Left atrial functional assessment and mortality in patients with severe aortic stenosis

Abstract Funding Acknowledgements Type of funding sources: None. Background/Introduction: Aortic valve stenosis (AS) is the most common primary valvular heart disease leading to surgical or percutaneous aortic valve replacement (AVR) in Europe. Both symptoms and systolic dysfunction can appear late in the course of the disease, being often synonym of irreversible damage to the myocardium when found. Thus, there is a necessity to find other sensitive markers present at an earlier stage of the disease. Purpose Our primary aim is to clarify the relationship between LA function measured at severe AS diagnosis (evaluated by means of volumetric assessment) and all-cause mortality during follow-up. Methods We retrospectively evaluated patients diagnosed with severe AS for the first time at our echocardiography laboratory. We evaluated all 3 left atrial (LA) functional phases (reservoir, conduit and pump) by measuring LA volumes at different timings of cardiac cycle. Treatment strategy was decided according to heart team consensus and own patient decision. We divided patients into groups according to terciles of LA reservoir, conduit and pump function. Primary outcome was defined by the occurrence of all-cause mortality during follow-up. Results After exclusion criteria, a total of 451 patients were included in the analysis (aged 74 ±11years, 54% male) and were followed during a median period of 73 months (interquartile range 44.5). A total of 55.8% of patients underwent AVR and 45,5% of patients registered the primary outcome. Left atrial emptying fraction (LAEF) was the best LA functional parameter in discriminating primary outcome (AUC 0.840, p < 0.001), even when compared to left ventricular ejection fraction, aortic valve area, aortic mean pressure gradient and aortic Vmax. Patients in the lower tercile of LAEF were older, had greater comorbidities, had greater AS severity, with greater degree of diastolic disfunction. After adjustment for clinical and demographic variables, cumulative survival of patients with LAEF <37% and LAEF 37 to 53% relative to patients with LAEF ≥54% remained significantly lower (adjusted HR 19.04, 95% CI 8.30-43.67, P < 0.001 and adjusted HR 4.09, 95% CI 1.85-9.06, P = 0.001). Survival was also higher in patients with LAEF 37 to 53% when compared to patients with LAEF <37% (adjusted HR 0.22, 95% CI 0.13-0.37, P < 0.001). All associations remained true after adjustment for AVR (LAEF <37% versus LAEF 37 to 53% and LAEF ≥54%, respectively, adjusted HR 3.97, 95% CI 1.80-8.78, P = 0.001 and adjusted HR 13.95, 95% CI 5.98-32.54, P < 0.001, respectively) Conclusion(s) In patients with a first diagnosis of severe AS in hospital setting, LA function assessed by volumetric parameters is an independent predictor of all-cause mortality. Compared to classical severity parameters, different LA functional parameters were found to be more potent predictors of death. These data can be useful in clinical practice for risk stratification and therefore for decision of timing for AVR. Abstract Figure. Survival of patients stratified by group

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Left atrial functional assessment and mortality in patients with severe aortic stenosis with sinus rhythm

Cardiovascular Ultrasound ◽

10.1186/s12947-020-00231-0 ◽

2021 ◽

Vol 19 (1) ◽

Author(s):

João Ferreira ◽

Valdirene Gonçalves ◽

Patrícia Marques-Alves ◽

Rui Martins ◽

Sílvia Monteiro ◽

...

Keyword(s):

Aortic Valve ◽

Left Atrial ◽

Primary Outcome ◽

Severe Aortic Stenosis ◽

Heart Team ◽

Pump Function ◽

Volumetric Assessment ◽

All Cause Mortality ◽

Echocardiography Laboratory

Abstract Background Aortic valve stenosis (AS) is the most common primary valvular heart disease leading to surgical or percutaneous aortic valve replacement (AVR) in Europe and its prevalence keeps growing. While other risk factors in severe AS are well documented, little is known about the prognostic value of left atrial (LA) function in AS. Our aim is to clarify the relationship between LA function measured at severe AS diagnosis (evaluated by means of volumetric assessment) and all-cause mortality during follow-up. Methods We retrospectively evaluated patients diagnosed with severe AS for the first time at our echocardiography laboratory. We evaluated LA reservoir, conduit and pump function by measuring LA volumes at different timings of cardiac cycle. Treatment strategy was decided according to heart team consensus and patient decision. We divided patients into groups according to terciles of LA reservoir, conduit and pump function. Primary outcome was defined by the occurrence of all-cause mortality during follow-up. Results A total of 408 patients were included in the analysis, with a median follow-up time of 45 months (interquartile range 54 months). 57.9% of patients underwent AVR and 44.9% of patients registered the primary outcome during follow-up. Left atrial emptying fraction (LAEF) was the best LA functional parameter and the best overall parameter in discriminating primary outcome (AUC 0.845, 95%CI 0.81–0.88, P < 0.001). After adjustment for clinical, demographic and echocardiographic variables, cumulative survival of patients with LAEF < 37% and LAEF 37 to 53% relative to patients with LAEF ≥54% remained significantly lower (HR 13.91, 95%CI 6.20–31.19, P < 0.001 and HR 3.40, 95%CI 1.57–7.37, P = 0.002, respectively). After adjustment for AVR, excess risk of LAEF < 37% and LAEF 37 to 53% relative to LAEF ≥54% remained significant (HR 11.71, 95%CI 5.20–26.40, P < 0.001 and HR 3.59, 95%CI 1.65–7.78, P = 0.001, respectively). Conclusions In patients with a first diagnosis of severe AS, LA function, evaluated by means of volumetric assessment, is an independent predictor of all-cause mortality and a more potent predictor of death compared to classical severity parameters. These data can be useful to identify high-risk patients who might benefit of AVR.

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Left atrial functional assessment and mortality in patients with severe aortic stenosis with sinus rhythm

10.21203/rs.3.rs-52491/v2 ◽

2020 ◽

Author(s):

João Ferreira ◽

Valdirene Gonçalves ◽

Patrícia Marques-Alves ◽

Rui Martins ◽

Sílvia Monteiro ◽

...

Keyword(s):

Aortic Valve ◽

Left Atrial ◽

Primary Outcome ◽

Severe Aortic Stenosis ◽

Heart Team ◽

Pump Function ◽

Volumetric Assessment ◽

All Cause Mortality ◽

Echocardiography Laboratory

Abstract Background: Aortic valve stenosis (AS) is the most common primary valvular heart disease leading to surgical or percutaneous aortic valve replacement (AVR) in Europe and its prevalence keeps growing. While other risk factors in severe AS are well documented, little is known about the prognostic value of left atrial (LA) function in AS. Our aim is to clarify the relationship between LA function measured at severe AS diagnosis (evaluated by means of volumetric assessment) and all-cause mortality during follow-up. Methods: We retrospectively evaluated patients diagnosed with severe AS for the first time at our echocardiography laboratory. We evaluated LA reservoir, conduit and pump function by measuring LA volumes at different timings of cardiac cycle. Treatment strategy was decided according to heart team consensus and patient decision. We divided patients into groups according to terciles of LA reservoir, conduit and pump function. Primary outcome was defined by the occurrence of all-cause mortality during follow-up. Results: A total of 408 patients were included in the analysis, with a median follow-up time of 45 months (interquartile range 54 months). 57.9% of patients underwent AVR and 44.9% of patients registered the primary outcome during follow-up. Left atrial emptying fraction (LAEF) was the best LA functional parameter and the best overall parameter in discriminating primary outcome (AUC 0.845, 95%CI 0.81-0.88, P <0.001). After adjustment for clinical, demographic and echocardiographic variables, cumulative survival of patients with LAEF <37% and LAEF 37 to 53% relative to patients with LAEF ≥54% remained significantly lower (HR 13.91, 95%CI 6.20-31.19, P <0.001 and HR 3.40, 95%CI 1.57-7.37, P =0.002, respectively). After adjustment for AVR, excess risk of LAEF <37% and LAEF 37 to 53% relative to LAEF ≥54% remained significant (HR 11.71, 95%CI 5.20-26.40, P <0.001 and HR 3.59, 95%CI 1.65-7.78, P =0.001, respectively). Conclusions: In patients with a first diagnosis of severe AS, LA function, evaluated by means of volumetric assessment, is an independent predictor of all-cause mortality and a more potent predictor of death compared to classical severity parameters. These data can be useful to identify high-risk patients who might benefit of AVR.

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Left atrial dynamics in the hemodynamic response during exercise in patients with asymptomatic severe aortic stenosis

European Heart Journal ◽

10.1093/eurheartj/ehab724.1671 ◽

2021 ◽

Vol 42 (Supplement_1) ◽

Author(s):

T Sugimoto ◽

F Bandera ◽

G Generati ◽

E Alfonzetti ◽

M Guazzi

Keyword(s):

Aortic Valve ◽

Aortic Stenosis ◽

Left Atrial ◽

Cardiopulmonary Exercise Testing ◽

Left Ventricular ◽

Low Flow ◽

Volume Index ◽

Left Ventricular Ejection ◽

Aortic Valve Area ◽

Ventricular Ejection Fraction

Abstract Background The hemodynamic impact of left atrial (LA) dynamics in aortic stenosis (AS) in relation to cardiopulmonary response to exercise has never been studied. We aimed at investigating the link between LA function vs hemodynamics and prognosis in asymptomatic severe AS patients. Methods A total of 106 patients: 76 asymptomatic severe AS patients (aortic valve area (AVA) <1.0 cm2 or AVA index <0.6 cm2/m2) and 30 gender-matched control subjects underwent cardiopulmonary exercise testing combined with Echo-Doppler with assessment of LA strain. AS patients were divided into 4 groups according to peak aortic jet velocity (PV), mean pressure gradient (MPG), stroke volume index (SVI), and left ventricular ejection fraction (LVEF). Results Normal-flow low-gradient AS (NFLG: PV <4 m/s and MPG <40 mmHg, SVI >35ml/m2, LVEF ≥50%, N=23), High-gradient AS (HG: PV ≥4 m/s or MPG ≥40 mmHg, LVEF ≥50%, N=23), Paradoxical low-flow low-gradient AS (PLFLG: PV <4 m/s and MPG <40 mmHg, SVI ≤35ml/m2, LVEF ≥50%, N=18), and Classical low-flow AS (CLF: LVEF <50%, N=12) had a higher LA volume index than Control (Control 22±6, NFLG 38±12*, HG 33±9*, PLFLG 33±11*, and CLF 49±15* ml/m2, *P<0.05 vs Control). In PLFLG and NFLG AS, LA strain at rest (21±9 and 26±13%) and during exercise (26±12 and 31±14%) were decreased compared to Control (37±8% at rest, 43±11% during exercise) but LA strain was increased from rest to exercise (P<0.001). HG and CLF AS had no increase in LA strain (31±15 and 19±10% at rest, 28±15 and 18±9% during exercise) (figure). In Cox proportional hazards analysis, age and gender adjusted hazard ratio for the composite end point (aortic valve replacement, hospitalization for heart failure, and all-cause mortality) of changes in LA-strain from rest to exercise (1% increase) was 1.05 (95% CI 1.00 to 1.09, P=0.044) among AS patients. Conclusions In asymptomatic severe AS, the study of LA functional adaptation to exercise plays a key role in the hemodynamic unfavorable cascade signaling major adaptive differences in dynamics during physical challenge. Overall, LA dynamics provides prognostic information also in AS patients. FUNDunding Acknowledgement Type of funding sources: None.

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Predictors of left ventricular ejection fraction recovery after transcatheter aortic valve replacement (TAVR)

European Heart Journal ◽

10.1093/eurheartj/ehab724.0847 ◽

2021 ◽

Vol 42 (Supplement_1) ◽

Author(s):

B Peiro Aventin ◽

E Gambo Ruberte ◽

T Simon Paracuellos ◽

D Gomez Martin ◽

A Perez Guerrero ◽

...

Keyword(s):

Aortic Valve ◽

Ejection Fraction ◽

Transcatheter Aortic Valve Replacement ◽

Systolic Function ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Ventricular Ejection Fraction ◽

Transcatheter Aortic Valve ◽

All Cause Mortality

Abstract Introduction Transcatheter aortic valve replacement (TAVR) has proven benefits in patients with reduced left ventricular ejection fraction (LVEF). A significant proportion of them shows recovery of systolic function Objective To analyse the main baseline, electrocardiographic and echocardiographic characteristics that may predict LVEF recovery after TAVR. Methods A cohort study was conducted. Consecutive patients undergoing TAVR in our center from January 2012 to December 2020 were included. Baseline clinical profile, electrocardiographic (EKG), echocardiographic (ECH) parameters were recorded, as well as MACE during follow-up (major adverse cardiovascular events including: all-cause mortality, myocardial infarction, cerebrovascular accident and heart failure hospitalization). Reduced systolic function was defined as LVEF <50%. We considered recovery of systolic function as LVEF ≥50% at follow-up. Results A total of 292 patients were included. 48% were women and the median age was 81.07 years (77.63–86.22). 22.6% (66 patients) had reduced LVEF at baseline. Half of them showed recovered systolic function during follow-up. Patients who did not recovered LVEF had a higher prevalence of dyslipidemia and peripheral artery disease. History of cardiac surgery was more frequently found in this group, and they showed a higher surgical risk estimated by EuroScore II. They had lower LVEF and aortic valve mean gradient, and more frequently presented non-synus rhythm (NSR), left bundle branch block and right ventricular dysfunction (RVD). These characteristics are shown in figure 1. In univariate analysis lower Euroscore II, presence of synus rhythm, absence of LBBB and RVD, as well as higher aortic valve mean gradient were predictors of LVEF recovery. In multivariate analysis RVD and mean aortic gradient were independent predictors. Among all patients included in our study, those presenting with RV dysfunction were significantly associated with lower LVEF mean values (46,0% vs 57,2%; p<0,01) After a median follow-up of 21.3 (8.52–38.94) months, MACE were lower in recovered LVEF group (HR 0.25 95% CI: 0.05–1.21). There were no statistically significant differences in all-cause mortality, nevertheless there was a trend towards a higher non-cardiovascular mortality in this group, essentially at the expense of deaths from malignant neoplasms and SARS-COV-2 infections. Survival curves for MACE are represented in figure 2. Conclusion In our study, half of the patients with impaired ventricular function undergoing TAVR showed recovery of ejection fraction. Right ventricular function and aortic valve mean gradient at baseline were independent predictors of recovery. Identifying predictors of LVEF recovery is fundamental in the evaluation of potential candidates for TAVR, and can help clinicians assess risks and benefits, as well as long-term prognosis of these patients. FUNDunding Acknowledgement Type of funding sources: None. Characteristics and analysis Survival curves for MACE

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P3632Prognostic impact of aortic valve stenosis in patients with acute myocardial infarction

European Heart Journal ◽

10.1093/eurheartj/ehz745.0490 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

H Mizutani ◽

T Kurita ◽

S Kasuya ◽

T Mori ◽

H Ito ◽

...

Keyword(s):

Risk Factors ◽

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Aortic Valve ◽

Aortic Valve Stenosis ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Ventricular Ejection Fraction ◽

All Cause Mortality

Abstract Background Aortic valve stenosis (AS) is associated with the presence and severity of coronary artery disease independently of clinical risk factors, which leads to increased cardiovascular mortality. However, the prevalence of AS and its prognostic value among patients with acute myocardial infarction (AMI) remain unknown. Purpose The purpose of this study was to investigate the prevalence and prognostic impact of AS in AMI patients. Methods We studied 2,803 AMI patients using data from Mie ACS registry, a prospective and multicenter registry. Patients were divided into subgroups according to the presence and severity of AS based on maximal aortic flow rate by Doppler echocardiography before hospital discharge: non-AS <2.0 m/s, 2.0 m/s≤mild AS <3.0 m/s, 3.0 m/s≤moderate AS <4.0m/s and severe AS≥4.0 m/s. The primary outcome was defined as 2-year all-cause mortality. Results AS was detected in 79 patients (2.8%) including 49 mild AS, 23 moderate AS and 6 severe AS. AS patients were significantly older (79.9±9.8 versus 68.3±12.6 years), and higher killip classification than non-AS patients (P<0.01, respectively). However, left ventricular ejection fraction, and prevalence of primary PCI was similar between the 2 groups. During the follow-up periods (median 725 days), 333 (11.9%) patients experienced all-cause death. AS patients demonstrated the higher all-cause mortality rate compared to that of non-AS patients during follow up (47.3% versus 11.3%, P<0.0001, chi square). Kaplan-Meier curves showed that the probability of all-cause mortality was significantly higher among AS patients than non-AS patients, and was highest among moderate and severe AS (See figure A and B). Cox regression analyses for all-cause mortality demonstrated that the severity of AS was the strongest and independent poor prognostic factor (HR 1.71, 95% CI 1.30–2.24, P<0.001, See table). Cox hazard regression analysis Hazard ratio 95% Confidential interval P-value Severity of aortic valve stenosis 1.71 1.30–2.24 <0.001 Killip classification 1.63 1.46–1.82 <0.001 Age 1.07 1.06–1.09 <0.001 Serum creatinine level 1.05 1.03–1.08 <0.001 Max CPK level 1.00 1.00–1.01 <0.001 Left ventricular ejection fraction 0.96 0.95–0.97 <0.001 Primary percutaneous coronary intervention 0.67 0.47–0.96 0.03 CPK suggests creatinine phosphokinase. All cause mortality Conclusions The presence of AS of any severity contributes to worsening of patients' prognosis following AMI independently of other known risk factors. Acknowledgement/Funding None

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Clinical and echocardiographic outcomes of patients with moderate to severe aortic stenosis and preserved, mid-range and reduced ejection fraction

European Heart Journal ◽

10.1093/ehjci/ehaa946.1982 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

N Chew ◽

N Ngiam ◽

B.Y.Q Tan ◽

C.H Sia ◽

H.W Sim ◽

...

Keyword(s):

Heart Failure ◽

Aortic Valve ◽

Aortic Stenosis ◽

Ejection Fraction ◽

Severe Aortic Stenosis ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Aortic Valve Area ◽

Ventricular Ejection Fraction ◽

All Cause Mortality

Abstract Background Left ventricular ejection fraction (EF) plays an important role in risk stratifying and guiding therapy for patients with aortic stenosis (AS). This study aims to describe the clinical and echocardiographic outcomes of AS patients with preserved (ASpEF), mid-range (ASmrEF) and reduced (ASrEF) EF. Methods 713 consecutive patients with index echocardiographic diagnosis of moderate-severe AS (aortic valve area <1.5cm2) were allocated according to the EF into three groups: ASrEF (EF<40%), ASmrEF (EF 40–50%), and ASpEF (EF>50%). The study outcomes were defined as 5-year all-cause mortality, heart failure admissions, and aortic valve replacement (AVR). Results In comparison to patients with ASpEF, those with ASrEF were more frequently male, and systolic blood pressure was significantly lower on enrolment (p<0.001). Diabetes, ischemic heart disease and atrial fibrillation were more commonly seen in the ASrEF and ASmrEF groups, compared to ASpEF group. All-cause mortality rates were 30.5% for ASpEF, 50.8% for ASmrEF, 55.0% for ASrEF groups (p<0.001). Increased rates of heart failure admissions were seen in the ASmrEF and ASrEF groups (30.5% and 33.9%, respectively, vs. 14.9% in ASpEF group). Patients with ASrEF had significantly higher rates of AVR as compared to those in the ASmrEF and ASpEF groups (p=0.032). Conclusion Echocardiographic and clinical outcomes of ASmrEF patients resembled those of ASrEF more closely than the ASpEF patients. Stratifying AS patients according to the different EF groups may improve risk assessment and treatment strategies. Figure 1 Funding Acknowledgement Type of funding source: None

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Left Atrial Functional Assessment and Mortality in Patients with Severe Aortic Stenosis

10.21203/rs.3.rs-52491/v1 ◽

2020 ◽

Author(s):

João Ferreira ◽

Valdirene Gonçalves ◽

Patrícia Marques-Alves ◽

Rui Martins ◽

Sílvia Monteiro ◽

...

Keyword(s):

Aortic Valve ◽

Left Atrial ◽

Primary Outcome ◽

Severe Aortic Stenosis ◽

Hazard Ratio ◽

Heart Team ◽

Pump Function ◽

Volumetric Assessment ◽

All Cause Mortality

Abstract Background: Aortic valve stenosis (AS) is the most common primary valvular heart disease leading to surgical or percutaneous aortic valve replacement (AVR) in Europe and its prevalence is growing. While other risk factors in severe AS are well documented, less is known about the association between left atrial (LA) function and prognosis in AS. Our aim is to clarify the relationship between LA function measured at severe AS diagnosis (evaluated by means of volumetric assessment) and all-cause mortality during follow-up.Methods: We retrospectively evaluated patients diagnosed with severe AS for the first time at our echocardiography laboratory. We evaluated LA reservoir, conduit and pump function by measuring LA volumes at different timings of cardiac cycle. Treatment strategy was decided according to heart team consensus and patient decision. We divided patients into groups according to terciles of LA reservoir, conduit and pump function. Primary outcome was defined by the occurrence of all-cause mortality during follow-up.Results: A total of 451 patients were included in the analysis, with a median follow-up time of 73 months (interquartile range 44.5). 55.8% of patients underwent AVR and 45.5% of patients registered the primary outcome during follow-up. Left atrial emptying fraction (LAEF) was the best LA functional parameter and the best overall parameter in discriminating primary outcome (AUC 0.840, 95% CI 0.803-0.872, p<0.001). After adjustment for clinical, demographic and echocardiographic variables, cumulative survival of patients with LAEF <37% and LAEF 37 to 53% relative to patients with LAEF ≥54% remained significantly lower (hazard ratio 19.04, 95% CI 8.30-43.67, P<0.001 and hazard ratio 4.09, 95% CI 1.85-9.06, p=0.001, respectively). After adjustment for AVR, excess risk of LAEF <37% and LAEF 37 to 53% relative to LAEF ≥54% remained significant (hazard ratio 13.95, 95% CI 5.98-32.54, P<0.001 and hazard ratio 3.97, 95% CI 1.80-8.78, P=0.001, respectively).Conclusions: In patients with a first diagnosis of severe AS, LA function, evaluated by means of volumetric assessment, is an independent predictor of all-cause mortality and a more potent predictor of death compared to classical severity parameters. These data can be useful to identify high-risk patients who might benefit of AVR.

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Natural Progression of Low-Gradient Severe Aortic Stenosis with Preserved Ejection Fraction

Texas Heart Institute Journal ◽

10.14503/thij-13-3167 ◽

2014 ◽

Vol 41 (3) ◽

pp. 273-279 ◽

Cited By ~ 2

Author(s):

Antony Leslie Innasimuthu ◽

Sanjay Kumar ◽

Jason Lazar ◽

William E. Katz

Keyword(s):

Aortic Stenosis ◽

Ejection Fraction ◽

Severe Aortic Stenosis ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Aortic Valve Area ◽

Ventricular Ejection Fraction ◽

Mild Stenosis ◽

Natural Progression

Because the natural progression of low-gradient aortic stenosis (LGAS) has not been well defined, we performed a retrospective study of 116 consecutive patients with aortic stenosis who had undergone follow-up echocardiography at a median interval of 698 days (range, 371–1,020 d). All patients had preserved left ventricular ejection fraction (>0.50) during and after follow-up. At baseline, patients were classified by aortic valve area (AVA) as having mild stenosis (≥1.5 cm2), moderate stenosis (≥1 to <1.5 cm2), or severe stenosis (<1 cm2). Severe aortic stenosis was further classified by mean gradient (LGAS, mean <40 mmHg; high-gradient aortic stenosis [HGAS], mean ≥40 mmHg). We compared baseline and follow-up values among 4 groups: patients with mild stenosis, moderate stenosis, LGAS, and HGAS. At baseline, 30 patients had mild stenosis, 54 had moderate stenosis, 24 had LGAS, and 8 had HGAS. Compared with the moderate group, the LGAS group had lower AVA but similar mean gradient. Yet the actuarial curves for progressing to HGAS were significantly different: 25% of patients in LGAS reached HGAS status significantly earlier than did 25% of patients in the moderate-AS group (713 vs 881 d; P=0.035). Because LGAS has a high propensity to progress to HGAS, we propose that low-gradient aortic stenosis patients be closely monitored as a distinct subgroup that warrants more frequent echocardiographic follow-up.

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Clinical characteristics, one-year change in ejection fraction and long-term outcomes in patients with heart failure with mid-range ejection fraction: a multicentre prospective observational study in Catalonia (Spain)

BMJ Open ◽

10.1136/bmjopen-2017-018719 ◽

2017 ◽

Vol 7 (12) ◽

pp. e018719 ◽

Cited By ~ 17

Author(s):

Nuria Farré ◽

Josep Lupon ◽

Eulàlia Roig ◽

Jose Gonzalez-Costello ◽

Joan Vila ◽

...

Keyword(s):

Ejection Fraction ◽

Prospective Observational Study ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Ventricular Ejection Fraction ◽

End Point ◽

Patients With Heart Failure ◽

All Cause Mortality ◽

Baseline Characteristics

ObjectivesThe aim of this study was to analyse baseline characteristics and outcome of patients with heart failure and mid-range left ventricular ejection fraction (HFmrEF, left ventricular ejection fraction (LVEF) 40%–49%) and the effect of 1-year change in LVEF in this group.SettingMulticentre prospective observational study of ambulatory patients with HF followed up at four university hospitals with dedicated HF units.ParticipantsFourteen per cent (n=504) of the 3580 patients included had HFmrEF.InterventionsBaseline characteristics, 1-year LVEF and outcomes were collected. All-cause death, HF hospitalisation and the composite end-point were the primary outcomes.ResultsMedian follow-up was 3.66 (1.69–6.04) years. All-cause death, HF hospitalisation and the composite end-point were 47%, 35% and 59%, respectively. Outcomes were worse in HF with preserved ejection fraction (HFpEF) (LVEF>50%), without differences between HF with reduced ejection fraction (HFrEF) (LVEF<40%) and HFmrEF (all-cause mortality 52.6% vs 45.8% and 43.8%, respectively, P=0.001). After multivariable Cox regression analyses, no differences in all-cause death and the composite end-point were seen between the three groups. HF hospitalisation and cardiovascular death were not statistically different between patients with HFmrEF and HFrEF. At 1-year follow-up, 62% of patients with HFmrEF had LVEF measured: 24% had LVEF<40%, 43% maintained LVEF 40%–49% and 33% had LVEF>50%. While change in LVEF as continuous variable was not associated with better outcomes, those patients who evolved from HFmrEF to HFpEF did have a better outcome. Those who remained in the HFmrEF and HFrEF groups had higher all-cause mortality after adjustment for age, sex and baseline LVEF (HR 1.96 (95% CI 1.08 to 3.54, P=0.027) and HR 2.01 (95% CI 1.04 to 3.86, P=0.037), respectively).ConclusionsPatients with HFmrEF have a clinical profile in-between HFpEF and HFrEF, without differences in all-cause mortality and the composite end-point between the three groups. At 1 year, patients with HFmrEF exhibited the greatest variability in LVEF and this change was associated with survival.

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High Prevalence of Severe Aortic Stenosis in Low-Flow State Associated With Atrial Fibrillation

Circulation Cardiovascular Imaging ◽

10.1161/circimaging.120.012453 ◽

2021 ◽

Author(s):

Said Alsidawi ◽

Sana Khan ◽

Sorin V. Pislaru ◽

Jeremy J. Thaden ◽

Edward A. El-Am ◽

...

Keyword(s):

Atrial Fibrillation ◽

Aortic Valve ◽

Aortic Stenosis ◽

Left Ventricular ◽

Hazard Ratio ◽

Low Flow ◽

Left Ventricular Ejection ◽

Aortic Valve Area ◽

Flow State ◽

Ventricular Ejection Fraction

Background: Atrial fibrillation (AF) is a low-flow state and may underestimate aortic stenosis (AS) severity. Single-high Doppler signals (HS) consistent with severe AS (peak velocity ≥4 m/s or mean gradient ≥40 mm Hg) are averaged down in current practice. The objective for the study was to determine the significance of HS in AF low-gradient AS (LGAS). Methods: One thousand five hundred forty-one patients with aortic valve area ≤1 cm 2 and left ventricular ejection fraction ≥50% were identified and classified as high-gradient AS (HGAS) (≥40 mm Hg) and LGAS (<40 mm Hg), and AF versus sinus rhythm (SR). Available computed tomography aortic valve calcium scores (AVCS) were retrieved from the medical record. Outcomes were assessed. Results: Mean age was 76±11 years, female 47%. Mean gradient was 51±12 in SR-HGAS, 48±10 in AF-HGAS, 31±5 in SR-LGAS, and 29±7 mm Hg in AF-LGAS, all P ≤0.001 versus SR-HGAS; HS were present in 33% of AF-LGAS. AVCS were available in 34%. Compared with SR-HGAS (2409 arbitrary units; interquartile range, 1581–3462) AVCS were higher in AF-HGAS (2991 arbitrary units; IQR1978–4229, P =0.001), not different in AF-LGAS (2399 arbitrary units; IQR1817–2810, P =0.47), and lower in SR-LGAS (1593 arbitrary units; IQR945–1832, P <0.001); AVCS in AF-LGAS were higher when HS were present ( P =0.048). Compared with SR-HGAS, the age-, sex-, comorbidity index-, and time-dependent aortic valve replacement-adjusted mortality risk was higher in AF-HGAS (hazard ratio=1.82 [1.40–2.36], P <0.001) and AF-LGAS with HS (hazard ratio=1.54 [1.04–2.26], P =0.03) but not different in AF-LGAS without HS or SR-LGAS (both P =not significant). Conclusions: Severe AS was common in AF-LGAS. AVCS in AF-LGAS were not different from SR-HGAS. AVCS were higher and mortality worse in AF-LGAS when HS were present.

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