Meta-analysis and meta-regression of early aortic valve replacement versus watchful waiting in asymptomatic severe aortic stenosis: a 2020 boost of evidence

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
G Costa ◽  
B Oliveiros ◽  
L Goncalves ◽  
R Teixeira
Keyword(s):  
Aortic Valve ◽  
Aortic Stenosis ◽  
Aortic Valve Replacement ◽  
Valve Replacement ◽  
Watchful Waiting ◽  
Meta Analysis ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
All Cause Mortality ◽  
Meta Regression

Abstract Background Current guidelines recommend aortic-valve replacement (AVR) as the only effective therapy for severe symptomatic aortic stenosis (AS) patients. Nevertheless, management and timing of intervention in asymptomatic AS remains a controversial topic, with sparse evidence to support the recommendations (level C). Purpose To assess an early-AVR strategy in asymptomatic severe AS, comparing it with a watchful waiting (WW) strategy Methods We systematically searched PubMed, Embase and Cochrane databases, in February 2020, for both interventional or observational studies comparing early-AVR with WW in the treatment of asymptomatic severe AS. Random-effects meta-analysis for early-AVR and WW were performed. Meta-regression was used to assess the influence of study characteristics on the outcome. Results Eight studies were included (seven registry-based or unrandomized studies and one randomized clinical trial) providing a total of 3985 patients, and 1232 pooled all-cause deaths (172 in early-AVR and 1060 in watchful waiting). Meta-analysis showed a significantly lower all-cause mortality for the early-AVR compared with WW group (pooled OR 0.24 [0.17, 0.32], P<0.01) although with a moderate amount of heterogeneity between studies in the magnitude of effect (I2=57%, P=0.02). The early-AVR patients also displayed a lower cardiovascular mortality (pooled OR 0.27 [0.15, 0.48], P<0.01) plus a lower heart failure hospitalization rate (pooled OR 0.27 [0.06, 0.65], P<0.007). No difference in clinical thromboembolic event rate (stroke or myocardial infarction) was noted. The meta-regression for all cause mortality based on possible confounders such as time of follow-up, age, gender, diabetes mellitus, coronary artery disease, left ventricular ejection fraction, and mean peak aortic jet velocity showed that effect sizes reported by the individual studies seem to be independent from the covariates considered (P>0.05). Conclusions Our 2020 pooled data reinforces the previous evidence suggesting the benefit of early-AVR in asymptomatic patients with severe AS. Early AVR vs WW, All-cause death Funding Acknowledgement Type of funding source: None

scholarly journals The impact of aortic valve replacement on survival in patients with normal flow low gradient severe aortic stenosis: a propensity-matched comparison

2019 ◽  
Vol 20 (10) ◽  
pp. 1094-1101 ◽  
Author(s):  
Sahrai Saeed ◽  
Anastasia Vamvakidou ◽  
Reinhard Seifert ◽  
Rajdeep Khattar ◽  
Wei Li ◽  
...  
Keyword(s):  
Aortic Valve ◽  
Aortic Stenosis ◽  
Aortic Valve Replacement ◽  
Valve Replacement ◽  
Severe Aortic Stenosis ◽  
Left Ventricular ◽  
Volume Index ◽  
Left Ventricular Ejection ◽  
Normal Flow ◽  
All Cause Mortality

Abstract Aims To assess the survival benefit of aortic valve replacement (AVR) in patients with normal flow low gradient severe aortic stenosis (AS). Methods and results A retrospective study of prospectively collected data of 276 patients (mean age 75 ± 15 years, 51% male) with normal transaortic flow [flow rate (FR) ≥200 mL/s or stroke volume index (SVi) ≥35 mL/m2] and severe AS (aortic valve area <1.0 cm2). The outcome measure was all-cause mortality. Of the 276 patients, 151 (55%) were medically treated, while 125 (45%) underwent an AVR. Over a mean follow-up of 3.2 ± 1.8 years (range 0–6.9 years), a total of 96 (34.8%) deaths occurred: 17 (13.6%) in AVR group vs. 79 (52.3%) in those medically treated, when transaortic flow was defined by FR (P < 0.001). When transaortic flow was defined by SVi, a total of 79 (31.3%) deaths occurred: 18 (15.1%) in AVR group vs. 61 (45.9%) in medically treated (P < 0.001). In a propensity-matched multivariable Cox regression analysis adjusting for age, gender, body surface area, smoking, hypertension, diabetes mellitus, atrial fibrillation, peripheral vascular disease, chronic kidney disease, left ventricular ejection fraction, left ventricular mass, and mean aortic gradient, not having AVR was associated with a 6.3-fold higher hazard ratio (HR) of all-cause mortality [HR 6.28, 95% confidence interval (CI) 3.34–13.16; P < 0.001] when flow was defined by FR. In the SVi-guided model, it was 3.83-fold (HR 3.83, 95% CI 2.30–6.37; P < 0.001). Conclusion In patients with normal flow low gradient severe AS, AVR was associated with a significantly improved survival compared with those who received standard medical treatment.

scholarly journals Distribution and prognostic value of left ventricular global longitudinal strain in elderly patients with symptomatic severe aortic stenosis undergoing transcatheter aortic valve replacement

2020 ◽  
Vol 20 (1) ◽  
Author(s):  
Jonas Agerlund Povlsen ◽  
Vibeke Guldbrand Rasmussen ◽  
Henrik Vase ◽  
Kaare Troels Jensen ◽  
Christian Juhl Terkelsen ◽  
...  
Keyword(s):  
Aortic Valve ◽  
Aortic Stenosis ◽  
Aortic Valve Replacement ◽  
Elderly Patients ◽  
Valve Replacement ◽  
Prognostic Value ◽  
Longitudinal Strain ◽  
Global Longitudinal Strain ◽  
Left Ventricular ◽  
All Cause Mortality

Abstract Aims The aim of present study was to examine the preoperative prevalence and distribution of impaired left ventricular global longitudinal strain (LVGLS) in elderly patients with symptomatic aortic stenosis (AS) undergoing transcutaneous aortic valve replacement (TAVR) and to determine the predictive value of LVGLS on survival. Methods We included 411 patients with symptomatic severe AS treated with TAVR during a 5-year period, where a baseline echocardiography including LVGLS assessment was available. Results Mean age was 80.1 ± 7.1 years and aortic valve area (AVA) index 0.4 ± 0.1 cm2. 78 patients died during a median follow-up of 762 days. Mean left ventricular ejection fraction (LVEF) was 50 ± 13% and mean LVGLS was − 14.0%. LVEF was preserved in 60% of patients, while impaired LVGLS > − 18% was seen in 75% of the patients. Previous myocardial infarction, LVEF < 50%, LVGLS > − 14%, low gradient AS (< 4.0 m/s), tricuspid regurgitant gradient > 30 mmHg were identified as significant univariate predictors of all-cause mortality. On multivariate analysis LVGLS > − 14% (HR 1.79 [1.02–3.14], p = 0.04) was identified as the only independent variable associated with all-cause mortality. Reduced survival was observed with an impaired LVGLS > − 14% in the total population (p < 0.002) but also in patients with high AS gradient with preserved LVEF. LVGLS provided incremental prognostic value with respect to clinical characteristics, AVA and LVEF (χ2 19.9, p = 0.006). Conclusions In patients with symptomatic AS undergoing TAVR, impaired LVGLS was highly prevalent despite preserved LVEF. LVGLS > − 14% was an independent predictor of all-cause mortality, and survival was reduced if LVGLS > − 14%.

scholarly journals Regression of Left Ventricular Mass after Implantation of the Sutureless 3f Enable Aortic Bioprosthesis

2015 ◽  
Vol 42 (2) ◽  
pp. 117-123
Author(s):  
Giovanni Concistrè ◽  
Antonio Miceli ◽  
Federica Marchi ◽  
Francesca Chiaramonti ◽  
Mattia Glauber ◽  
...  
Keyword(s):  
Aortic Valve ◽  
Aortic Stenosis ◽  
Aortic Valve Replacement ◽  
Left Ventricular Mass ◽  
Valve Replacement ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Ventricular Mass ◽  
The Mean

Left ventricular hypertrophy in aortic stenosis is considered a compensatory response for the maintenance of systolic function but a risk factor for cardiac morbidity and death. We investigated the degree of left ventricular mass regression after implantation of the sutureless Medtronic 3f Enable® Aortic Bioprosthesis. We studied 19 patients who, from May 2010 through July 2011, underwent isolated aortic valve replacement with the 3f Enable bioprosthetic valve, with clinical and echocardiographic follow-up at 6 months. The mean age was 77.1 ± 5.1 years (range, 68–86 yr); 14 patients were women (73.7%); and the mean logistic EuroSCORE was 15.4% ± 11.8%. Echocardiography was performed preoperatively, at discharge, and at 6 months' follow-up. The left ventricular mass was calculated by means of the Devereux formula and indexed to body surface area. The left ventricular mass index decreased from 146.1 ± 47.6 g/m2 at baseline to 118.1 ± 39.8 g/m2 at follow-up (P=0.003). The left ventricular ejection fraction did not change significantly. The mean transaortic gradient decreased from 57.3 ± 14.2 mmHg at baseline to 12.3 ± 4.6 mmHg at discharge and 12.2 ± 5.3 mmHg at follow-up (P &lt;0.001), and these decreases were accompanied by substantial clinical improvement. No moderate or severe paravalvular leakage was present at discharge or at follow-up. In isolated aortic stenosis, aortic valve replacement with the 3f Enable bioprosthesis results in significant regression of left ventricular mass at 6 months' follow-up. However, this regression needs to be verified by long-term echocardiographic follow-up.

scholarly journals prognostic evaluation of patients benefiting from a trans aortic valve replacement according to the type of aortic stenosis

2021 ◽  
Vol 22 (Supplement_1) ◽  
Author(s):  
M Lacout ◽  
C David ◽  
A Bernard ◽  
C Saint Etienne ◽  
JM Clerc ◽  
...  
Keyword(s):  
Aortic Valve ◽  
Aortic Stenosis ◽  
Aortic Valve Replacement ◽  
Valve Replacement ◽  
Left Ventricular ◽  
Low Flow ◽  
Left Ventricular Ejection ◽  
Normal Flow ◽  
High Gradient ◽  
Normal Lvef

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Aortic Stenosis (AS) is a common condition in patients over 75 years.  Latest ESC recommendations differentiate 4 types of AS according to: Indexed Stroke Volume (SVi), mean gradient and left ventricular ejection fraction (LVEF). The aim of our study is to evaluate prognosis of patients who have had a transcatheter aortic valve replacement (TAVR), in terms of mortality, according  to the 4 types of AS. Methods This study compares prognosis of 620 patients who had TAVR between January 1, 2015 and December 31, 2018. Patients were classified into 4 groups according to AS type: high gradient; low gradient, low flow, low LVEF; low gradient, low flow, normal LVEF; low gradient, normal flow. Results 69 patients (11.1%) died within 12 months of the procedure: 49 in the high gradient group (9.4%); 13 in the low gradient, low flow, low LVEF group (47.1%); 1 in the low gradient, low flow, normal LVEF group (5%); 6 in the low gradient, normal flow, normal LVEF group (18.2%). All-cause mortality at one year follow-up is higher in low-gradient, low-flow, altered LVEF group (p = 0.0004) than in other groups. Patients in this group were significantly more often admitted for heart failure than patients in high-gradient group (p = 0.009). Conclusion A complete echocardiography evaluation is needed to evaluate AS, its severity and type. Patients in the low gradient, low flow, low LVEF group have an independent risk of mortality at 12 months higher than other groups and are more hospitalized than patients in the high gradient group.

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