatomy, simultaneous severe left ventricular (LV) impairment and/or extensive coronary artery disease. In this case series we present examples where the use of mechanical circulatory support (MCS) facilitated a safe aortic and coronary intervention in extremely complex patients who would have otherwise carried prohibitive procedural risk.
Mahon C, Davies A, Gambaro A, et al., 2021, Association of individual aortic leaflet calcification on paravalvular regurgitation and conduction abnormalities with self-expanding trans-catheter aortic valve insertion, Quantitative Imaging in Medicine and Surgery, Vol: 11, Pages: 1970-1982, ISSN: 2223-4292
Background: Complication rates of paravalvular aortic regurgitation (PVR) and permanent pacemaker insertion remain high in patients undergoing trans-catheter aortic valve insertion for severe aortic stenosis. The spatial distribution of calcium between individual aortic valve leaflets, and its potential role in these complications is gaining interest. We aimed to assess the accuracy of individual aortic valve leaflet calcium quantification, and to determine its effect on the frequency of these complications.Methods: This was a retrospective study of 251 patients who underwent trans-catheter aortic valve insertion using the Evolut RTM valve. The off-line Terarecon software platform was used for Agatston scoring the short axis views.Results: There was a correlation between the sum of the individual leaflet and the total aortic valve calcium score. There was a univariate association between an increase [per 100 Agatston unit (AU)] in both right coronary leaflet (RCL) and left coronary leaflet (LCL) calcium with the risk of PVR. There was an association between an increase in LCL calcium score (per 100 AU) and need for post-implantation balloon aortic valvuloplasty (BAV). There was no association between individual leaflet calcification on the risk of permanent pacemaker insertion.Conclusions: This study supports the idea that a quantifiable and reproducible method of individual valve leaflet calcification score may serve as an independent risk factor for paravalvular regurgitation, beyond visual assessment of asymmetry. However, the same may not be true of spatial calcium distribution and permanent pacemaker implantation (PPI).
Vela MM, Baston VR, Panoulas V, et al., 2021, A detailed explantation assessment protocol for patients with left ventricular assist devices with myocardial recovery, INTERACTIVE CARDIOVASCULAR AND THORACIC SURGERY, Vol: 32, Pages: 298-305, ISSN: 1569-9293
Panoulas V, Rathod KS, Jain AK, et al., 2021, Impact of Early (<= 24 h) Versus Delayed (> 24 h) Intervention in Patients With Non-ST Segment Elevation Myocardial Infarction: An Observational Study of 20,882 Patients From the London Heart Attack Group, CARDIOVASCULAR REVASCULARIZATION MEDICINE, Vol: 22, Pages: 3-7, ISSN: 1553-8389
Panoulas V, Monteagudo-Vela M, 2021, Predictors of Short-term Survival in Cardiogenic Shock Patients Requiring Left Ventricular Support Using the Impella CP or 5.0, CJC Open
Background: Percutaneous ventricular assist devices (pVADs) have been used to support patients who are in cardiogenic shock (CS). There is limited data on 30-day mortality predictors in patients supported by an Impella pVAD. Methods: All CS patients requiring left-sided Impella implantation in Harefield Hospital (Greater London, United Kingdom) between 2017 and 2020 were included in the current study. Logistic regression analysis was used to identify predictors of 30-day mortality. Results: A total of 92 patients were included. The mean age was 53.8 ± 14.9 years, and 78.3% were male. CS etiology was predominantly acute coronary syndromes (44.6%), followed by decompensated dilated cardiomyopathy (28.3%). Survival at 30 days was 63% (58 of 92). Deceased patients had a lower left ventricular ejection fraction (LVEF) (15.1 ± 9.6 vs 21.8 ± 14.2, P < 0.001), higher serum lactate levels (2.8[1.6 to 5.4] vs 1.45 [1.08 to 3.53], P = 0.012), a higher percentage of prolonged invasive ventilation (> 24 hours) (64.7% vs 13.8%, P < 0.001), and worse renal and liver function. Serum lactate, baseline LVEF, and prolonged ventilation (> 24 hours) were independent predictors of 30-day survival with an area under the curve of 0.85 (95% confidence interval 0.769 to 0.930), P < 0.001. Conclusions: In the current retrospective registry of patients requiring Impella pVAD implantation, independent 30-day mortality predictors included serum lactate, baseline LVEF, and prolonged invasive ventilation (> 24 hours). These parameters could highlight patients who would benefit from earlier mechanical circulatory support escalation or neurologic assessment to inform withdrawal decisions.
Ruparelia N, Panoulas V, 2020, The missing acute coronary syndromes in the COVID-19 era, THERAPEUTIC ADVANCES IN CARDIOVASCULAR DISEASE, Vol: 14, ISSN: 1753-9447
Monteagudo-Vela M, Panoulas V, Garcia-Saez D, et al., 2020, Outcomes of heart transplantation in patients bridged with Impella 5.0: Comparison with native chest transplanted patients without preoperative mechanical circulatory support, ARTIFICIAL ORGANS, Vol: 45, Pages: 254-262, ISSN: 0160-564X
Tsampasian V, Panoulas V, Jabbour RJ, et al., 2020, Left ventricular speckle tracking echocardiographic evaluation before and after TAVI, ECHO RESEARCH AND PRACTICE, Vol: 7, Pages: 29-38, ISSN: 2055-0464
Panoulas VF, Chandrasekhar J, Busi G, et al., 2020, Prevalence, predictors, and outcomes of patient prosthesis mismatch in women undergoingTAVIfor severe aortic stenosis: Insights from theWIN-TAVIregistry, CATHETERIZATION AND CARDIOVASCULAR INTERVENTIONS, Vol: 97, Pages: 516-526, ISSN: 1522-1946
Kaura A, Sterne J, Trickey A, et al., 2020, Invasive versus non-invasive management of elderly patients with non-ST elevation myocardial infarction: cohort study based on routine clinical data, The Lancet, Vol: 396, Pages: 623-634, ISSN: 0140-6736
BackgroundPrevious trials suggest lower long-term mortality after invasive rather than non-invasive management among patients with non-ST elevation myocardial infarction (NSTEMI), but these excluded very elderly patients.MethodsWe estimated the effect of invasive versus non-invasive management within 3 days of peak troponin on survival in NSTEMI patients aged ≥80 years, using routine clinical data collected during 2010–2017 (NIHR Health Informatics Collaborative). Propensity scores based on pre-treatment variables were derived using logistic regression; patients with high probabilities of non-invasive or invasive management were excluded. Patients who died within 3 days without receiving invasive management were assigned to the invasive or non-invasive management groups based on their propensity scores, to mitigate immortal time bias. We estimated mortality hazard ratios comparing invasive with non-invasive management, and also compared rates of hospital admission for heart failure.FindingsOf 1976 patients with NSTEMI, 101 died within 3 days of their peak troponin, whilst 375 were excluded because of extreme propensity scores. The remaining 1500 patients (56% non-invasive management) had a median age 86 (IQR 82-89) years. During median follow-up of 3.0 (IQR 1.2-4.8) years, there were 613 (41%) deaths. Using inverse probability weighting, adjusted cumulative 5-year mortality was 36% and 55% in the invasive and non-invasive management groups, respectively. The mortality hazard ratio comparing invasive with non-invasive management was 0.64 (95% CI 0.52-0.79) after multivariable adjustment for clinical characteristics and propensity score and inclusion of patients who died within three days. Invasive management was associated with lower incidence of hospital admissions for heart failure (adjusted rate ratio compared with non-invasive management 0.67, 95% CI 0.48–0.93).
Kalogeras K, Ruparelia N, Kabir T, et al., 2020, Comparison of the self-expanding Evolut-PRO transcatheter aortic valve to its predecessor Evolut-R in the real world multicenter ATLAS registry, INTERNATIONAL JOURNAL OF CARDIOLOGY, Vol: 310, Pages: 120-125, ISSN: 0167-5273
Monteagudo-Vela M, Panoulas V, Riesgo-Gil F, et al., 2020, Surgical explant of a right ventricular assist device with sternum-sparing technique, EUROPEAN JOURNAL OF CARDIO-THORACIC SURGERY, Vol: 58, Pages: 193-195, ISSN: 1010-7940
Panoulas V, Kitas GD, 2020, Pharmacological management of cardiovascular risk in chronic inflammatory rheumatic diseases., Expert Rev Clin Pharmacol, Vol: 13, Pages: 605-613
INTRODUCTION: Cardiovascular comorbidity is a major burden in patients with chronic inflammatory rheumatic diseases and a significant determinant of their outcome. In addition to optimal management of the underlying inflammatory condition according to current guidelines, individual cardiovascular risk factors, particularly dyslipidaemia, hypertension, and impaired glucose tolerance should be assessed regularly and guide risk stratification and requirement for treatment. AREAS DISCUSSED: We critically reviewed manuscripts and guidelines on the pharmacological management of dyslipidaemia, hypertension, and diabetes in patients with chronic inflammatory rheumatic diseases (PubMed, MEDLINE, EMBASE, Scopus, Web of Science and Google Scholar, up to 1 March 2020). Lifestyle changes are of paramount importance for the management of these risk factors. In the current narrative review, we discuss pharmacological therapies available and emerging therapies aiming to help patients achieve recommended targets, depending on their individual risk. EXPERT OPINION: CVD risk is increased in people with chronic inflammatory rheumatic diseases. Cardiovascular risk factor management is an essential part of their care. Although relevant guidance exists, there are still major gaps in knowledge and risk factor management implementation in these patient groups. Some practical guidance based on our interpretation of existing data and experience in the field is provided in this review.
Vela MM, Simon A, Gil FR, et al., 2020, Clinical Indications of IMPELLA Short-Term Mechanical Circulatory Support in a Tertiary Centre, CARDIOVASCULAR REVASCULARIZATION MEDICINE, Vol: 21, Pages: 629-637, ISSN: 1553-8389
Monteagudo Vela M, Panoulas V, 2020, Impella in Cardiogenic Shock: Who and When?, Cardiovasc Revasc Med, Vol: 21
Monteagudo-Vela M, Simon A, Panoulas V, 2020, Initial experience with Impella RP in a quaternary transplant center., Artif Organs, Vol: 44, Pages: 473-477
Right ventricular failure is one of the most common complications encountered after left ventricular assist device implantation and heart transplantation. It has been reported to have an incidence up to 30%. It increases morbidity and short-term mortality. Impella RP is a small pump that can provide up to 4L/min of flow. We analyzed all the patients with right ventricular failure that were treated with Impella RP in our institution. The Impella RP was implanted percutaneously in the catheterization laboratory guided by fluoroscopy. Overall, 7 patients required the implantation of an Impella RP due to right ventricular failure: 2 after long-term LVAD, 3 presented with acute right ventricular failure immediately after LVAD implantation, and 2 needed it after heart transplantation. Regarding complications, we report 2 patients with hemolysis. Hemodynamic parameters as well as end-organ perfusion and inotropic requirements improved after the insertion of the Impella. Overall, 30-day survival is 58%. Median time of support was 9 (5-19) days. RV failure is one of the most challenging complications after LVAD implantation and heart transplantation. The major challenge is the timing of implantation. The minimally invasive nature of the Impella RP facilitates de-escalation of treatment and paves the road to recovery. Impella RP proved useful in facilitating ECMO wean. Used in a prompt manner alongside the ease of implantation and the minimal rate of complications, Impella RP seems to be an appropriate device to tackle RV failure providing enough flow to allow for recovery or escalation decision-making.
Panoulas V, Monteagudo-Vela M, Kalogeras K, et al., 2020, Subclavian Impella 5.0 to the rescue in a non-ST elevation myocardial infarction patient requiring unprotected left main rotablation: A case report, WORLD JOURNAL OF CARDIOLOGY, Vol: 12, Pages: 155-160, ISSN: 1949-8462
Kaura A, Arnold AD, Vasileios P, et al., 2020, Prognostic significance of troponin level in 3,121 patients presenting with atrial fibrillation (The NIHR Health Informatics Collaborative TROP-AF study), Journal of the American Heart Association, Vol: 9, ISSN: 2047-9980
Background-—Patients presenting with atrial fibrillation (AF) often undergo a blood test to measure troponin, but interpretation of theresult is impeded by uncertainty about its clinical importance. We investigated the relationship between troponin level, coronaryangiography, and all-cause mortality in real-world patients presenting with AF.Methods and Results-—We used National Institute of Health Research Health Informatics Collaborative data to identify patients admitted between 2010 and 2017 at 5 tertiary centers in the United Kingdom with a primary diagnosis of AF. Peak troponin results 7 were scaled as multiples of the upper limit of normal. A total of 3121 patients were included in the analysis. Over a median followup of 1462 (interquartile range, 929–1975) days, there were 586 deaths (18.8%). The adjusted hazard ratio for mortality associatedwith a positive troponin (value above upper limit of normal) was 1.20 (95% CI, 1.01–1.43; P<0.05). Higher troponin levels were associated with higher risk of mortality, reaching a maximum hazard ratio of 2.6 (95% CI, 1.9–3.4) at 250 multiples of the upper limit of normal. There was an exponential relationship between higher troponin levels and increased odds of coronary angiography.The mortality risk was 36% lower in patients undergoing coronary angiography than in those who did not (adjusted hazard ratio, 0.61; 95% CI, 0.42–0.89; P=0.01).Conclusions-—Increased troponin was associated with increased risk of mortality in patients presenting with AF. The lower hazard ratio in patients undergoing invasive management raises the possibility that the clinical importance of troponin release in AF may be mediated by coronary artery disease, which may be responsive to revascularization.
Cummings IG, Lucchese G, Garg S, et al., 2020, Ten-year improved survival in patients with multi-vessel coronary disease and poor left ventricular function following surgery: A retrospective cohort study., Int J Surg, Vol: 76, Pages: 146-152
OBJECTIVE: Patients with multi-vessel coronary artery disease and poor left ventricular (LV) function (ejection fraction [EF] < 30%) requiring revascularization are considered 'high-risk'. Limited long-term survival data exists comparing percutaneous coronary intervention (PCI) with second-generation drug-eluting stents (DES) versus surgery for this cohort of patients. METHODS: We retrospectively reviewed our data for 321 patients with EF < 30% who underwent multi-vessel revascularization from January 2005 to December 2015 using Cox regression analyses and inverse probability treatment weighted (IPTW) methods. We stratified patients that underwent surgical revascularization into on-pump coronary artery bypass grafting (CABG) and off-pump CABG and analyzed all-cause mortality at 10 years compared to PCI. RESULTS: 214 patients underwent CABG (n [on-pump CABG] = 94; n [off-pump CABG] = 120) and 107 patients had PCI with second generation DES. PCI with DES had higher 10-year mortality compared with on-pump CABG (Hazard ratio [HR] = 1.86, 95% confidence interval [CI] = 1.46-2.42; p < 0.001) and off-pump CABG (HR = 2.32, 95% CI = 1.75-3.15; p < 0.001). This was confirmed in IPTW analyses. When adjusting for both measured and unmeasured factors using instrumental variable analyses, PCI with DES had higher 10-year mortality compared with on-pump CABG (Δ = 13.5, 95% CI = 3.2-24.5; p = 0.012) and off-pump CABG (Δ = 16.1, 95% CI = 5.9-25.8; p < 0.001). CONCLUSION: Surgical revascularization, preferably off-pump CABG, results in better long-term survival compared with PCI using second generation DES for patients with multi-vessel coronary artery disease and poor left ventricular function. Randomized controlled trials in this patient group should be undertaken.
Kaura A, Panoulas V, Glampson B, et al., 2019, Association of troponin level and age with mortality in 250 000 patients: cohort study across five UK acute care centres, BMJ-British Medical Journal, Vol: 367, ISSN: 1756-1833
ObjectiveTo determine the relation between age and troponinlevel and its prognostic implication.DesignRetrospective cohort study.SettingFive cardiovascular centres in the UK National Institutefor Health Research Health Informatics Collaborative(UK-NIHR HIC).Participants257948 consecutive patients undergoing troponintesting for any clinical reason between 2010 and2017.Main outcome measureAll cause mortality.Results257948 patients had troponin measured during thestudy period. Analyses on troponin were performedusing the peak troponin level, which was the highesttroponin level measured during the patient’s hospitalstay. Troponin levels were standardised as a multipleof each laboratory’s 99th centile of the upper limitof normal (ULN). During a median follow-up of 1198days (interquartile range 514-1866 days), 55850(21.7%) deaths occurred. A positive troponin result(that is, higher than the upper limit of normal)signified an overall 3.2-fold higher mortality hazard(95% confidence interval 3.1-fold to 3.2-fold) overthree years. The mortality hazard varied markedly withage, from 10.6-fold (8.5-fold to 13.3-fold) in 18-29year olds to 1.5 (1.4 to 1.6) in those older than 90.A positive troponin result was associated with anapproximately 15 percentage points higher absolutethree year mortality across all age groups. The excessmortality with a positive troponin result was heavilyconcentrated in the first few weeks. Results wereanalysed using multivariable adjusted restrictedcubic spline Cox regression. A direct relation wasseen between troponin level and mortality in patientswithout acute coronary syndrome (ACS, n=120049),whereas an inverted U shaped relation was foundin patients with ACS (n=14468), with a paradoxicaldecline in mortality at peak troponin levels >70xULN.In the group with ACS, the inverted U shaped relationpersisted after multivariable adjustment in those whowere managed invasively; however, a direct positiverelation was found between troponin level
Dowling C, Firoozi S, Panoulas V, et al., 2019, Initial experience of a self-expanding transcatheter aortic valve with an outer pericardial wrap: The United Kingdom and Ireland Implanters' registry, CATHETERIZATION AND CARDIOVASCULAR INTERVENTIONS, Vol: 95, Pages: 1340-1346, ISSN: 1522-1946
Panoulas VF, Ilsley CJ, Kalogeras K, et al., 2019, Coronary artery bypass confers intermediate-term survival benefit over percutaneous coronary intervention with new-generation stents in real-world patients with multivessel coronary artery disease, including left main disease: a retrospective analysis of 6383 patients, EUROPEAN JOURNAL OF CARDIO-THORACIC SURGERY, Vol: 56, Pages: 911-918, ISSN: 1010-7940
Panoulas VF, Monteagudo Vela M, Kalogeras K, et al., 2019, Percutaneous Impella CP exchange with preservation of transfemoral access., Cardiovasc Revasc Med, Vol: 20, Pages: 63-66
In patients with cardiogenic shock, the global use of percutaneous mechanical circulatory support using the Impella CP device has increased with early data suggesting potential benefits over conservative management. In the current case report we describe a simple technique facilitating percutaneous Impella CP or RP exchange with preservation of transfemoral access, which does not require the use of a 0.035' wire. This technique allows for percutaneous sealing of the 14F arteriotomy using new closure devices avoiding the traditional cut-down.
Monteagudo-Vela M, Panoulas V, Fernandez-Garda R, et al., 2019, Combined Use of Left Ventricular Assist Device, Extra Corporeal Life Support and Impella RP., Cardiovasc Revasc Med, Vol: 20, Pages: 67-69
Kalogeras K, Jabbour RJ, Ruparelia N, et al., 2019, Comparison of warfarin versus DOACs in patients with concomitant indication for oral anticoagulation undergoing TAVI; results from the ATLAS registry, JOURNAL OF THROMBOSIS AND THROMBOLYSIS, Vol: 50, Pages: 82-89, ISSN: 0929-5305
Mittal TK, Reichmuth L, Bhattacharyya S, et al., 2019, Inconsistency in aortic stenosis severity between CT and echocardiography: prevalence and insights into mechanistic differences using computational fluid dynamics, Open Heart, Vol: 6, ISSN: 2053-3624
Objectives The aims of this study were to evaluate the inconsistency of aortic stenosis (AS) severity between CT aortic valve area (CT-AVA) and echocardiographic Doppler parameters, and to investigate potential underlying mechanisms using computational fluid dynamics (CFD).Methods A total of 450 consecutive eligible patients undergoing transcatheter AV implantation assessment underwent CT cardiac angiography (CTCA) following echocardiography. CT-AVA derived by direct planimetry and echocardiographic parameters were used to assess severity. CFD simulation was performed in 46 CTCA cases to evaluate velocity profiles.Results A CT-AVA>1 cm2 was present in 23% of patients with echocardiographic peak velocity≥4 m/s (r=−0.33) and in 15% patients with mean Doppler gradient≥40 mm Hg (r=−0.39). Patients with inconsistent severity grading between CT and echocardiography had higher stroke volume index (43 vs 38 mL/m2, p<0.003) and left ventricular outflow tract (LVOT) flow rate (235 vs 192 cm3/s, p<0.001). CFD simulation revealed high flow, either in isolation (p=0.01), or when associated with a skewed velocity profile (p=0.007), as the main cause for inconsistency between CT and echocardiography.Conclusion Severe AS by Doppler criteria may be associated with a CT-AVA>1 cm2 in up to a quarter of patients. CFD demonstrates that haemodynamic severity may be exaggerated on Doppler analysis due to high LVOT flow rates, with or without skewed velocity profiles, across the valve orifice. These factors should be considered before making a firm diagnosis of severe AS and evaluation with CT can be helpful.
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