External validation of a new staging system for severe aortic stenosis in a Portuguese cohort

Abstract Background Recently, a new staging system for severe aortic stenosis (AS) based upon the extent of extra-aortic-valve cardiac damage has been developed (Genereux et al. Eur Heart J 2017). The present study aimed to: 1) determine the prevalence of the different stages of extra-aortic valvular cardiac damage and its impact on prognosis in a real-world Portuguese cohort and; 2) evaluate the distribution of aortic valve calcium score (AV-CaSc) and its prognostic value. Methods Consecutive patients evaluated at a single-centre TAVI-programme between Nov/2015 and Nov/2018 were retrospective selected. The extent of extra-aortic valve cardiac damage was defined by echocardiography as stage 0 (no cardiac damage), stage 1 (left ventricular damage), stage 2 (mitral valve or left atrial damage), stage 3 (tricuspid valve or pulmonary artery vasculature damage) or stage 4 (right ventricular damage). AV-CaSc was estimated routinely at CT-angiography as per TAVI-programme protocol. The primary endpoint was 1-year all-cause mortality after CT-angiography. Survival analysis (Cox-regression hazards model and Kaplan-Meier) was performed. To account for the effect of aortic valve replacement (AVR), this variable entered the Cox-regression model as a time-dependent covariate. Results A total of 443 patients (mean age 82±7 years, 44% men, median euroSCORE II 4% [IQR 2.4–5.8]) were identified. After Heart Team discussion, 79% (n=349) underwent AVR (TAVI=307; surgical valve repair=42); 9% (n=42) await intervention; 6% (n=25) remain under medical treatment; 4% (n=19) died during the period of evaluation; and 2% (n=8) underwent palliative aortic balloon valvuloplasty. According to the proposed classification, the distribution of patients from stages 0 through 4 was: 0.2% (n=1), 7.5% (n=34), 67.8% (n=306), 14% (n=63), and 10.4% (n=47). Additionally, for each increasing stage of cardiac damage, the burden of AV-CaSc was higher (from stage 1 through 4: 1776 [IQR 1217–2448]; 2448 [1796–3442]; 2448 [1832–3622]; 2960 [1936–4878] units; p for trend = 0.002). All-cause mortality at 1-year was 14% (n=63). Mortality increased alongside with increasing extent of cardiac damage (from stage 0 through 4: 0% [n=0], 6% [n=2], 12% [n=36], 20% [n=12], and 30% [n=13]) – Fig. Multivariable analysis revealed chronic renal disease (HR 1.37 per stage [1.15–1.64], p<0.001), AV-CaSc (HR 1.02 per 100 units [1.01–1.03], p=0.007), AVR (HR 0.46 [0.26–0.81], p=0.007) and stage of cardiac damage (HR 1.54 per stage [1.15–2.05], p=0.004) as independent predictors of 1-year mortality. Conclusion In a real-world Portuguese cohort of severe AS patients, the extent of cardiac damage was associated with 1-year mortality. AV- CaSc grants additional prognostic information to this classification. Incorporation of this staging system into patient evaluation may be useful in the risk assessment of severe AS. Survival analysis Funding Acknowledgement Type of funding source: None

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Cardiac damage grading in patients with aortic stenosis using multi-detector computed tomography and the impact on prognosis after transcatheter aortic valve intervention

European Heart Journal ◽

10.1093/ehjci/ehaa946.0164 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

K Hirasawa ◽

P.J Rosendael ◽

F Fortuni ◽

G.K Singh ◽

J Kuneman ◽

...

Keyword(s):

Computed Tomography ◽

Aortic Valve ◽

Aortic Stenosis ◽

Staging System ◽

Funding Source ◽

Cardiac Damage ◽

Transcatheter Aortic Valve ◽

Stage 4 ◽

All Cause Mortality ◽

Stage 1

Abstract Introduction A staging of severe aortic stenosis (AS) based on additional extra-valvular cardiac damage has been associated with prognosis after transcatheter aortic valve implantation (TAVI). Multi-detector row computed tomography (MDCT) has a central role in the evaluation of AS patients undergoing TAVI and can detect extra-valvular cardiac damage. Purpose To evaluate the prognostic implications of an MDCT staging system of severe AS in patients undergoing TAVI. Methods Patients who underwent full-beat MDCT prior to TAVI were included. Patients with intra-cardiac devices, prior valvular surgery, and insufficient image quality were excluded. The extent of cardiac damage was assessed by MDCT and classified into following 5 groups; stage 0 (no cardiac damage), stage 1 (left ventricular damage), stage 2 (left atrium and mitral valve damage), stage 3 (right atrial damage), stage 4 (right ventricular damage). The primary end-point was all-cause mortality. Results A total of 405 patients (80±7 years, 52% men) were stratified according to the MDCT staging system: 27 (7%) were in stage 0, 96 (24%) in stage 1, 152 (38%) in stage 2, 78 (19%) in stage 3, and 52 (13%) in stage 4 (left panel). During follow-up (median 3.7 years, IQR: 1.7–5.5 years), 150 (37%) died (right panel). On multivariable analysis, cardiac damage stage, presence of chronic obstructive pulmonary disease, NYHA ≥3, eGFR, and transapical approach were independently associated with all-cause mortality. When evaluating each stage, stage 3 (HR: 4.725, P=0.033) and stage 4 (HR 5.678, P=0.018) were independently associated with worse outcomes as compared to the other stages. Conclusion MDCT-based staging system of severe AS identifies the patients who are at higher risk of death after TAVI. MDCT staging and the mortality Funding Acknowledgement Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): ESC research grant

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Staging cardiac damage in aortic valve disease: one size fits all?

European Heart Journal ◽

10.1093/eurheartj/ehab724.1616 ◽

2021 ◽

Vol 42 (Supplement_1) ◽

Author(s):

G Silva ◽

F Sampaio ◽

C Espada Guerreiro ◽

P Goncalves Teixeira ◽

P Ribeiro Queiros ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Stenosis ◽

Aortic Regurgitation ◽

Severe Aortic Stenosis ◽

Multivariable Analysis ◽

Staging System ◽

Left Ventricular ◽

Cardiac Damage ◽

Stage 4 ◽

Stage 1

Abstract Background Nowadays, in patients with aortic regurgitation (AR), aortic valve surgery is indicated when severe and symptomatic or those with depressed LVEF. However, clinical outcomes of patients with significant aortic regurgitation are not influenced by these factors only. Recently, a new staging system for severe aortic stenosis has been proposed by Généreux on the basis of the extent of anatomic and functional cardiac damage. If this model could be applicable to an unselected significant AR population has not been tested. Purpose The aim of our study was to evaluate the prevalence of the different stages of extra-aortic valvular cardiac damage by the application of Généreux staging and its impact on prognosis in a large, real world cohort of significant AR patients. Methods This study retrospectively analysed the clinical, Doppler echocardiographic and outcome data in patients with grade III or greater AR between January 2014 and September 2019. According to the extent of cardiac damage on echocardiography, patients were classified as Stage 0 (no cardiac damage), Stage 1 (left ventricular damage), Stage 2 (mitral valve or left atrial damage), Stage 3 (tricuspid valve or pulmonary artery vasculature damage) or Stage 4 (right ventricular damage). Exclusion criteria were severe aortic stenosis and previous valve repair or replacement. The primary end-point was all-cause mortality. Results A total of 572 patients, aged 70.1±13.9 years, 294 (51.3%) men were enrolled. One third of patients were in NYHA I. Based on the proposed classification, 82 patients (14.3%) were classified in stage 0, 130 (22.7%) in stage 1, 276 (48.2%) in stage 2, 68 (11.8%) in stage 3 and 17 (3.0%) in stage 4. Median follow-up time was 3.3±1.9 years. There was a progressive increase in mortality rates according to staging: 8.5% in stage 0, 10.8% in stage 1, 24.9% in stage 2, 42.6% in stage 3 and 52.9% in stage 4 (p<0.001). On multivariable analysis, the extent of cardiac damage was independently associated with excess mortality (HR 1.69, 95% CI 1.29 to 2.21) Conclusion Our study demonstrated that this new staging system studied for aortic stenosis also provides increased prognostic value to patients with significant aortic regurgitation. This staging system can be helpful to identify the degree of extra-aortic valvular cardiac damage and to optimize the time of valvular intervention. Further prospective studies are needed to confirm the benefit of the applicability of this model in clinical practice. FUNDunding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): Centro Hospitalar Vila Nova de Gaia / Espinho Distribution of stages of cardiac damage Survival analysis according to stage

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P3364Cardiac damage in a real-world severe aortic stenosis population

European Heart Journal ◽

10.1093/eurheartj/ehz745.0240 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

R Ventura Gomes ◽

J Pais ◽

A R Pereira ◽

D Sebaiti ◽

I Cruz ◽

...

Keyword(s):

Multivariate Analysis ◽

Aortic Stenosis ◽

Real World ◽

Primary Outcome ◽

Severe Aortic Stenosis ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Cardiac Damage ◽

Stage 4 ◽

Stage 1

Abstract Introduction The cardiac consequences of aortic stenosis, besides left ventricular ejection fraction and systolic pulmonary artery pressure, aren't considered in the recommendations for surgical intervention in patients (pts) with severe aortic stenosis (SAS). In 2017, a new staging echo classification was presented to accurately describe them. Purpose To evaluate this new echo classification in risk stratification of pts with SAS with or without AVR, in a real–world setting. Methods Retrospective cohort study of pts with SAS (mean transvalvular pressure gradient (MG) ≥40 mmHg or a peak transvalvular velocity (PTV) ≥4.0 m/s), examined between January 2014 and December 2016. Pts were classified according to the new staging echo classification (no extravalvular cardiac damage - Stage 0, left ventricular damage - Stage 1, left atrial or mitral valve damage - Stage 2, pulmonary vasculature or tricuspid valve damage - Stage 3, or right ventricular damage - Stage 4). Follow-up (FU) was 2.6±1.0 years. The primary outcome was a composite of cardiovascular death or heart failure hospitalization. Results 212 pts with SAS were included (age 76.1±9.1 years, 31.6% men; aortic valve area 0.69±0.21cm2; PTV 4.5±0.4m/s; MG 48.5±11.6mmHg; LVEF 58.8±12.2%). 19 (9.0%) pts were classified as Stage 0, 29 (13.7%) as Stage 1, 129 (60.8%) as Stage 2, 12 (5.7%) as Stage 3 and 23 (10.8%) as Stage 4. Pts with more advanced stages had more events (stage 0: 5.3%; stage 1: 10.3%; stage 2: 17.1%; stage 3: 50.0%; stage 4: 52.2%; p<0.0001). In the multivariate analysis, the classification system was also a predictor of the outcome, even when including the AVR in the model (table 1). Similar findings in the uni and multivariate analysis were identified when analyzing only the pts with SAS and no aortic intervention (events in stage 0: 16.7%; stage 1: 18.2%; stage 2: 29.3%; stage 3: 75.0%; stage 4: 64.7%, p<0.005; Figure 1). Table 1. Predictors of the outcome Variables Adjusted HR (95% CI) p-value Sex* 1.86 (1.01–3.44) 0.047 eGFR* 0.99 (0.98–1.01) 0.201 AVR* 8.97 (3.85–20.90) 0.0001 Classification* – 0.031 Stage 0 0.19 (0.02–1.537) 0.120 Stage 1 0.28 (0.08–1.01) 0.052 Stage 2 0.36 (0.17–0.74) 0,006 Stage 3 0.81 (0.30–2.19) 0.675 Stage 4 1 – *Variables with p<0.05 in univariate analysis. Figure 1. Survival of SAS pts with no AVR Conclusion In a real-world experience, the new staging echo classification showed a significant relationship between the extent of cardiac damage at baseline and the primary outcome in pts with SAS, even after controlling for AVR. This classification was also able to identify the SAS pts who did not perform AVR and had a significant risk of adverse events.

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Effect of the Extent of Cardiac Damage on Transcatheter Aortic Valve Replacement Outcome: A New Aortic Stenosis Staging System

US Cardiology Review ◽

10.15420/usc.2019.9.1 ◽

2020 ◽

Vol 13 (2) ◽

pp. 69-73

Author(s):

Miho Fukui ◽

João L Cavalcante

Keyword(s):

Aortic Valve ◽

Aortic Stenosis ◽

Aortic Valve Replacement ◽

Valve Replacement ◽

Transcatheter Aortic Valve Replacement ◽

Severe Aortic Stenosis ◽

Staging System ◽

Cardiac Damage ◽

Transcatheter Aortic Valve ◽

Staging Classification

Severe aortic stenosis (AS) causes chronic pressure overload of the left ventricle (LV), resulting in progressive cardiac change that can extend beyond the LV. A new AS staging classification has been recently proposed encompassing the extent of cardiac changes in AS. The AS staging classification has important prognostic implications for clinical outcomes after aortic valve replacement. This article introduces the AS staging system and demonstrates the association of the extent of cardiac change with outcomes after transcatheter aortic valve replacement.

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Prognostic implications of cardiac damage classification based on computed tomography in severe aortic stenosis

European Heart Journal - Cardiovascular Imaging ◽

10.1093/ehjci/jeab071 ◽

2021 ◽

Author(s):

Kensuke Hirasawa ◽

Philippe J vanRosendael ◽

Federico Fortuni ◽

Gurpreet K Singh ◽

Jurrien H Kuneman ◽

...

Keyword(s):

Computed Tomography ◽

Aortic Stenosis ◽

Severe Aortic Stenosis ◽

Staging System ◽

Left Ventricular ◽

Right Atrial ◽

Cardiac Damage ◽

Stage 4 ◽

Prognostic Implications ◽

Stage 1

Abstract Aims An echocardiographic staging system of severe aortic stenosis (AS) based on additional extra-valvular cardiac damage has been associated with prognosis after transcatheter aortic valve implantation (TAVI). Multidetector row computed tomography (MDCT) is key in the evaluation of AS patients undergoing TAVI and can potentially detect extra-valvular cardiac damage. This study aimed at evaluating the prognostic implications of an MDCT staging system of severe AS in patients undergoing TAVI. Methods and results A total of 405 patients (80 ± 7 years, 52% men) who underwent full-beat MDCT prior to TAVI were included. The extent of cardiac damage was assessed by MDCT and classified in five categories; Stage 0 (no cardiac damage), Stage 1 (left ventricular damage), Stage 2 (left atrium and mitral valve damage), Stage 3 (right atrial damage), and Stage 4 (right ventricular damage). Twenty-seven (7%) patients were stratified as Stage 0, 96 (24%) as Stage 1, 152 (38%) as Stage 2, 78 (19%) as Stage 3, and 52 (13%) as Stage 4. During a median follow-up of 3.7 (IQR 1.7–5.5) years, 150 (37%) died. On multivariable Cox regression analysis, cardiac damage Stage 3 (HR vs. Stage 0: 4.496, P = 0.039) and Stage 4 (HR vs. Stage 0: 5.565, P = 0.020) were independently associated with all-cause mortality. Conclusion The MDCT-based staging system of cardiac damage in severe AS effectively identifies the patients who are at higher risk of death after TAVI.

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Demographic characteristics, aortic valve intervention rates and all-cause mortality in 4 flow-gradient sub-types of severe aortic stenosis

European Heart Journal ◽

10.1093/ehjci/ehaa946.0060 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

S Saeed ◽

A Vamvakidou ◽

H.Y Yakupoglu ◽

R Senior ◽

R.S Khattar

Keyword(s):

Aortic Valve ◽

Aortic Stenosis ◽

Severe Aortic Stenosis ◽

Stroke Volume Index ◽

Low Flow ◽

Volume Index ◽

Mortality Data ◽

Aortic Valve Area ◽

Flow Gradient ◽

All Cause Mortality

Abstract Introduction Severe aortic stenosis (AS), defined as aortic valve area (AVA) <1.0 cm2, can be divided into 4 categories based on flow status and mean gradient. Stroke volume index <35 ml/m2 has classically been used to define low flow, but recent data suggest that flow rate (FR) <200ml/sec may be a more accurate and robust marker of low flow. Methods We prospectively collected demographic, echocardiographic, aortic valve intervention (AVI) and all-cause mortality data on 1562 patients with symptomatic severe AS from 2010 to 2017 with a mean follow up period of 35±22 months. Patients were divided into 4 flow-gradient sub-groups based on a FR threshold of 200ml/s and mean pressure gradient of 40mmHg. Comparative analyses were performed among the 4 groups using analysis of variance. Results The prevalence of normal flow high gradient (NFHG) severe AS was 30%, NF low gradient (NFLG) 21%, low flow HG (LFHG) 18% and LFLG 31% (Table). Across these 4 sub-groups, there was a graded reduction in LVEF and FR, and an increase in age and all–cause mortality. Conclusions Classification of aortic stenosis based on flow-gradient patterns, shows important differences in the demographic profile and clinical outcome among the 4 groups. Classical NFHG AS was associated with the highest rate of AVI and lowest all-cause mortality compared to the 3 discordant flow-gradient subtypes. The LFLG group had the lowest AVI rates and worst outcome. Funding Acknowledgement Type of funding source: None

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Early Aortic Valve Replacement vs. Conservative Management in Asymptomatic Severe Aortic Stenosis Patients With Preserved Ejection Fraction: A Meta-Analysis

Frontiers in Cardiovascular Medicine ◽

10.3389/fcvm.2020.621149 ◽

2021 ◽

Vol 7 ◽

Author(s):

Tan Yuan ◽

Yi Lu ◽

Chang Bian ◽

Zhejun Cai

Keyword(s):

Aortic Valve ◽

Aortic Stenosis ◽

Ejection Fraction ◽

Aortic Valve Replacement ◽

Conservative Management ◽

Severe Aortic Stenosis ◽

Preserved Ejection Fraction ◽

Cardiac Mortality ◽

Asymptomatic Patients ◽

All Cause Mortality

Background: Aortic stenosis (AS) is the most common valvular disease in developed countries. Until now, the specific timing of intervention for asymptomatic patients with severe aortic stenosis and preserved ejection fraction remains controversial.Methods: A systematic search of four databases (Pubmed, Web of science, Cochrane library, Embase) was conducted. Studies of asymptomatic patients with severe AS or very severe AS and preserved left ventricular ejection fraction underwent early aortic valve replacement (AVR) or conservative care were included. The end points included all-cause mortality, cardiac mortality, and non-cardiac mortality.Results: Four eligible studies were identified with a total of 1,249 participants. Compared to conservative management, patients who underwent early AVR were associated with lower all-cause mortality, cardiac mortality, and non-cardiac mortality rate (OR 0.16, 95% CI 0.09–0.31, P < 0.00001; OR 0.12, 95% CI 0.02–0.62, P = 0.01; OR 0.36, 95% CI 0.21–0.63, P = 0.0003, respectively).Conclusions: Early AVR is preferable for asymptomatic severe AS patients with preserved ejection fraction.

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480Right ventricular dysfunction is associated with late mortality in severe aortic stenosis: results from a multi-centre outcome study in patients undergoing aortic valve replacement

European Heart Journal ◽

10.1093/eurheartj/ehz747.0130 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

M Rigolli ◽

T A Musa ◽

T A Treibel ◽

M Loudon ◽

V S Vassiliou ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Stenosis ◽

Ejection Fraction ◽

Aortic Valve Replacement ◽

Valve Replacement ◽

Severe Aortic Stenosis ◽

Term Survival ◽

Early Stages ◽

All Cause Mortality ◽

Rv Function

Abstract Background The right ventricle (RV) is relatively understudied and often not routinely assessed in aortic stenosis (AS). However, there are several potential reasons for its importance. RV function is sensitive to left-sided afterload changes which can result in pulmonary hypertension (PH) in severe AS. PH is also a recognised predictor of poor prognosis in AS, but RV afterload and function can be difficult to assess. Cardiovascular magnetic resonance (CMR) may reveal unrecognised RV dysfunction and simultaneously evaluate other prognostic markers in AS. Purpose To investigate preoperative RV function assessed by CMR in severe AS and its association with mortality after aortic valve replacement (AVR). Methods 674 severe AS patients listed for either surgical or percutaneous AVR at six cardiothoracic centres underwent preoperative CMR (for ventricular function, mass and scar) along with echocardiography for valve severity. Scans were core-lab analysed for LV and RV volumes, function and scar quantification. Eight patients were excluded due to inadequate RV image quality for a total of 666 patients finally included. All-cause mortality was tracked for a minimum of 2 years after AVR. Results 107 (16%) of severe AS undergoing invasive AVR had a RV ejection fraction (RVEF) <55%. CMR detected overt RV dysfunction (RVEF <50%) in 61 (9%) patients. During a median 3.6 years follow-up, 145 (22%) patients died. Baseline RV dysfunction was the most powerful predictor of all-cause mortality (hazard ratio [HR] 2.5, 95% CI 1.6–3.9, p<0.0001). RV function was independent from other clinical characteristics but associated with signs of LV maladaptation (LV ejection fraction [LVEF] and late gadolinium enhancement [LGE]). The strongest Cox multivariable model for all-cause mortality accounted for RV dysfunction, age and LGE (adjusted HRs 1.7, 1.1, 2.2, respectively). Even early stages of pre-procedural RV dysfunction (RVEF 45–50%) were associated with reduced long-term survival. Cox and Kaplan-Meier for all-cause death Conclusion One out of 6 patients with severe AS undergoing valve replacement manifests a reduction in RV function detectable by CMR. Those with RV dysfunction (RVEF<50%) have a 2.5-fold increase in all-cause mortality after AVR at 3.6 years. Whilst RV dysfunction is associated with LV maladaptation (LGE, LVEF), it is a powerful independent factor associated with all-cause mortality and impacts survival even at early stages. Thus, the RV appears to be important in cardiac adaptation to AS and longevity after AS intervention. Acknowledgement/Funding British Heart Foundation and National Institute of Health Research

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Transcatheter aortic valve implantation vs. surgical aortic valve replacement for treatment of symptomatic severe aortic stenosis: an updated meta-analysis

European Heart Journal ◽

10.1093/eurheartj/ehz275 ◽

2019 ◽

Vol 40 (38) ◽

pp. 3143-3153 ◽

Cited By ~ 83

Author(s):

George C M Siontis ◽

Pavel Overtchouk ◽

Thomas J Cahill ◽

Thomas Modine ◽

Bernard Prendergast ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Stenosis ◽

Transcatheter Aortic Valve Implantation ◽

Severe Aortic Stenosis ◽

Surgical Aortic Valve Replacement ◽

Surgical Risk ◽

Transcatheter Aortic Valve ◽

All Cause Mortality ◽

Aortic Valve Implantation ◽

Valve Implantation

Abstract Aims Owing to new evidence from randomized controlled trials (RCTs) in low-risk patients with severe aortic stenosis, we compared the collective safety and efficacy of transcatheter aortic valve implantation (TAVI) vs. surgical aortic valve replacement (SAVR) across the entire spectrum of surgical risk patients. Methods and results The meta-analysis is registered with PROSPERO (CRD42016037273). We identified RCTs comparing TAVI with SAVR in patients with severe aortic stenosis reporting at different follow-up periods. We extracted trial, patient, intervention, and outcome characteristics following predefined criteria. The primary outcome was all-cause mortality up to 2 years for the main analysis. Seven trials that randomly assigned 8020 participants to TAVI (4014 patients) and SAVR (4006 patients) were included. The combined mean STS score in the TAVI arm was 9.4%, 5.1%, and 2.0% for high-, intermediate-, and low surgical risk trials, respectively. Transcatheter aortic valve implantation was associated with a significant reduction of all-cause mortality compared to SAVR {hazard ratio [HR] 0.88 [95% confidence interval (CI) 0.78–0.99], P = 0.030}; an effect that was consistent across the entire spectrum of surgical risk (P-for-interaction = 0.410) and irrespective of type of transcatheter heart valve (THV) system (P-for-interaction = 0.674). Transcatheter aortic valve implantation resulted in lower risk of strokes [HR 0.81 (95% CI 0.68–0.98), P = 0.028]. Surgical aortic valve replacement was associated with a lower risk of major vascular complications [HR 1.99 (95% CI 1.34–2.93), P = 0.001] and permanent pacemaker implantations [HR 2.27 (95% CI 1.47–3.64), P < 0.001] compared to TAVI. Conclusion Compared with SAVR, TAVI is associated with reduction in all-cause mortality and stroke up to 2 years irrespective of baseline surgical risk and type of THV system.

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Propensity score-matched analysis of patients with severe aortic stenosis undergoing surgical aortic valve replacement

Open Heart ◽

10.1136/openhrt-2018-000992 ◽

2019 ◽

Vol 6 (1) ◽

pp. e000992 ◽

Cited By ~ 2

Author(s):

Shiro Miura ◽

Takehiro Yamashita ◽

Michiya Hanyu ◽

Hiraku Kumamaru ◽

Shinichi Shirai ◽

...

Keyword(s):

Aortic Valve ◽

Propensity Score ◽

Aortic Stenosis ◽

Aortic Valve Replacement ◽

Cardiovascular Events ◽

Severe Aortic Stenosis ◽

Surgical Aortic Valve Replacement ◽

Asymptomatic Patients ◽

All Cause Mortality ◽

Baseline Characteristics

ObjectiveSevere aortic stenosis (AS) is one of the most serious valve conditions. Patient demography and the aetiology of AS have substantially changed in the past several decades along with a drastic improvement of surgical aortic valve replacement (SAVR) and its associated procedures. Contemporary patients with severe AS have multiple comorbidities and live much longer. We aimed to elucidate the treatment effects of SAVR on long-term outcome in propensity score (PS)-matched and the entire patient populations.MethodsWe retrospectively reviewed 570 patients with severe AS defined as an aortic valve area of 1.0 cm2 or less. Systemic differences in 39 baseline characteristics between non-SAVR and SAVR groups were adjusted using PS matching method. The endpoints included all-cause mortality and cardiovascular events that included heart failure, non-fatal stroke, syncope and acute coronary syndrome.ResultsOverall, 55% of the entire population (mean age 78 years; males 41%) were symptomatic. During 3.9 years of the median follow-up, 210 (36%) patients underwent SAVR and 231 (41%) died. Cumulative incidences of mortality and both mortality and cardiovascular events were significantly higher in the non-SAVR group than in the other group (p<0.001, each). Among 101 PS-matched pairs, SAVR correlated with a lower mortality risk (HR 0.35; 95% CI 0.21 to 0.59; p<0.001)) and mortality and cardiovascular events combined (HR 0.62; 95% CI 0.42 to 0.92; p=0.02). However, survival difference between both groups was markedly smaller among asymptomatic patients in the subgroup of matched patients.ConclusionPatients with AS undergoing SAVR exhibit a lower incidence of all-cause mortality and major cardiovascular events than those not undergoing surgical interventions, even after the baseline characteristics are balanced by the PS matching. The correlation between SAVR and survival from cardiovascular events is less evident among asymptomatic patients.

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