The severity of aortic stenosis according to echocardiographic criteria.
\\n\\n
Released this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\\n\\nWe wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
\\n"}]',published:!0,mainMedia:null},components:[{type:"htmlEditorComponent",content:'IntechOpen is proud to announce that 179 of our authors have made the Clarivate™ Highly Cited Researchers List for 2020, ranking them among the top 1% most-cited.
\n\nThroughout the years, the list has named a total of 252 IntechOpen authors as Highly Cited. Of those researchers, 69 have been featured on the list multiple times.
\n\n\n\nReleased this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\n\nWe wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
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He is an international reviewer of recognized journals and an expert editor in ad hoc networks, mobile networks, computer technology, telecommunication networks, wearables, Industry 4.0, drones swarms, and algorithms. He has published more than 100 publications of various kind among which are seven books with more than 300,000 downloads.\nDr. Ortiz is also a thesis director for undergraduates and postgraduates in telematics, computer, telecommunication, and electronic engineering programs. Currently, he is a professor at UNAD and CEO of CloseMobile R&D.",institutionString:"CloseMobile R&D",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"2",totalChapterViews:"0",totalEditedBooks:"1",institution:null}],coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"536",title:"Mobile Computing",slug:"communications-and-security-mobile-computing"}],chapters:[{id:"67574",title:"Wireless Communications Challenges to Flying Ad Hoc Networks (FANET)",slug:"wireless-communications-challenges-to-flying-ad-hoc-networks-fanet-",totalDownloads:772,totalCrossrefCites:2,authors:[{id:"290776",title:"Dr.",name:"José",surname:"Jailton",slug:"jose-jailton",fullName:"José Jailton"},{id:"290799",title:"Dr.",name:"Tassio",surname:"Costa Carvalho",slug:"tassio-costa-carvalho",fullName:"Tassio Costa Carvalho"},{id:"298486",title:"BSc.",name:"Miguel Itallo B.",surname:"Azevedo",slug:"miguel-itallo-b.-azevedo",fullName:"Miguel Itallo B. 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In 2016 the global production was above 33 × 106 metric tons and occupied about 5.6 × 106 hectares [1]. According to a survey in 2013, 1.55 million holdings in the European Union (UE) managed fruit orchards, and in 2015 3.2 million hectares were dedicated to fruit growing that represented more than 28 × 106 euros in 2018 [2]. In 2017, the world area under vines rose to 7534 kha, and grape production reached 73 million tons most of it for wine production estimated at 279 million hectoliters in 2018 [3]. Europe is a leading producer of wine grapes with 3.2 million hectares under vines worth of almost 22 billion euros of wine exports [2]. In 2018, the global production of table olives was estimated in 1.8 × 106 tons (EU 0.9 × 106) and 3.1 × 106 tons of olive oil (EU 2.2 × 106), representing a trade value of 2.8 × 106 euros for olive oil (EU 2.1 million euros) [2]. These figures render the importance of fruit production on a global scale that is likely to increase in the near future in tandem with larger demand for food, fiber, and fuel as a result of growing population, change in dietary preferences, and bioenergy policies [4]. The food demand driven by a larger and more affluent population challenges the agricultural systems to increase the output with reduced external inputs and minimal environmental impacts [5, 6] all under more difficult environmental conditions given the forecasts of an increased temperatures and more irregular rainfalls that negatively affect agriculture [7], and the Southern Europe will be strongly affected where yield losses and impaired product quality are expected [8, 9].
Average temperature is expected to rise somewhere between 1.5 and 4°C from pre-industrial time until the end of the century [7]. Temperature increase affects photosynthesis, causing changes in concentration of sugars and organic acids, flavonoid contents, fruit firmness, and antioxidant activity [10].
Some unripe fruits with green skin can photosynthesize, but the fruits are primarily a sink of photosynthetic products with origin in the leaves. The temperature of the leaves follows approximately the air temperature, and net photosynthesis increases with temperature up to a certain limit that is species dependent, but in general at values greater than 35°C, there is a reduction of photosynthetic activity [11]. Temperature has strong influence on leaf water potential (ψl), stomatal conductance (gs), and intercellular CO2 concentration [12]. Rising temperatures increase the water loss from the leaves, and their water potential becomes more negative to a point the stomata start closing reducing stomatal conductance and the flow of intercellular CO2 that further impairs photosynthesis [13]. High temperature also diminishes starch and sucrose synthesis, by reduced activity of sucrose phosphate synthase, ADP-glucose pyrophosphorylase, and invertase [14]. Heat stress can reduce the total leaf area of the plants and trigger earlier leaf senescence that have a negative impact on the total photosynthesis performance [12]. Prolonged periods of low photosynthetic activity deplete reserves of carbohydrates, and plants might starve [15].
Soluble sugars (sucrose, glucose, and fructose) and organic acids (tartaric, malic, and citric acids) are major osmotic compounds that accumulate in fleshy fruits [15]. The biosynthesis of these compounds is related to photosynthesis that uses light (solar radiation) as source of energy, and it has been shown that the photosynthetic rate is positively correlated with light intensity till a saturation point is reached depending on the plant species and on temperature [12]. Increased light intensity also raises the temperature, and, above a critical level, protein and enzymes are broken, photosynthetic tissue is killed, cells might die, and fruits are sunburnt, all resulting in yield loss and low-quality produce [16].
At molecular level, temperature influences the protein structure, and the activity of cellular proteins becomes less stable under high and low temperatures indirectly affecting the activity of transmembrane transporters necessary to import assimilates and nutrients and to accumulate sugars and polyphenols in the fruit for the completion of the maturation process [17].
Fruits and vegetables contain different antioxidant compounds such as vitamin C, vitamin E, carotenoids, and polyphenol compounds. Among the polyphenols, flavonoids (flavanols, flavonols, and anthocyanins) are largely present in plants, and their content is partially responsible for antioxidant activity. Temperature is the most significant factor affecting antioxidant activity in vegetables and fruits, and, as temperature raises, the enzyme reactions are accelerated, antioxidant activity is augmented, and existing antioxidants decline [18].
Stressful conditions related to high temperatures are coupled with water availability that can mitigate or aggravate the effects of temperature. The increase in water demand when temperature rises is driven by plant transpiration necessary just to keep their canopies cool by water evaporation. Thus, water demand will increase at the same time as rainfall is scarcer and irregular in its frequency; therefore, an efficient use of water is particularly important for agriculture, which is the major sector for the use of freshwater resources and whose economic viability is dependent on water availability. Water uptake from the soil brings mineral nutrients that are circulated together with organic nutrients through the vascular tissues of the plant as water circulates throughout the plant. Water retention determines cell turgor, drives plant cell expansion, and permits many plant functions such as stomatal movements and transpiration [19]. Water is the abiotic factor that exerts a major effect on growth and productivity of agricultural crops, and increasingly frequent periods of drought, particularly in the Mediterranean region, is expected to be the most adverse among the abiotic factors [20].
Moderate drought reduces yields but can have a beneficial effect in fruit quality via two major mechanisms: (a) reduction in leaf stomatal conductance that results in a decrease in net photosynthesis and (b) exacerbation of oxidative stress/oxidative signaling. Net photosynthesis is responsible for primary metabolites that are the major source of precursors for the biosynthesis of phenolic compounds, carotenoids, and ascorbate. Oxidative stress may trigger the biosynthetic pathways of these compounds [21, 22]. The balance between productivity and quality benefits from a certain level of water deficit, but it depends upon the intensity, duration, and repetition of events of water deficit [23]. Water deficits during the vegetative growth stages difficult canopy development, flowering and fruit setting, and the accumulation of carbon compounds. On other hand, deficits occurring during the maturation of fruits show positive impacts on soluble sugar accumulation and enhancement of fruit aroma. The level of stress that benefits the entire cycle of the plant is likely to be depend, simultaneously, on species and environmental conditions, but when a certain threshold of water stress is surpassed, the beneficial effects are no longer observed [23, 24].
The fruit quality is a composition of physicochemical properties and the perception of the consumer allowing for a definition of quality that discriminates between natural characteristics of the fruit and those dictated by socioeconomic and marketing factors [25, 26]. The quality of grapes (Vitis vinifera L.) for winemaking is evaluated on characteristics imparted to the final product, and as such their quality is referred to the berry composition, in particular, to the content of sugars, organic acids, amino acids, phenolics, and aroma precursors that are function of genotypic, environmental, and agronomic factors [25, 27].
After fruit setting, the berry pericarp and the seeds augment in volume rapidly; organic acids, mostly malic, tartaric, and citric, accumulate in the mesocarp cell vacuoles. At the end of this period, growth slows down, and the seed maturation is completed. The maturation phase initiates at veraison, when berries of red varieties accumulate anthocyanins (red pigments) in the exocarp, glucose and fructose accumulate, malate is metabolized as a source of carbon for respiration, and volatile organic compounds are biosynthesized [28].
Abiotic stress, temperature, radiation, and water changes the pattern of growth and development of vines, and they trigger the accumulation in berry pulps, seeds, and skins of secondary metabolites (polyphenols and volatiles) as defense against cell damage [29]. The secondary metabolites present in the must contribute to wine characteristics as taste, aroma, antioxidant capacity, and stabilization during the aging process. Thus, the vineyards are managed to influence the profile and concentration of secondary metabolite to obtain the desirable wine typicity.
The Mediterranean-type climate has long warm periods well suited to growth and development of grape vines, but that period is also low in rainfall that can create serious lack of water availability. The wine regions of Northeastern Portugal are distinctively Mediterranean and have already shown the alterations in temperatures and rainfalls expected under the forecasted climatic change. Annual rainfall has been declining since the 1950s, winter temperatures are milder, and average temperatures for the grape growing season are reaching the upper limit for producing high-end wines [30, 31]. To maintain the grape quality desirable to meet the demand of a world market will be a challenging task involving the best suitable varieties and agronomic practices supported on knowledge gained by experience and research.
A clearly noticeable phenomenon resulting from higher temperatures is the advance of the phenological stages of the grapevines, with a short growing season leaving the maturation to develop under hotter and drier conditions [32, 33]. Berries maturing under high temperature have reduced content of anthocyanins [34] that are hydrophilic secondary metabolites that confer orange, red, or blue coloration to grapes and help protecting the plant tissues against abiotic stressors such as high radiation. A lower content of anthocyanins has a negative impact on the color of red wines, an important organoleptic characteristic. Sugar accumulation in the berries increases as the temperature rises, but there is a sharp fall in acidity and malate content creating an imbalance alcohol/acidity that is deleterious to high-quality wines [35, 36]. These phenomena are dependent on variety tolerance to high temperatures [35]; thus, the viticulturists must choose carefully before they start new plantations, reaching for a compromise between adaptability and quality. Usually, native varieties thrive better on a given environment than exotic ones even when conditions suffer large alterations that is the case of Touriga Nacional in Portugal, a valuable premium variety to produce high-quality wines, well adapted to regions with intense solar radiation and warm climates [37, 38], and the adaptability to different climatic conditions is a variety trait important to mitigate the effects of stressful factors on the berry quality [39, 40].
High temperatures increase evapotranspiration that coupled with declining rainfalls further deplete soil water availability, and this is actually the most pressing challenge to wine grape production in areas where aridity is advancing [41]. Nevertheless, berry quality benefits from moderate levels of water stress because skin-to-pulp ratio increases as the berries become smaller [24, 42], elevating the concentration of total soluble solids (mostly sugars) and secondary metabolites, such as phenolic compounds (especially anthocyanins) and aromatic compound (in particular norisoprenoids) whose biosynthesis is enhanced as response of the vine to water stress [43, 44, 45]. Higher content on sugar and secondary metabolites in berries will produce wines higher in alcohol, deeper in colors, and richer in aromas but also lower in titrable acidity as organic acids, mainly malic and tartaric, are depleted [24, 44].
Temperature and water stresses have different outcomes on yield and berry quality depending on their intensity and timing related to the development phase of the vine. The vineyard manager can use this knowledge to manipulate agronomic practices and obtain the desirable yield and berry quality with the most efficient use of resources, in particular, water. New vineyards must be planted with known varieties to be well to actual conditions but also with plasticity to withstand more stressful conditions; the vine rows trellised at vertical shoot position are to be oriented north to south where the terrain permits and the location carefully chosen to avoid the most severe effects expected to be brought about by coming changes. In vineyards already under commercial exploration and that are expected to have a life span of a few decades there are technical practices that can reduce the worst effects of excessive temperature and radiation, and of low amount of available soil water.
The most common result of high-intensity radiation, usually coupled with elevated temperatures, is the shriveling and sunburn of berries, reducing both yields and quality of the musts. The incidence of these phenomena is felt more acutely in vineyards where the rows are oriented west to east and one of the faces (south face in northern hemisphere) is directly illuminated all day long. One solution is to shade the lower third of the canopy with a vertically placed net close to the canopy during the period when intense radiation and its effects are expected to cause damages. Shaded vineyards maintain much higher yields than non-shaded ones but at the cost of lower concentration of anthocyanins, and their musts render wines with lighter color that can be considered detrimental to its quality [46].
Other techniques that can maintain higher photosynthetic activity and simultaneously reduce the incidence of berry sunburn are canopy coating with kaolin and intermittent nebulization with water at high pressure. They reduce plant temperature and allow for higher stomatal conductance and, consequently, increased photosynthetic rate that contributes to larger berry sugar content [33, 47]. Treated plants keep better yields, produce berries with higher concentration of sugars, and show no significant difference on other must characteristics [33].
Irrigation is already common in many wine-producing regions in Southern Europe, the Western United States, and Australia, among others, and with expected reduction in rainfall, it will be indispensable to maintain the economic activity. The challenge is to keep a balance between productivity, quality, and efficiency in the use of resources, especially water. Moderate water deficits at optimized timing can improve berry quality and support economical yields [40, 48]. Better water use efficiency was reached with no irrigation at all, but the productivity is so low that economically is not viable [49]; irrigation increases the yield but dilutes sugars and compounds responsible for color and aroma rendering a wine of lower quality. An acceptable compromise is to deficit irrigate from flowering to veraison, a phase very sensitive to severe water shortage, and no irrigation after veraison assuming that the soil still stores enough water to dispense up to the completion of the vine cycle. The effects of irrigation on berry composition are subjected to controversy with contradictory results among authors, but the source of these inconsistencies is probably related to the climatic conditions prevalent during the studies that each author carried out [50].
Under increasing competition for scarcer water resources, the imposition of moderate water stress on certain developmental periods of wine grapes is an adequate irrigation strategy to save water and maintain both yields and must quality with positive reflexes on the farm economy. Such strategy, termed by some authors as regulated deficit irrigation (RDI), has received great attention by researchers and producers [51]. Drip irrigation, from aboveground supply lines, is the most efficient form for vineyards, particularly for RDI, as it minimizes runoff and evaporation while delivering water uniformly and directly to the root zone; significant amounts of water are saved, and water contact with the plants is avoided, reducing the risks for disease development [52]. RDI with deliver lines buried underground is an expensive alternative with little benefits to offset its high costs [53].
Recent technical advances permit a more affordable and widespread use of phenomics defined by Houle et al. [54] as “a sub-discipline of biology concerned with the rapid measurement of an organism’s phenotype or physical and biochemical make-up.” Phenomics can help growers and managers to survey their crops to quantify spatial variability in fruit quality, yield, soil characteristics, and incidence of diseases, among other parameters, with many benefits for the more efficient use of resources and forecasts of yields [55, 56]. One example of such survey is presented by Rossi et al. [57] with the integration of soil spatial information of soil electrical resistivity, obtained automatically with a soil sensor on the go, with variation of vegetative growth and yield permitted to identify areas of a vineyard with similar traits. These areas would be subjected to differentiated agronomic practices to maximize potential benefits in yield and quality and, simultaneously, increase the efficiency of used resources.
Climatic conditions and different agronomic practices may influence the physiological behavior of the olive tree [58] and consequently the fruit ripening process modifying both the amount and oil quality in Olea europaea L., although the response is cultivar dependent [59, 60, 61].
Olive oil quality may be defined from commercial, nutritional, or organoleptic perspectives. The overall quality of olive oil, from production to consumption, is strongly related to oxidative stability and its impact on the evolution of flavor, taste, color, and the content of endogenous antioxidants and other minor constituents that are beneficial to health. The International Olive Oil Council [62] and the EEC [63] have defined the quality of olive oil based on parameters that include free fatty acid (FFA) content, peroxide value (PV), ultraviolet (UV)-specific extinction coefficients (K232 and K270), and sensory score. In particular, commercial quality is based on FFA as an important factor for classifying olive oil into commercial grades and sensory characteristics (taste and aroma). The nutritional value of olive oil arises from high levels of oleic acid and minor and health-related and antioxidative components such as phenolic compounds, tocopherols, chlorophyll, and carotenoids [64], whereas the aroma is strongly influenced by volatile compounds [65].
Fatty acid composition is one of the primary chemical parameters used to distinguish virgin olive oil from other vegetable oils [66]. Fatty acid profile may be greatly affected by environmental factors. Variability in acid composition has been correlated to the temperature sum of the period from fruit setting to fruit maturation by regulating fatty acid desaturases [67]. In fact, it has been reported that the contents of oleic acid decreased during ripening, while that of linoleic acid increased due to the transformation of oleic acid into linoleic acid by the oleate desaturase activity, which is active during triacylglycerol biosynthesis [68].
Despite the response being cultivar dependent, it has been shown that high temperatures during the maturation of olive fruits, early in the triacylglycerol biosynthesis, reduced oleic acid which is accompanied by increased palmitic and/or linoleic acids [69, 70]. In cv. Arauco, García-Inza et al. [71] observed that oleic acid concentration decreased linearly 0.7% per °C, while palmitic, linoleic, and linolenic acid percentages increased with increasing temperature. In cv. Arbequina, Rondanini et al. [72] reported a higher reduction of oleic acid with high temperatures (2% per °C).
Solar radiation and water availability are crucial not only for tree productivity, [60] but also they clearly affect olive oil quality. In cv. Frantoio, palmitoleic and linoleic acids increased in oils obtained from fruits exposed to high solar radiation intensity, whereas oleic acid and the oleic-linoleic acid ratio decreased [61].
To overcome the negative effects of combined heat and high radiation stresses, application of kaolin in olive trees growing in rainfed conditions has been used. The kaolin coat film could reduce solar radiation damage; reduce heat stress by reflecting UV light, decreasing leaf temperature, and reducing transpiration rate; increase photosynthetic efficiency in plants grown under high level of photosynthetic active radiation; and reduce heat caused by radiation [73, 74]. Khaleghi et al. [75] evaluated the effect of kaolin application in rainfed olive orchard, and they found that the highest palmitic acid was observed in olive oil obtained from untreated trees and that kaolin increased oleic acid but decreased linoleic and linolenic acid contents. Also, the percentage of monounsaturated fatty acids (MUFA) and oleic acid/linoleic acid ratio were higher in the oil obtained from trees treated with kaolin than that obtained from untreated trees. Moreover, saturated and polyunsaturated fatty acids (PUFA) were higher in untreated trees. Therefore, it can be expected that extracted olive oil from kaolin-treated trees has a higher oxidative stability and shelf life than the oil from untreated trees.
The ratio of unsaturated/saturated fatty acids influences the viscosity of oils, increasing with the amount of saturated fatty acids. This has an effect on the sensation of “fatty” on the oral cavity as a viscose oil has more time in contact with the mucous membranes of the oral cavity, giving rise to the “fatty” defect [76]. Moreover, the degree of unsaturation of fatty acids affects the oxidative stability. A high degree of unsaturation of a fatty acid increases the susceptibility to oxidation and shortens the olive oil shelf life [77]. Dag et al. [78] reported that in cv. Koroneiki, the monounsaturated/polyunsaturated fatty acid ratio and free fatty acid content generally decreased with the increased tree water deficit. Besides, olive oil oxidative stability might depend on some synergistic effects among fatty acid composition, phenolic compounds, tocopherols, carotenoids, and chlorophylls [79].
A water deficit during the initial development of the fruit can result in a decrease in the size of the cells of the mesocarp that cannot be recovered. Water deficit affects fruit maturation, which occurs earlier and more rapidly, and can result in more intense preharvest fruit fall [80]. However, a number of studies have shown that the water status of the plant has marginal, if any, effects on free acidity and peroxide value of the olive oil produced [81, 82].
Minor constituents of olive oil, such as phenolic and volatile compounds, are also influenced by the degree of maturation of the olive fruit. So, environmental factors or agronomics practices that affect the evolution of maturation of the drupe can also affect the qualitative characteristics of the resulting olive oil [83]. For example, a very high temperature sum also tends to reduce the total polyphenol content [84]. A positive correlation between the temperature sum from August to October and the total polyphenol content of olive oil was reported by Tura et al. [85].
It has been recognized that polyphenols and tocopherols are substances with natural antioxidant properties and their presence in olive oils has been associated to their general quality, improving stability, nutritional value, and sensorial properties. In cv. Cobrançosa, Fernandes-Silva et al. [82] reported a good linear relationship between total polyphenols and water stress integral. Therefore, olive trees that had been exposed to a certain level of water deficit produced oils with higher concentrations of polyphenols which were seemingly richer in the olive fruit [86, 87].
Virgin olive oil (VOO) obtained from rainfed olive orchards shows the highest resistance to oxidation in relation to irrigated olive orchards as a result of higher values of oxidative stability. The decrease in oxidative stability with water applied by irrigation is usually explained by the decrease in natural antioxidants like polyphenols and tocopherols [82, 86]. Given this assumption, several researchers have tried to find which of the mentioned substances is more correlated with oxidative stability. A number of studies have demonstrated that polyphenol contents are, among the minor compounds, the group more correlated with this parameter [88]. The antioxidant behavior of tocopherols represents a complicated phenomenon as they are efficient antioxidants at low concentrations, but they steadily lose efficiency as their oil content in the vegetables increases [76].
Olive tree water status has marked effects on concentrations of volatile compounds in the oil. Thus, olive oil from plants grown under water deficit-conditions can be bitter and pungent to the taste in opposite to those obtained in well-watering conditions [81, 89]. Williams and Harwood [90] have clearly shown that drought regimes, in Crete, reduced the relative activity of enzymes of lipoxygenase pathway and consequently the volatile compounds.
Regulated deficit irrigation (RDI) in olive orchard is an agronomic practice in which plants were irrigated avoiding water deficit during phases I and III of olive fruit growth and saving water during phase II, the noncritical phenological period of pit hardening [91]. This strategy of irrigation can affect some table olives’ characteristics, for example, phenolic composition, antioxidant activity, fatty acid composition, volatile compounds, and phytoprostanes [92]. Table olives from RDI belong to a group of vegetable products named hydroSOStainable which are characterized by having distinctive proprieties such as high content of some nutritional and functional compounds, high intensity of sensorial attributes, and are produced with reduced use of water, which is a benefit for both farmers and for the environment [93]. Sánchez-Rodríguez et al. [93] reported that hydroSOStainable table olives (cv. “Manzanilla”) showed the most attractive shape and color with highest fruit weight, roundest fruit, hardest texture, and a lightest and greenest color than control olives, whereas minerals, antioxidants, phenols, and organic acids and sugars of hydroSOStainable olives were similar to well-irrigated olives. Hence, hydroSOStainable table olives have advantages over those obtained in well-watered conditions reducing the use of freshwater, while they have better morphological traits that are more attractive for consumers.
Lower latitudes of temperate regions are expected to experience climate changes in coming decades that will bring about conditions less favorable to agriculture activities. Yields are likely to decrease, and the quality of produce might suffer a negative alteration. Commercial wine vines and olive trees are very sensitive to their environment, and to keep their economic value, it is necessary to adopt agronomic practices to minimize the adverse effects of climate change. The less favorable location for their growth and development might be abandoned, the choice of varieties to plant will be selected among the best adapted to future conditions, and management techniques of highly efficient irrigation, shading, spraying with reflecting materials, and tight control of canopy development, among others, will have to be commonly adopted.
This work was possible thanks to the contribution of our university, Universidade Trás-os-Montes e Alto Douro.
This work is supported by European Investment Funds by FEDER/COMPETE/POCI-Operational Competitiveness and Internationalization Programme, under Project POCI-01-0145-FEDER-006958, and National Funds by the FCT (Portuguese Foundation for Science and Technology), under the project UID/AGR/04033/2013.
We report no conflict of interests and no other benefit from our work.
Valve disease still a significant health problem in the developed countries, In United states nearly 2.5% of the population has moderate or severe valve disease, with increased the prevalence for people older than 64 years and is 13% in those older than 75 years [1].
The commonest valve diseases in the elderly are calcific aortic valve disease and aortic dilation causing aortic regurgitation [2].
While rheumatic heart disease is the most prevalent pathology of valve disease globally, especially in the adolescent and young adults with a projected prevalence of 16–20 million, rheumatic fever is the most frequent trigger of valve disease in the young, particularly in Africa, India, the Middle East, South America, and parts of Australia and New Zealand, China, and Russia [3]. In western countries, the incidence of rheumatic disease declined in the latter half of the twentieth century, with the occurrence of transitory local episodes. In Africa, endomyocardial fibrosis is a common, poorly investigated pathology that leads to valve disease in all ages [4]. On the other hand, in the developed countries valve diseases of elderly predominate, particularly calcific aortic stenosis and functional mitral regurgitation, with a prevalence of 13% in those older than 75 years reported in North America [5, 6, 7].
Other pathological conditions like infective endocarditis and drug-induced valve disease (5-HT2B receptor agonists) are on the rise [8, 9, 10].
Structural biological valves deterioration would be the future burden on health resources world-wide; this is due to its current popularity as a therapeutic option even in young patients, mainly to avoid the complications of anticoagulation [11, 12].
Lack of equitable access to health care takes place in all countries, as a consequence of many complex economic and social forces. Because of the escalating technological cost of health care around the world, the situation is the same, even those industrially developed countries.
The salient global errand is the prevention of rheumatic heart disease, which would necessitate cooperation among social, political, and medical programs that lead to creating enhancements in living conditions by better housing, nutrition and improved access to health care [13, 14, 15, 16]. Penicillin for streptococcal throat infections and secondary prophylaxis would continue to be a cornerstone in the global fight against rheumatic heart disease [17, 18, 19]. It is also reported that there was a natural reduction in the virulence of streptococcal serotypes, but it happened after the incidence of rheumatic fever had declined.
Most of the serum biomarkers that have been shown related to VHD are detecting secondary effects on the ventricular myocardium. Biomarkers associated with myocardial stress include the natriuretic peptides and GDF-15. Troponin is linked to myocardial necrosis, and the micro RNAs, ST2, and galectin-3 are associated with myocardial hypertrophy and fibrosis. Of these, the natriuretic peptides are the most widely studied, but they are not specific to VHD, and there is considerable overlap in serum levels between different clinical groups [20, 21, 22].
The aortic valve is the last gate the blood pumped from the heart to the rest of the organs. It is at the junction between the aorta and the outflow tract of the left ventricle. Its function is to maintain unidirectional blood flow during the diastole while allowing the blood forward flow with minimal resistance during systole. The aortic valve has typically three semilunar cusps (tricuspid) named by their relationship to the coronary Ostia: the left coronary and right coronary, and the third is the noncoronary cusp. Cusps are attached to the aortic annulus at the bottom of slight dilations of the aorta associated with each cusp (sinuses of Valsalva end at the sinotubular junction). The sinotubular junction is the narrowest part of the aortic root (Figure 1). The fibrous skeleton supports the aortic valve and is continuous with the anterior leaflet of the mitral valve [23, 24].
Aortic valve anatomy.
Detection of valvular heart disorder can be difficult. The state of the patient may range in gravity from asymptomatic to cardiogenic shock. Endocarditis may mimic systemic illness, vascular or neurologic condition, while acute aortic incompetence may be presented as a primary respiratory disorder (acute asthmatic episode). Making a timely, accurate diagnosis, while averting excessive laboratory studies, may try the acumen of a seasoned clinician.
Commonly, observing a murmur in a well individual or a patient with symptom referable to the cardiovascular system, arouse the suspicion of valvular abnormality. It is essential to reassure the patients; murmur is not synonymous with heart disease. It does represent turbulent blood flow which may result from several possible conditions. These include: (i) increased flow secondary to anaemia, pregnancy, or a hyperadrenergic state; accelerated flow through a restricted orifice (ii) regurgitant flow through a leaking valve; or (iii) abnormal shunting between two chambers. In an unselected population, most systolic murmurs are physiologic, caused by conditions of increased blood flow [25, 26]. The echocardiogram is the best way to evaluate the patients and reassure them [27, 28].
The practical approach to these patients relies upon an open-minded history and thorough physical examination.
As in nearly all of medicine, most cues to a diagnosis are from history.
The clinician assessment should not be compromised, trying to spare minutes at this stage drain hours in the wasted investigation later.
The patient may provide a history of rheumatic fever, pervious episode of infective endocarditis, intravenous drug use, use of anorectic medications, carcinoid tumours, indwelling vascular devices, dental, genitourinary or gastrointestinal procedures; Marfan’s syndrome, syphilis; congenital bicuspid aortic valve; treated or untreated coronary artery disease, radiation therapy.
Finally, a history of past surgery increases the risk of future valve problems by way of prosthetic valve endocarditis or structural failure.
Family genetics undoubtedly plays a role in so doing; the clinician may identify a family with a previously unrecognised genetic mutation and allowed early diagnosis of relatives. The social history may provide valuable information. For example, a childhood spent in a no industrialised region of the world dramatically increases the risk of rheumatic valve disease. History of unprotected sex or intravenous drug abuse raises the TE.
Course for valvular heart disease varies widely, ranging from minutes to decades dependent on primary pathology and age and risk factors related to patients as well as the geographical location in the world.
Unfortunately, it is also very nonspecific, occurring in nearly any disturbance of cardiopulmonary function. Orthopnoea and paroxysmal nocturnal dyspnea are somewhat more specific for left ventricular failure.
The sensation of a rapid or unusually vigorous heartbeat may signal the development of atrial fibrillation.
Maybe the initial manifestation of valvular heart disease.
In hospitalised patients, excess extra cellular fluid is first presented as pitting oedema overlying the sacrum predominantly; the elevated systemic venous pressure is the cause of all the above.
The toxic appearance of acute infection, wasting of cardiac cachexia, the distressed facial expression, wet cough, accessory muscle use, and diaphoresis of pulmonary oedema, and the cool skin characteristic of poor perfusion.
Skin and mucosa cyanosis of the lips cold sweat (Osler nodes). (Janeway lesions), painless red macule lesions of the palms and soles (Janeway lesions), conjunctive petechial, and subungual hematomas (splinter haemorrhages).
Central venous pulsations jugular venous pulsation and mean central venous pressure (CVP) are often abnormal in valvular heart disease. In most cases, right heart failure is secondary left-sided valve disease-causing left heart failure. Less direct clues to the level of right atrial pressure; include the presence of pedal oedema, sacral oedema, anasarca, tender hepatomegaly, ecchymosis (hepatic synthetic dysfunction), hepatojugular pulsation and ascites.
However, auscultation technical skill like any other and improves with repetition [29]. Therefore, students’ physicians-in-training reading this text should lose heart, but rather, should apply themselves diligently to acquire these valuable bedside skills. Listening to patients before and after echocardiographic findings are known is particularly helpful.
In majority of patients with aortic valve disease with have abnormal ECG which commonly non-specific such as left ventricle hypertrophy, with or without repolarization abnormalities is seen on electrocardiography (ECG). Left atrial enlargement, left axis deviation and conduction disorders are also common. Atrial fibrillation can be seen at late state and in older patients or those with hypertension.
Pulmonary vascular congestion. Enlargement, valvular calcification, and type position of prosthetic valve may all be ascertained plain radiographs. Comparing changes over time particularly helpful; hence obtaining previous studies is very valuable (Figure 2).
Cardiomegaly and pulmonary congestion.
Echocardiography is the most valuable tool in valvular heart disease due to its portability, ease of use. Low cost, steadily improving resolution, and its ability to assess hemodynamics, additional ultrasound-based modalities can provide information about cardiac anatomy, function, and hemodynamics. These modalities include two dimensional (2D) or B-mode in which sound waves are in a fan-like distribution, yielding a real wedge-shaped tomographic image of the heart. There are three subtypes of Doppler ultrasound. Continuous-wave Doppler, all velocities along a continuous line through the heart are displayed as a spectrum over time. In pulse wave Doppler, the sample volume is placed on a 2D image, and the spectral splay of velocities represents the blood flow velocities in this region only.
Tissue Doppler is yet another form of Doppler echocardiography which measures the velocity of anatomic structures rather than red blood cells; it currently has very limited application in valvular heart disease [30, 31].
Hemodynamic assessment. Firstly, the pressure gradient a valve or between two chambers can be estimated by taking advantage of the relationship between pressure (P), and velocity (v) as described in is the conservation of flow and different diameter, the flow of fluid through one section match flow through the other end. Since flow equals the product of orifice area and flow velocity, this principle can be stated as Area 1 × Velocity 1 = Area 2 × Velocity 2. This is used explicitly in the determination of aortic valve area (Figure 3) [30].
Echocardiogram assessment of aortic valve.
Another hemodynamic measure important valvular heart disease are the rate of pressure equilibration between two chambers (e.g. pressure half-time, deceleration).
Cardiac catheterisation and direct measure of intracardiac pressures, ventriculography, aortography, and assessment of coronary vessels before valve surgery all continue to be an essential tool in the evaluation of valvular heart disease.
Occasionally, balloon valvotomy serves an important therapeutic and diagnostic role in mitral, and occasionally, aortic stenosis.
Positron emission tomography (PET) is an emerging imaging technique which allows improved resolution more flexibility than SPECT, including the possibility of imaging metabolic substrates and neural transmitters. In light of its expense and dependency mostly cyclotron-produced isotopes, its role in valvular heart disease remains to be determined.
Aortic stenosis (AS) may be to congenital or acquired, and the congenital form could be above (supra), below (subvalvular) or at the valve level. A supravalvular is a rare form of long and tubular narrowing is associated with, (William’s Syndrome) hypercalcemia, mental retardation, and peripheral pulmonic stenosis. Subvalvular stenosis may be caused by the septum extending into the outflow tract, a cylindrical constriction of the outflow tract or, in hypertrophic cardiomyopathy the obstruction caused by the anterior movement of the mitral valve leaflets. In some patients, this is present only at diminished ventricular (LV) volumes recreated in the echocardiography laboratory by Valsalva cause aortic regurgitation [32].
Isolated aortic stenosis (AS) is more frequent in men and is found in 2% of people 65 years of age and older. The most frequent causes of AS include age-related calcific degeneration, bicuspid aortic valve, and rheumatic aortic valve. The distribution of these causes diverges across age groups and geographic regions. Age-related degeneration is the commonest cause of AS in elderly patients. In comparison, bicuspid aortic valve calcification accounts for most surgical cases in younger patients (>65) [33].
There is 0 gradient exists across the standard aortic valve during the cardiac cycle. The cross-sectional area of a normal aortic valve is >2 cm2. While reductions in the valve area to 1.5–2.0 leads to minimal pressure gradient, further narrowing produces dramatic increases in the mean pressure gradient [34]. In AS, progressive obstruction of outflow tract increases afterload ventricular, and wall stress of the left ventricle leads to high left ventricular systolic and diastolic pressures, decreased aortic pressure, and prolonged left ventricular ejection time.
Obstruction to flow usually develops slowly allowing the LV to adapt by concentric thickening hypertrophy serves to reduce wall tension (the law of Laplace describes wall tension is proportional to pressure and radius and adversely proportional to thickness). As long as the process of muscular wall thickening keeps pace with narrowing of the aortic orifice, the ‘wall tension’ is maintained. Gradually, this results in compensatory concentric left ventricular hypertrophy (LVH) to maintain ejection fraction [35].
The stability comes at a price, now the hypertrophied walls are less compliant and LV less able to fill rapidly. Satisfactory end-diastolic volume becomes heavily reliant upon atrial contraction. Atrial fibrillation often precipitates dramatic acute congestive heart failure in patients with severe AS. The concentric hypertrophy increases myocardial oxygen requirement coupled with reduced coronary flow due to deviated diastole and low diastolic pressures, which aggravates subendocardial ischemia in the presence of normal coronary artery ventricular arrhythmias are common as well. The compensatory mechanism may become insufficient in patients with chronic severe AS, resulting in thinning and dilation of the left ventricle, leading to a decrease in ejection fraction and congestive heart failure [36].
Exertional syncope may develop resulting from peripheral vasodilation induced by exercise with the background of a fixed cardiac output. Blood pressure drop may reduce cerebral perfusion, below the minimum required for consciousness [37].
A negative balance between oxygen supply and demand is the norm in AS. LVH increased afterload, and the long systole increases myocardial oxygen demand. The high filling pressure and longer systolic time decrease myocardial oxygen supply by reducing myocardial perfusion time. Myocardial ischemia in patients with AS is due to the alteration in myocardial oxygen supply and demand even in the absence of coronary artery disease.
Patients with, mild or moderate AS are usually asymptomatic unless they have the coexisting cardiopulmonary disease or infective endocarditis. Patients often remain asymptomatic until the ventricle begins to fail. At this initially, they usually develop fatigue followed by cardinal symptoms of angina, syncope, and dyspnea expected survival following the onset of these symptoms is 2, 3, and 5 years, respectively [38].
In rare instances, sudden tragic death is the first manifestation of the disease. Patients may be sedentary; it unclear whether they are inactive by choice or have gradually restricted their activity to avoid symptoms. A treadmill stress test under close medical supervision may help in their assessment.
The classic finding in the assessment of peripheral pulses is a delayed and slowly rising wave contour pulsus parvus et tardus. However, it may be absent patients with associated aortic regurgitation or in patients with associated aortic regurgitation or calcified, inelastic arteries.
Precordial palpation may reveal a sustained and laterally displaced cardiac impulse. Because the hypertrophied LV is noncompliant, the critical contribution to filling provided by atrial contraction severe thrill is often palpable at the base of the heart.
Standard features on the electrocardiogram include ventricular hypertrophy (LVH) with a strain and a biphasic p wave in V1 corresponding to atrial (LA) hypertrophy. Atrioventricular and intra ventricular conduction abnormalities maybe when calcification extends from the valve into the induction system.
The chest X-ray rounding of the left heart border and apex, post stenotic dilation of the aorta calcification of the aortic valve, and pulmonary congestion may be apparent. Note, these findings are neither highly sensitive nor specific.
Echocardiography serves as the principal modality for and quantitating AS. 2D imaging provides information on chamber size, degree of hypertrophy, LV systolic function, valve mobility, and calcification. Doppler measurement of transvalvular blood flow velocity can be used to ermine peak and mean pressure gradients using the.
The symptomatic triad of AS is angina, exertional syncope, and symptoms of congestive heart failure, such as shortness of breath. The mechanisms for angina and congestive heart failure are explained in the previous section. The mechanism for syncope is likely related to the blunting of exercise-induced augmentation in stroke volume as a result of outflow obstruction coupled with exercise-induced peripheral vasodilation. These changes cause a drop in systemic blood pressure leading to cerebral hypoperfusion and syncope.
The classic physical finding is a systolic ejection murmur heard loudest at the second right intercostal space, which commonly radiates to the carotid arteries. And maybe associated with severe cases of AS palpable thrill may be present. Palpation of the pulse may reveal a weak and delayed pulse known as pulsus parvus et tardus.
The most common method for the diagnosis and grading of AS is two-dimensional transthoracic echocardiography Doppler velocity measurement (Table 1). In most patients, this modality can reliably establish aortic jet velocity, aortic valve peak and mean gradients, and aortic valve area [39].
Parameter | Mild | Moderate | Severe |
---|---|---|---|
Aortic valve area (cm2) | 1.6–2.5 | 1.1–1.5 | ≤1.0 |
Mean pressure gradient (mm Hg) | <20 | 20–39 | ≥40 |
Aortic jet velocity (m/s) | 2.0–2.9 | 3.0–3.9 | ≥4.0 |
The severity of aortic stenosis according to echocardiographic criteria.
Without valve replacement symptomatic AS has a bleak outcome. Numerous studies consistently reported survivals of 3 years for angina and syncope and 1.5–2 years for dyspnea and heart failure. These findings have determined the recommendations for timely surgical intervention in patients with symptomatic AS. Thirty percent of truly asymptomatic severe AS patients will become symptomatic in 2 years with mortality risks of less than 1–5% each year to 5% each year. Progression rate correlates with AS severity, which seems to progress faster with higher mean gradient. Moderate AS progress, with aortic valve area, decreases on average by 0.1 cm2 per cent annually the pressure gradient across the valve rises on average by 7 mm Hg per year, and the jet velocity increases by 0.3 m/s per year [40, 41].
The definitions of the conditions “low-gradient AS” and “high-gradient AS” are the most relevant new changes in the recommendations for the management of aortic valve stenosis (AS). Precise thresholds of biomarkers and pulmonary hypertension are considered, and the emphasis is focused on computed tomography, particularly for assessing the degree of calcification of the aortic valve and for planning therapy [42].
The reasons of aortic regurgitation (AR) are many and can be credited to a disruption of any components of the functional unit of the aortic root valve composite (e.g., cusps, sinuses of Valsalva, sinotubular junction, annulus). In general, the causes can be divided into those that involve the valve cusps (e.g., calcific degeneration, congenitally bicuspid valve, infective endocarditis, rheumatic disease, myxomatous degeneration) and those that encompass the aortic root (e.g., aortic dissection, aortitis of various etiologies such as syphilis, connective tissue disorders such as Marfan syndrome) [43].
The pathophysiology of AR is determined by the speed of onset and duration of the disease process. In acute AR, typically caused by aortic dissection, infective endocarditis, trauma, or valve prosthesis failure, there is an abrupt escalation in left ventricular end-diastolic volume because of the regurgitation. Since the left ventricle has restricted compliance and does not have enough time to gradually adapt to the extra volume, the left ventricular end-diastolic pressure (LVEDP) rises rapidly [44, 45].
In chronic AR, there is a gradual and stealthy evolution of left ventricular (LV) dilation and eccentric hypertrophy because of an increase in left ventricular end-diastolic volume, LVEDP, and wall stress. Dilation of the LV maintains normal systolic function and forward flow but requiring extra work to achieve normality. Sooner or later, the hypertrophic response is exhausted, and LVEF deteriorates as afterload increases, resulting in heart failure and its related clinical presentation [44].
Patients with acute AR present with unexpected or precipitously cardiovascular collapse, which is a life-threatening emergency. They often demonstrate ischemic symptoms because of the diminished coronary blood flow and heightened myocardial oxygen demand. In comparison, patients with chronic AR are often asymptomatic for an extended time because of the compensator remodelling of their LV mentioned earlier. Once the compensatory response is depleted, the patients experience heart failure symptoms such as exertional dyspnea, orthopnea, and paroxysmal nocturnal dyspnea. Patients may also suffer palpitations and angina [46].
The classic murmur of AR is an early diastolic, blowing, a decrescendo murmur heard best at the level of the diaphragm at the left sternal border while the patient is sitting, leaning forward, and in deep exhalation.
Classic signs of widened pulse pressure may also be found, including Corrigan or water-hammer pulse, De Musset sign (bobbing of the head with heartbeats), Quincke pulse (pulsations of the lip and fingers), Traube sign (pistol shot sounds over the femoral artery), and Müller sign (pulsations of the uvula).
Transthoracic echocardiography with Doppler colour-flow is the most useful tool for the diagnosis of AR. The jet width and vena contracta width on Doppler colour-flow are used to qualitatively assess the severity of AR, whereas the regurgitant volume, regurgitant fraction, and regurgitant orifice area are used for the quantitative assessment.
Many adverse outcomes in adults with valvular heart disease are due to sequelae of the disease process, including atrial fibrillation, embolic events, left ventricular (LV) dysfunction, pulmonary hypertension, and endocarditis. Patients with valvular heart disease are best cared for in the context of a multidisciplinary heart valve clinic [47].
Medical therapy in adults with valvular heart disease focuses on prevention and treatment of complications because there are no specific therapies to prevent progression of the valve disease itself apart from primary and secondary prophylaxis of rheumatic fever. Rheumatic fever is a multiorgan inflammatory disease that occurs 10 days to 3 weeks after group A streptococcal pharyngitis. The clinical diagnosis is based on the conjunction of an antecedent streptococcal throat infection and classic manifestations of the disease, including carditis, polyarthritis, chorea, erythema marginatum, and subcutaneous nodules [48]. Reducing the frequency of streptococcal pharyngitis with benzylpenicillin monthly intramuscular injection helps to reduce the progression of Rheumatic heart disease. The risk of recurrent disease is related to the number of previous episodes, time interval since the last episode, the risk of exposure to streptococcal infections (contact with children or crowded situations), and patient age. A longer duration of secondary prevention is recommended in patients with evidence of carditis or persistent valvular disease than in those with no evidence of valvular damage [49].
Endocarditis prophylaxis guidelines recommend antibiotics therapy before dental procedures, or other procedures associated with bacteraemia, in adults with prosthetic valves but not in patients with native valve disease unless the patient had an episode of endocarditis, dental hygiene and gum health are the primary preventive measure to reduce endocarditis [50].
Prevention of embolic events in patients with valvular heart disease, particularly those with prosthetic valves, MS, or AF, is a key component of optimal medical therapy.
Therapy for the prevention of embolic events in patients with valvular heart disease typically includes antiplatelet agents or long-term warfarin anticoagulation [51, 52]. There is data on the use of newer anticoagulants, such as direct thrombin inhibitors and anti-Xa agents, for prevention of embolic events in patients with valve disease [53]. At the initiation of therapy, a target INR and acceptable range are defined by the referring physician for each patient on the basis of published guidelines and clinical factors unique to that patient, In addition, patient education about anticoagulation, possible dietary and drug interactions, recognition of complications of therapy, and the need for careful monitoring of the INR is provided verbally and through the use of a variety of media (such as pamphlets, recorded presentations, and computer-based material).
Periodic evaluation of disease severity by echocardiography and clinical evaluation of the LV response to chronic volume and/or pressure overload allows optimal timing of surgical and percutaneous interventions. General health maintenance is important, including evaluation and treatment of coronary disease risk factors, regular exercise, standard immunisations. Both pneumococcal and annual influenza vaccinations are recommended for all adults older than 65 years and are especially important in patients with valvular disease, in whom the increased hemodynamic demands of acute infection may lead to cardiac decompensation. In younger patients with valve disease, routine immunisation is only indicated in conditions associated with immunocompromise are also present and optimal dental care. Management of concurrent cardiovascular disease follows standard approaches with modification, as needed, based on the potential confounding effects of valve haemodynamics. Evaluation of coronary anatomy usually is needed before valve surgery because of the high prevalence of coronary disease and improved surgical outcomes with concurrent coronary revascularisation.
Periodic noninvasive monitoring is essential for the optimal timing of interventions in patients with valve dysfunction. Disease progression may be evident as changes in valve anatomy or motion; an increase in the severity of valve stenosis or regurgitation; LV dilation, hypertrophy, or dysfunction in response to pressure and/or volume overload; or secondary effects of the valvular lesion, such as pulmonary hypertension or AF.
Although the goal in the management of patients with valvular disease is to avoid symptoms and the need for medical therapy by optimising the timing of surgical intervention, some patients have persistent symptoms after surgery, have symptoms only in response to superimposed hemodynamic stress (such as pregnancy), or are not candidates for surgical intervention. In these situations, medical therapy is based primarily on adjustment of loading conditions and control of heart rate and rhythm.
Most adverse outcomes of noncardiac surgery in adults with valve disease are due to failure to recognise the presence of valve disease preoperatively. When valve disease is suspected from history or physical examination findings, echocardiography is appropriate to identify and define the severity of any valve lesions. In patients with valvular disease undergoing noncardiac surgery, management focuses on an accurate assessment of disease severity and symptom status, with appropriate hemodynamic monitoring and optimisation of loading conditions in the perioperative period [54].
Patient education is the key to compliance with periodic noninvasive monitoring, prevention of complications, and the early recognition of symptoms in patients with valvular heart disease. Each patient should understand the expected long-term prognosis, potential complications, typical symptoms, the rationale for sequential monitoring, and the indications for surgical intervention. Appropriate education avoids needless concern and prompts early reporting of symptoms, allowing optimal timing of surgical intervention. Increasingly, patients are actively involved in decisions about the timing of surgery and choice of intervention.
Patients also should be knowledgeable about the risk of infective endocarditis and the importance of maintaining optimal oral hygiene, including regular dental care.
Patients undergoing long-term anticoagulation need both education and a reliable and available source for consultation regarding warfarin dose, interactions with other medications, and prompt evaluation of any complications.
The decision for intervention for a faulty aortic valve needs to incorporate the natural history of the medically managed disease, the risks associated with the intervention, and longer-term problems that might build up as a result of prosthetic valve implantation.
Currently, the heart team plays a decisive role in decision making. In addition, it is prudent to cultivate and set up heart valve centres with specialist services in order to generate an ideal environment for the treatment of patients with valvular heart disease.
Criteria for decision-making are clear for surgical valve and transcatheter aortic valve implantation (TAVI) from the current European guidelines. Recently TAVI is also recommended for patients with intermediate surgical risk. Currently, publish literature also supports TAVI implantation in low risk patients as non-inferior to surgical therapy [55, 56].
For symptomatic, AS recommendations are made with regard to the choice of procedure. For high risk (STS score or EuroSCORE II <4% or a log EuroSCORE <10%) TAVI is the default choice. Surgical replacement is indicated for patients with a low perioperative risk (STS score > 4%). Patients with an intermediate surgical risk, the heart team, should consider other criteria for decision making such as anatomical and functional parameters [57, 58], and frailty to reach the best option for the patients considering the current knowledge.
Current data from two large prospective randomised studies, have confirmed that TAVI was noninferior to surgical treatment with regard to mortality, stroke and additional endpoints in both in patients with a low perioperative risk (the mean STS score in both trials was 1.9%), expansion of the indication for TAVI which would also include younger patients, can be expected [59].
Choice of prosthesis is a complex decision in a patient undergoing AVR with profound long-term consequences for the patient. Currently available prostheses are different with regard to key features, such as the requirement of anticoagulation, incidence of thromboembolism, durability, ease of implantation, haemodynamic performance, and susbtibilty for infection. Currently age-based guidelines do exist, but the final choice must be tailored to the individual patient including consideration of general lifestyle and physical activity, surgeon expertise, diseases, especially those affecting life expectancy, and, ultimately, overall patient preference.
The patient age is a primary factor in prosthesis selection is. Elderly patients have lower life expectancy and physical activity than Younger patients. Which place a greater demand on the prosthesis with regard to durability and hemodynamic performance. Age has long been recognised as a major determinant of bioprosthesis durability. Traditionally target age between 65 and 70 years has been the indications for bioprosthesis and like hood of a second operation for structural valve dysfunction in a life time 65-year-old person is less than 10%. As a result, it is not common to choose a mechanical valve in an old patient. Even if the patient is already treated with warfarin for another condition, for example AF, which should not necessarily favour the choice of a mechanical valve because it converts a relative indication for low-level anticoagulation to an absolute indication for higher levels. It also removes the option to stop warfarin in a case of a significant bleeding event. Moreover even if the patient had previously received mechanical valve, the choice does not mandate a second mechanical valve, because risk of complications thromboembolic and bleeding is higher with two mechanical valves than it is with one.
It is more complex and controversial to choose of prosthesis in patients younger than 65 years. Although traditionally, these patients would receive a mechanical valve; the current, improved durability in bioprosthesis and lower operative risk of a redo operation for a failed prosthesis have increased the number of patients younger than 65 years who receive bioprosthesis, including patients in their 50s and even younger.
A particular dilemma women of child-bearing age often it is safer avoid warfarin so they choose a bioprosthesis, with the knowledge that they will face at least one reoperation in their lifetime.
Stentless valves may provide a larger effective orifice area such as the Toronto SPV, Freestyle, and Prima Plus valves although the hemodynamic profiles of stentless valves are superior to those of stented valves, especially at the smaller sizes [42] durability and survival benefits still is unproven [47, 48]. Some reports suggest fewer thromboembolic complications [49]. Currently no specifics indication form stentless valve. Maybe these hemodynamic benefits justify implanting stentless valves in younger active patients.
The use of homografts has declined in recent years as a primary aortic valve substitute because without a durability advantage, it is cumbersome to recommend their routine while they have limited availability and the cumbersome storage requirements. However, their ability to resist infection renders them an excellent solution for patients with endocarditis.
The Ross procedure involves replacing the aortic valve with the patient’s own pulmonic valve, which have to be is replaced with a homograft or a stentless xenograft. The benefits are near-normal haemodynamic and excellent durability; the disadvantages are the technical complexity and need for reoperation for the homograft or Late AR. The procedure peaked in popularity in the mid to late 1990s, but procedure volume has declined since then. On the basis of the data from the Ross Procedure International Registry, several centres continue to report excellent results [50, 51] although it is now primarily a procedure for paediatric patients, in whom the potential for growth is important, and for young adults in their 20s and 30s when no other good alternatives exist.
The precise assessment within the heart team of the pathology and anatomy, as well as the evaluation of the patient, are emphasised in the new graduated recommendations regarding low-flow, low-gradient aortic valve stenosis in symptomatic patients [60].
It is also highly recommended to take into account the morphology of the device landing zone and the resulting individual risks for TAVI procedures.
For asymptomatic patients with an indication for aortic valve replacement, surgical replacement is still the gold standard, because no data are available for this patient cohort concerning TAVI treatment.
Surgical aortic valve replacement remains the standard gold treatment of aortic valve regurgitation (AR). Transcatheter aortic valve implantation (TAVI) plays only a minor role. Currently, the JenaValve (JenaValve Technology GmbH, Munich, Germany) is the only prosthesis available for pure AR as an investigational device [61]. All other prostheses are used off label [61]. Concerning the choice of the type of prosthesis, criteria used in aortic stenosis are not merely interchangeable. The percentage of oversizing has to be calculated in a different way because of the absence annular calcification. Although outcomes have improved with newer-generation TAVI devices outcomes are still inferior to surgery. In a few circumstances, TAVI might be an option for patients with severe AR and high surgical risk.
The class I recommendations for aortic valve intervention, in patients with AR according to the 2014 American College of Cardiology and the American Heart Association are the following: symptomatic patients with chronic severe AR, asymptomatic patients with chronic severe AR and LV dysfunction (ejection fraction < 50%) at rest, and patients with chronic severe AR who are undergoing concomitant coronary artery bypass grafting, aortic surgery, or other heart valve surgery.
The class IIa recommendation is for patients with asymptomatic AR and normal LV systolic function (ejection fraction > 50%) but with severe LV dilation (end-systolic diameter > 50 mm). The class IIb recommendation is for patients with moderate AR who are undergoing coronary artery bypass grafting, aortic surgery, or other heart valve surgery. Aortic valve intervention may also be reasonable in asymptomatic patients with chronic severe AR, normal LV systolic function, and severe LV dilation (end-diastolic diameter > 65 mm) if the operative risk is low. Other considerations can include evidence of progressive LV dilation, declining exercise tolerance, or abnormal hemodynamic response to exercise [62, 63].
However, aortic valve repair carries a similar, if not lower, risk of perioperative complication with a low risk of valve-related events over time. Similar to mitral valve repair for mitral regurgitation, six there is some suggestion that aortic valve intervention should be considered earlier in patients in whom aortic valve repair is likely [64].
Another broad category of patients who undergo aortic valve preservation and repair are those with primary aortic pathology involving the aortic root or the ascending aorta and varying degrees of associated aortic valvular disease. In these patients, the primary indication for intervention is driven by aortic size, discussed in the American, European, and Canadian Guidelines.
From a technical perspective, all patients with primary aortic insufficiency are potential candidates for repair. However, the success of aortic valve repair is determined largely by the quality of cusp tissue available. Thus, patients with significant leaflet calcification, destruction owing to active endocarditis, or rheumatic involvement are least likely to undergo successful and durable aortic valve repair. In contrast, repair has been shown to have good results in patients with bicuspid (and in smaller series, unicuspid, and quadricuspid aortic valves), despite the abnormalities in cusp anatomy. An important limitation to the universal application of aortic valve repair techniques is the lack of surgical expertise and experience in this field; however, this is changing rapidly with increasing interest in aortic valve repair. Patients who are candidates for repair should be referred to centres with appropriate expertise.
Surgery of the aortic valve can now be accomplished with greater safety and efficacy in the majority of patients. In patients with higher operative risks, TAVI is already a proven acceptable alternative to AVR. The choice of valve prosthesis is guided by patient preference, life expectancy, and comorbidities relevant to SVD and anticoagulation. Aortic valve repair in the young patient with AR avoids the risks associated with valve prostheses, but long-term durability is unknown. Aortic root surgery similarly can be performed with the replacement of both the aortic valve and aortic wall, but valve-sparing techniques may offer the advantage of durability equivalent to that of normal native aortic valves with avoidance of prosthetic valve-related complications. Reoperative aortic valve and aortic root surgery, like isolated AVR, can be performed safely with best outcomes at high-volume centres.
Aortic valve replacement (AVR) is becoming safe despite the elderly population of patients is now being treated, with the best outcomes achieved at high-volume centres. The standard approach is a median sternotomy aortic valve and aortic root replacement. However, minimally invasive approaches, including the upper hemisternotomy and right anterior thoracotomy (Figure 4), can be performed with equivalent safety and better outcomes. The use of stented bioprosthetic valves surpassed the use of mechanical valves, homografts, and pulmonary autografts combined, reflecting advances in valve technology. The Novel Sutureless valves combine the advantages of a surgical AVR procedure (control of aortic atheroemboli, resection of the diseased native valve) with transcatheter technique (decreased procedure time, improved valve hemodynamic function). Bentall procedure: root replacement with a composite valve-graft is the gold standard for aortic root aneurysm (Figure 5). However, for patients who want to avoid the long-term oral anticoagulation required for mechanical valves and structural valve deterioration of the bioprosthetic valves, valve-sparing aortic root replacement (David or Yacoub procedures) is a good option (Figure 6).
Aortic valve replacement.
Bio Bentall procedures.
Valve sparing repair.
Indications for aortic root replacement include aneurysms of the ascending aorta, aortic valve endocarditis with annular abscess, and acute type A aortic dissection. The most common indication is an aneurysm of the aortic root or ascending aorta. The size threshold for aneurysm repair depends on whether the aneurysm is the primary indication for surgery or whether it coexists in a patient already requiring cardiac surgery.
Primary aneurysms of the aortic root are secondary to either genetically mediated disorders or acquired disorders. The acquired disorders include degenerative thoracic aortic aneurysm, chronic aortic dissection, intramural hematoma, penetrating atherosclerotic ulcer, mycotic aneurysm, and pseudoaneurysm. The size threshold for surgical repair in this group of patients is 5.5 cm for both the aortic root and ascending aorta according to class I recommendations by the 2010 ACC/AHA Guidelines for the Diagnosis and management of Patients with Thoracic Aortic Disease developed by a multigroup-sponsored task force [65]. The genetically mediated disorders include Marfan syndrome, vascular Ehlers-Danlos syndrome, Turner syndrome, BAV, familial thoracic aortic aneurysm and dissection, and Loeys-Dietz syndrome. These disorders are associated with a greater risk of rupture, dissection, and death, in particular Loeys-Dietz syndrome. The size threshold for operative intervention in this group of patients is 5.0 cm, according to the same guidelines [51]. This recommendation is consistent with a size threshold of 5.0 cm in patients with BAV in the 2006 ACC/AHA Guidelines for the Management of Patients with Valvular Heart Disease [9]. Surgical repair may be considered in patients with Loeys-Dietz syndrome and aortic diameters as small as 4.2 cm, depending on imaging modality [66].
Reoperative aortic valve and aortic root surgery can also be performed safely, utilisation CT/MRI imaging, meticulous myocardial protection, and safe management of existing bypass grafts.
Two devices of aortic valves for percutaneous transcatheter aortic valve implantation (TAVI) have been used in a large number of patients: balloon-expandable and self-expanding. Many new valve technologies are in development [67] (Figure 7).
Current commonly implanted TAVI valves.
Current data from randomised trials confirmed that TAVI is superior to medical therapy in patients with prohibitive risks for surgery, and it is equivalent to surgical aortic valve replacement in high-risk and medium-risk patients with aortic stenosis [68].
TAVI is technically possible in most patients with aortic stenosis. The larger question is when should TAVI be offered? Evaluation should identify patients in whom a significant improvement in quality and duration of life is likely and avoid unnecessary intervention in patients in whom the procedure can be performed, but the benefit is unlikely. For this reason evaluation of neurocognitive functioning, frailty, functional status, mobility, and social support is important in patient selection [68].
Transthoracic and transesophageal echocardiography, cardiac computed tomography, and invasive angiography are all used to perform anatomic evaluations specific to TAVI.
Evaluation of appropriate candidates for TAVI requires a non-competitive team approach involving interventional cardiologists with expertise in structural heart disease, cardiac and vascular surgeons, anesthesiologists, imaging specialists, and specialised nurses. The proper equipment and a minimum volume of TAVI procedures performed per operator are required.
Randomised trials and large registries of TAVI indicate procedural success rates of more than 95%, 30-day survival of more than 90%, meaningful improvement in the quality of life, and acceptable complication rates (procedure-related stroke < 2%, vascular access site complications < 5%, permanent pacemaker rates < 5%) [69].
Experience with TAVI within failed bioprostheses (valve-in-valve procedures) has been reported. Critical issues in achieving a successful valve-in-valve procedure include an understanding of the manufacturer sizing and labelling of surgical bioprostheses and correct positioning of the valve in the valve. Early experience suggests that TAVI will be an important option for the treatment of patients with failed bioprostheses [70].
More than 100,000 TAVI procedures have been performed to date. Alternatives to TAVI include surgical aortic valve replacement, aortic balloon valvuloplasty (with or without external beam radiation), and apical-to-aortic conduits.
Data from the STS indicates that the operative mortality for patients 70 years of age or older who underwent isolated AVR or AVR with coronary artery bypass grafting surgery (CABG) between 1994 and 2003 fell from 10% to less than 6% [71]. In the most recent analysis using the STS database on 108,687 patients from 1997 to 2006 with a mean age of 68 years undergoing isolated AVR, the in-hospital mortality was 2.6% with an observed stroke rate of 1.3% and length of stay of 7.8 days for the year 2006. Among patients 80–85 years of age, 30-day mortality was 4.9% with an observed stroke rate of 2.0%.
Experience at centres of excellence within the last 5 years has demonstrated significantly improved operative mortality, less than 1%, after isolated AVR. The incidence of perioperative stroke in these contemporary series ranged from 0% to 1.9%, and the length of stay was as short as 5 days [72].
In the prospective, randomised, multicenter Placement of Aortic Transcatheter Valves (PARTNER) trial comparing high-risk patients (mean STS score 11.8%) receiving TAVI or AVR for severe, symptomatic AS, outcomes for both procedures were excellent [73]. Patients undergoing AVR (n = 351, mean age 85 years) had a 30-day mortality of 6.5%, setting a new benchmark for operative outcomes in a high-risk cohort of patients treated at centres of excellence [74]. Moreover, comparative results showed that early and late strokes and transient ischemic attacks were significantly lower in the AVR group than the TAVI group (30 days, 2.4% vs. 5.5%, respectively, P = 0.04; 1 year, 4.3% vs. 8.3%, respectively, P = 0.04) [75].
Freedom from reoperation depends on both the prosthesis and patient age. Although they do not degenerate, modern mechanical valves do have a finite reoperation rate of 0.5–1% per year from endocarditis, pannus overgrowth, and thrombosis. Actual freedom from reoperation of modern bioprostheses at 15 years approaches 100% in elderly patients older than 70 years, but it can be as low as 50% in patients younger than 50 years.
The most common complications following aortic valve surgery are similar to those of other cardiac surgeries and include stroke (1–4%), deep sternal wound infection (1–2%), reoperation for bleeding (1–3%), and myocardial infarction (MI; 1–5%). Transient heart block is not uncommon, presumably as a result of traction or oedema of the bundle of His in the vicinity of the right noncoronary commissure. It usually resolves within 5–6 days of surgery. The risk of complete heart block requiring pacemaker insertion is 3–5% [76].
Aortic valve replacement is the most commonly performed valve operation. It has been shown to be an effective therapy in all age groups, including the very elderly (age > 90 years). The most common etiologies for AS are calcific degeneration, rheumatic disease, and congenital bicuspid valves. The most common causes of pure aortic regurgitation include annuloaortic ectasia and associated dilation of the aortic root, endocarditis, aortic dissection, and rheumatic disease. The indications for surgery depend on the pathophysiology and symptoms. The choice of the prosthesis can be difficult and depends on multiple clinical and lifestyle considerations. Early and late outcomes are generally quite good, even in high-risk patients.
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