Staging classification of aortic stenosis based on the extent of cardiac damage

In patients with aortic stenosis (AS), a novel staging classification of extra-valvular left and right heart damage with prognostic relevance was introduced in 2017. The aim of the study was to evaluate the biomarkers of cardiovascular tissue remodelling in relation to this novel staging classification. Patients were categorized according to the novel staging classification into stages 0 to 4. The levels of matrix metalloproteinase 9 (MMP-9), tissue inhibitor of metalloproteinases 1 (TIMP-1), B and C domain containing tenascin-C (B+ Tn-C, C+ Tn-C), the ED-A and ED-B domain containing fibronectin (ED-A+ Fn, ED-B+ Fn), endothelin 1 (ET-1) and neutrophil gelatinase-associated lipocalin (NGAL) were determined in serum by ELISA. There were significantly decreased serum levels of MMP-9 and increased levels of B+ Tn-C and C+ Tn-C when comparing stages 0 and 1 with stage 2, with no further dynamics in stages 3 and 4. In contrast, for TIMP-1, C+ Tn-C, ED-A+ Fn, ET-1 and NGAL, significantly increased serum levels could be detected in stages 3 and 4 compared to both stages 0 and 1 and stage 2. ED-A+ Fn and ET-1 could be identified as independent predictors of the presence of stage 3 and/or 4. To the best of our knowledge, this is the first study identifying novel serum biomarkers differentially reflecting the patterns of left and right heart extra-valvular damage in patients suffering from AS. Our findings might indicate a more precise initial diagnosis and risk stratification.

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143Prognostic value of cardiac damage in patients with symptomatic severe aortic stenosis: implementation of a newly proposed staging classification

European Heart Journal ◽

10.1093/eurheartj/ehy564.143 ◽

2018 ◽

Vol 39 (suppl_1) ◽

Author(s):

E M Vollema ◽

M R Amanullah ◽

A C T Ng ◽

F Prevedello ◽

K Y Sin ◽

...

Keyword(s):

Aortic Stenosis ◽

Severe Aortic Stenosis ◽

Cardiac Damage ◽

Staging Classification

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Incremental value of left ventricular global longitudinal strain in a newly proposed staging classification based on cardiac damage in patients with severe aortic stenosis

European Heart Journal - Cardiovascular Imaging ◽

10.1093/ehjci/jeaa220 ◽

2020 ◽

Vol 21 (11) ◽

pp. 1248-1258 ◽

Cited By ~ 1

Author(s):

E Mara Vollema ◽

Mohammed R Amanullah ◽

Edgard A Prihadi ◽

Arnold C T Ng ◽

Pieter van der Bijl ◽

...

Keyword(s):

Aortic Stenosis ◽

Prognostic Value ◽

Longitudinal Strain ◽

Severe Aortic Stenosis ◽

Global Longitudinal Strain ◽

Left Ventricular ◽

Cardiac Damage ◽

All Cause Mortality ◽

Incremental Prognostic Value ◽

Staging Classification

Abstract Aims Cardiac damage in severe aortic stenosis (AS) can be classified according to a recently proposed staging classification. The present study investigated the incremental prognostic value of left ventricular (LV) global longitudinal strain (GLS) over stages of cardiac damage in patients with severe AS. Methods and results From an ongoing registry, a total of 616 severe symptomatic AS patients with available LV GLS by speckle tracking echocardiography were selected and retrospectively analysed. Patients were categorized according to cardiac damage on echocardiography: Stage 0 (no damage), Stage 1 (LV damage), Stage 2 (mitral valve or left atrial damage), Stage 3 (tricuspid valve or pulmonary artery vasculature damage), or Stage 4 (right ventricular damage). LV GLS was divided by quintiles and assigned to the different stages. The endpoint was all-cause mortality. Over a median follow-up of 44 [24–89] months, 234 (38%) patients died. LV GLS was associated with all-cause mortality independent of stage of cardiac damage. After incorporation of LV GLS by quintiles into the staging classification, Stages 2–4 were independently associated with outcome. LV GLS showed incremental prognostic value over clinical characteristics and stages of cardiac damage. Conclusion In this large single-centre cohort of severe AS patients, incorporation of LV GLS by quintiles in a novel proposed staging classification resulted in refinement of risk stratification by identifying patients with more advanced cardiac damage. LV GLS was shown to provide incremental prognostic value over the originally proposed staging classification.

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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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Classification of stages of severe aortic stenosis based on the prevalence of extravalvular heart damage

Kardiologiia ◽

10.18087/cardio.2021.1.n1024 ◽

2021 ◽

Vol 61 (1) ◽

pp. 98-103

Author(s):

M. N. Alekhin

Keyword(s):

Aortic Stenosis ◽

Valve Replacement ◽

Severe Aortic Stenosis ◽

Cardiac Damage ◽

Predictive Values ◽

Course Of Disease ◽

Heart Damage ◽

Asymptomatic Patients ◽

Thematic Review

This thematic review focuses on recently proposed classification of stages in pronounced aortic stenosis based on the prevalence of extravalvular cardiac damage and its modified variant designed for asymptomatic patients. The review presents studies, which analyzed the predictive significance of the proposed classification. The use of this classification allows predicting the course of disease in patients with pronounced aortic stenosis in valve replacement. The classification is based on routinely used structural and functional echocardiographic signs with already proven predictive values with respect of adverse events in patients after aortic valve replacement. The review discusses limitations of the classification for pronounced aortic stenosis stages based on the prevalence of extravalvular cardiac damage.

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P5582Predicting the clinical outcomes in moderate aortic stenosis: implementation of the newly proposed staging classification

European Heart Journal ◽

10.1093/eurheartj/ehz746.0526 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

M R Amanullah ◽

S M Pio ◽

K Y Sin ◽

N Ajmone Marsan ◽

Z P Ding ◽

...

Keyword(s):

Aortic Stenosis ◽

Rank Test ◽

Cardiac Damage ◽

Log Rank Test ◽

Stage 4 ◽

All Cause Mortality ◽

Grade 3 ◽

Stage 1 ◽

Staging Classification

Abstract Background While symptomatic severe aortic stenosis (AS) carries a worse prognosis and early intervention is favoured, it is always assumed that patients with moderate AS are more stable and their disease progression can be monitored yearly. However, it is known that patients with moderate AS have a higher risk of cardiovascular events but is unclear if other factors may also affect the overall prognosis. Purpose In this multicentre registry of patients with moderate AS, the prognostic value of a new staging classification on the extent of cardiac damage was examined. Methods Based on the echocardiographic findings at the time of diagnosis of moderate AS (valve area >1.0 and ≤1.5 cm2), they were re-classified into five stages depending on the extra-aortic valvular cardiac damage: no signs of cardiac damage (Stage 0), left ventricular (LV) damage [LV ejection fraction <50%, LV mass index >95 g/m2 for women or >115 g/m2 for men or E/e' >14] (Stage 1), mitral valve or left atrial (LA) damage [LA volume index >34 ml/m2 or mitral regurgitation ≥grade 3 or presence of atrial fibrillation] (Stage 2), tricuspid valve or pulmonary artery vasculature damage [systolic pulmonary arterial pressure ≥60 mmHg or tricuspid regurgitation ≥grade 3] (Stage 3), or right ventricular damage [tricuspid annular plane systolic excursion <17 mm] (Stage 4). The clinical endpoint was all-cause mortality. The association between the extent of cardiac damage and all-cause mortality was assessed by the Kaplan Meier method using log-rank test. Results Of the included 522 patients with moderate AS (age 71±11 years, 54% males), 12% (63) of patients were re-classified as Stage 0, 30% (157) in Stage 1, 47% (245) in Stage 2, 6% (31) in Stage 3 and 5% (26) in Stage 4. During follow-up, 43% (226) of patients underwent surgical or transcatheter aortic valve replacement. Over a median follow-up of 6.2 [interquartile range 3.2–9.0] years, 254 (49%) patients died. The cumulative event rates for all-cause mortality increased with increasing stage, particularly for Stages ≥2: 39% for Stage 0, 55% for Stage 1, 67% for Stage 2, 68% for Stage 3 and 57% for Stage 4, respectively (Figure, log-rank test p=0.001). Cumulative death rates after re-staging Conclusion In a real-world registry of patients with moderate AS patients, worsening extra-aortic valvular cardiac damage portends a worse long-term prognosis.

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